- Humana (Austin, TX)
- …put health first** The Staff Utilization Management Pharmacist is a clinical expert responsible for conducting medical necessity and comprehensive medication ... work **1 company holiday per calendar year** **Job Description:** The Staff Utilization Management Pharmacist is a clinical professional responsible for… more
- Centene Corporation (Austin, TX)
- …benefits including a fresh perspective on workplace flexibility. **Position Purpose:** Performs a clinical review and assesses care related to mental health and ... and substance abuse preferred. Knowledge of mental health and substance abuse utilization review process preferred. Experience working with providers and… more
- Humana (Austin, TX)
- …Coordinator or discharge planner in an acute care setting + Previous experience in utilization management/ utilization review for a health plan or acute care ... a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination,… more
- CenterWell (Austin, TX)
- …will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review ... or ability to obtain Compact Nursing License + A minimum of three years clinical RN experience; + Prior clinical experience, managed care experience, DME,… more
- CenterWell (Austin, TX)
- …A minimum of three years clinical RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + ... will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review … more
- Actalent (Austin, TX)
- Clinical Review Nurse - Concurrent Review Location: Remote - Compact Nursing License required; must be able to work CST hours Schedule: Tuesday-Friday, 10:00 ... Unit: Medicaid About the Role We are seeking a Clinical Review Nurse to perform concurrent reviews...medical necessity, and discharge planning in alignment with clinical policies and guidelines. This role is fully remote… more
- Actalent (Austin, TX)
- Clinical Review Nurse - Concurrent ...concurrent reviews to assess member health, care setting, and medical necessity + Review acuity, resource use, ... - 6:30 PM CST Position Overview We are seeking Clinical Review Nurses to join our remote...with providers to approve or recommend determinations based on review findings + Educate providers on utilization … more
- Evolent (Austin, TX)
- …requests** + Determines medical necessity and appropriateness of services using clinical review criteria. + Accurately documents all review rationales ... for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals.… more
- Molina Healthcare (Austin, TX)
- …At least 2 years clinical nursing experience, including at least 1 year of utilization review , medical claims review , long-term services and supports ... **Job Description** **Job Summary** The Medical Review Nurse provides support for...or modification of payment decisions. + Serves as a clinical resource for utilization management, CMOs, physicians… more
- Evolent (Austin, TX)
- …with call center staff. Clinical reviewers are supported by Field Medical Directors (MDs) in the utilization management determination process. + Reviews ... routinely interact with leadership and management staff, other CR's ( Clinical Reviewers), providers, office staff and Field Medical...**What You Will Be Doing:** + Functions in a clinical review capacity to evaluate all cases,… more
- CenterWell (Austin, TX)
- … of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and conducts ... delivery, and documentation requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking for performance … more
- CVS Health (Austin, TX)
- …and optimal, cost-effective outcomes. Assessment of Members: Through the use of clinical tools and information/data review , conducts comprehensive assessments of ... health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated. Provides crisis… more
- Cardinal Health (Austin, TX)
- **Ideal candidate will live near a major/regional airport.** **_What Clinical Operations contributes to Cardinal Health_** Clinical Operations is responsible for ... change management. + Demonstrates extensive knowledge and understanding of relevant clinical operations, products and services + Influences customer decision to… more
- Centene Corporation (Austin, TX)
- … management, cost containment, and medical quality improvement activities. + Performs medical review activities pertaining to utilization review , ... to clinical issues and policies. + Identifies utilization review studies and evaluates adverse trends... review studies and evaluates adverse trends in utilization of medical services, unusual provider practice… more
- Molina Healthcare (Austin, TX)
- …in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. * Provides leadership ... utilization . * Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy … more
- Evolent (Austin, TX)
- …providers, when available, within the regulatory timeframe of the request. + Utilizes medical / clinical review guidelines and parameters to assure consistency ... care in a non- clinical setting? Join our Utilization Management team as a Field Medical ... and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National… more
- Molina Healthcare (Austin, TX)
- …practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease ... state, and local laws and regulatory requirements affecting the medical and clinical staff. + Marketplace UM...Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage,… more
- HCA Healthcare (Austin, TX)
- …ongoing in-service programs to facility medical staff regarding clinical resource management, appropriate documents standards, utilization and quality ... of quality and cost improvement and develops systems to review utilization of resources and objectively measure...as requested. Business Development and Payer Relations: + Evaluates clinical appropriateness of new medical technologies and… more
- Molina Healthcare (Austin, TX)
- …care unit (ICU) or emergency room. Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / ... JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes....requests within required timelines. * Refers appropriate cases to medical directors (MDs) and presents them in a consistent… more
- Evolent (Austin, TX)
- …providers, when available, within the regulatory timeframe of the request. + Utilizes medical / clinical review guidelines and parameters to assure consistency ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more