- CVS Health (Madison, WI)
- …And we do it all with heart, each and every day. **Position Summary** The ** Utilization Management Clinical Nurse Consultant** utilizes clinical ... Arizona Time Zone. **Preferred Qualifications** : + Previous experience with utilization management . + Previous clinical experience in Emergency Department,… more
- Humana (Madison, WI)
- …of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... determination of the appropriate courses of action. The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent… more
- CenterWell (Madison, WI)
- …RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to ... Therapy, DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare… more
- Evolent (Madison, WI)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- Fresenius Medical Center (Fitchburg, WI)
- …requirements. Ensure provision of quality patient care while maintaining cost-effective clinical operations in accordance with all legal, compliance, and regulatory ... and FMS patient care and administrative policies as the clinical leader, has the authority to make daily decisions...the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member… more
- Molina Healthcare (Madison, WI)
- …recommendations for denial or modification of payment decisions. + Serves as a clinical resource for utilization management , CMOs, physicians and ... ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS)… more
- CVS Health (Madison, WI)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... self-insured clients. + Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures… more
- Molina Healthcare (Madison, WI)
- …reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees. + Participates as needed in joint ... **JOB DESCRIPTION** **Job Summary** The Delegation Oversight Nurse provides support for delegation oversight quality improvement activities. Responsible for… more
- Select Medical (Madison, WI)
- …focus on resource management . + Demonstrating compliance with facility-wide Utilization Management policies and procedures. + Coordinating UR compliance with ... doing what is right. As the Director of Case Management **,** you will use your clinical ...growth of the department, including, but not limited to: Utilization Review (UR) and resource management , discharge… more
- Molina Healthcare (Madison, WI)
- …of health care services provided to plan members. * Supports plan utilization management program and accompanying action plan(s), which includes strategies ... the most appropriate care at the most effective setting. *Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and… more
- Select Medical (Madison, WI)
- … within the plan of care. + Demonstrates compliance with facility-wide Utilization Management policies and procedures. + Coordinates UR compliance with ... **Case Manager (PRN)** _Requires a current licensure in a clinical discipline either as a Nurse or...what is right. The Case Manager is responsible for utilization reviews and resource management , discharge planning,… more
- Molina Healthcare (Madison, WI)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for...Preferred Experience Previous experience in managed care Prior Auth, Utilization Review / Utilization Management … more
- SSM Health (Madison, WI)
- …opportunities for improvement in standard work. + May also be responsible for: utilization management process, ED case management process, admission process, ... care is delivered based on patient's age-specific needs and clinical needs as described in the department's Scope of...department's Scope of Service. + As an SSM Health nurse , I will demonstrate the professional nursing standards defined… more
- Molina Healthcare (Dane, WI)
- …Preferred Qualifications * Previous experience as a registered nurse , nurse practitioner or physician assistant. * Previous clinical experience. To ... JOB DESCRIPTION Job Summary Facilitates advanced practice clinical consultations for enrolled members including in-home histories, physical assessments and care… more
- Datavant (Madison, WI)
- …function as delegated by management Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in DRG downgrade denials and appeal ... The purpose of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for medical necessity and… more
- Sharecare (Madison, WI)
- …3rd parties for care management and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case ... / new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical,… more
- Oracle (Madison, WI)
- …of analysts providing support for operationally required changes and enhancements to clinical applications, and aa group of analysts leading projects that will ... These include, but are not limited to, multiple Essential Clinical Dataset (ECD) alignments, Critical Care workflow implementation, Multi-Disciplinary Rounding,… more
- Molina Healthcare (Madison, WI)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is...and medical coding. JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying… more
- Molina Healthcare (Madison, WI)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... RN license required_** JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that… more
- Highmark Health (Madison, WI)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... data to assure appropriate level of payment and resource utilization . It is also used to identify issues which...- 5 years of related, progressive experience in a clinical setting **Preferred** + 1-3 years of experience in… more