- Molina Healthcare (Columbus, OH)
- …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 (Columbus, OH)
- …for conducting initial and ongoing interviews with claimants, obtaining, and reviewing medical records and making timely and ethical claim determinations. You'll ... 74082 **The Role at a Glance** As an **LTD Claims Specialist** , you will manage a workload of...and consulting physicians to make appropriate, ethical, and timely claim determinations + Reviewing complex medical records… more
- Lincoln Financial Group (Columbus, OH)
- …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 (Columbus, OH)
- …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
- CVS Health (Columbus, OH)
- …of residence.** **Position Summary** RN and certified coder Responsible for the review and evaluation of clinical information and documentation related to SIU ... line with regulatory and accreditation requirements for member and/or provider claims . Independently coordinates the clinical resolution with clinician/MD support as… more
- CVS Health (Columbus, OH)
- …and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness. RN ... - Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit...and multiple diagnoses that impact functionality. - Reviews prior claims to address potential impact on current case management… more
- Molina Healthcare (Columbus, OH)
- … 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 (Columbus, OH)
- …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 (Columbus, OH)
- …paid holidays, and flexibility as you coordinate the care of your members. Nurse Case Manager is responsible for telephonically and/or face to face assessing, ... all case management activities with members to evaluate the medical needs of the member to facilitate the member's...wellness. Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit… more
- CVS Health (Columbus, OH)
- …holidays, and flexibility as you coordinate the care of your members. + Nurse Case Manager is responsible for telephonically and/or face to face assessing, planning, ... all case management activities with members to evaluate the medical needs of the member to facilitate the member's...+ Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit… more
- CVS Health (Columbus, OH)
- …defined schedule, adhering to the defined metrics, as required by the business. Nurse Case Manager is responsible for telephonically and/or face to face assessing, ... and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness. Develops… more
- Evolent (Columbus, OH)
- …other clinicians who review the appeal, the claims department to review provider post-service claims for medical necessity, and managers for ... behind it. **What You'll Be Doing:** The Evolent Appeals Nurse team offers candidates the opportunity to make a...and accomplishments. **What You Will Be Doing:** Communicates with medical office personnel to obtain pertinent clinical history and… more
- United Therapeutics (Columbus, OH)
- …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
- Intermountain Health (Columbus, OH)
- …Prior Authorization RN provides timely review of authorization requests and/or review of denials to ensure medical necessity, payer policies, appeals and ... reviews and submission of complex authorization requests using appropriate criteria, medical policy review and department expectations + Collaborate with… more
- CVS Health (Columbus, OH)
- …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