- Molina Healthcare (Des Moines, IA)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... clinical/ medical reviews of retrospective medical claim reviews, medical claims and...Claims Auditing, Medical Necessity Review and Coding experience +… more
- Lincoln Financial Group (Des Moines, IA)
- …for conducting initial and ongoing interviews with claimants, obtaining, and reviewing medical records and making timely and ethical claim determinations. You'll ... through phone and e-mail to gather information regarding the Short Term Disability claim . + Collaborating with fellow case managers, nurse case managers and… more
- Lincoln Financial Group (Des Moines, IA)
- …organization. This position will be responsible for reviewing, analyzing, and interpreting medical information available for disability claims . In this role you ... a clinical resource for Group Protection benefit specialists and claim professionals. You will evaluate medical information...this role you will provide coaching and guidance to claims regarding medical management **What you'll be… more
- Elevance Health (West Des Moines, IA)
- …experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing ... the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims...you will make an impact:** + Analyzes and audits claims by integrating medical chart coding principles,… more
- Elevance Health (Des Moines, IA)
- ** Nurse and CPC - Clinical Fraud Investigator II -...control. + Review and conducts analysis of claims and medical records prior to payment. Researches ... + Performs in-depth investigations on identified providers as warranted. + Examines claims for compliance with relevant billing and processing guidelines and to… more
- Molina Healthcare (Des Moines, IA)
- … claims with corresponding medical records to determine accuracy of claims payments. + Review of applicable policies, CPT guidelines, and provider ... policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or… more
- Molina Healthcare (Des Moines, IA)
- …retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as ... Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial… more
- CVS Health (Des Moines, IA)
- …5pm within time zone of residence.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, ... Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.… more
- United Therapeutics (Des Moines, IA)
- …reimbursement support, patient support programs, field reimbursement managers, patient navigators and nurse educators + Review Needs Assessment Forms related to ... and biotech industry, including FDA advertising and promotion, False Claims Act, Anti-Kickback Statute, OIG Guidance, the PhRMA Code,...+ Serve as the Legal representative on the Company's medical communications review , including review … more
- Veterans Affairs, Veterans Health Administration (Des Moines, IA)
- …issues as requested. As needed, review and co-sign court reports of nurse practitioners if the Medical Director is not available. Complete such reports ... the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible...Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that… more
- Trinity Health (Des Moines, IA)
- …related to accidents, injuries, treatment or other events that may result in claims of medical malpractice or negligence. 8. Reviews, investigates, analyzes and ... and professional liability may include, but are not limited to, managing claims , administering the risk management plan/program on a day-to-day basis, adverse event… more
- Elevance Health (West Des Moines, IA)
- …Finder and follows up with provider on referrals given. + Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care. + ... make an impact:** + Managing incoming calls or incoming post services claims work. + Determines contract and benefit eligibility; provides authorization for… more
- CVS Health (Des Moines, IA)
- …Direct and oversee complex reviews. Ensure timely and accurate reporting of review findings and coordinate with investigative to take appropriate action. Conducts ... detection, investigation, or auditing In-depth knowledge of healthcare systems, claims processing, and regulatory requirements related to healthcare fraud.… more