- Humana (Madison, WI)
- …community and help us put health first** Full-Time, Remote Telephonic opportunity The Utilization Management Nurse 2 utilizes clinical nursing skills to ... communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work...appropriate courses of action. As a Utilization Management RN working on the OneHome/ Home Solutions… more
- CenterWell (Madison, WI)
- …RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability ... Therapy, DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare… more
- Humana (Madison, WI)
- **Become a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the ... documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are… 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 ... Abuse or Maternity/ Obstetrics experience. **Preferred Qualifications** + 1+ years' Case Management experience or discharge planning, nurse navigator or nurse… 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 ... must be technologically proficient, self-directed, autonomous and experience working from home . Care Management & Waiver Service Auditing experience is… more
- Evolent (Madison, WI)
- …Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are performed ... medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care across the continuum… more
- Fresenius Medical Center (Fitchburg, WI)
- …and acting on adverse events and action thresholds. + Oversees facility's Home Therapies Program if applicable. + Accountable for compliance with all applicable ... and acts as the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member eligibility. Facilitate timely… 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
- Molina Healthcare (Madison, WI)
- … and effective resource management . + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure ... IT and data analysts to produce tools to report, monitor and improve Utilization Management . + Actively participates in regulatory, professional and community… 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, ... liaison with post acute providers (skilled nursing facilities, rehab, home health, etc.). + Applies the existing body of...department's Scope of Service. + As an SSM Health nurse , I will demonstrate the professional nursing standards defined… more
- Molina Healthcare (Dane, WI)
- …Summary Facilitates advanced practice clinical consultations for enrolled members including in- home histories, physical assessments and care plans; strives to ensure ... cost-effective member care. Essential Job Duties * Conducts comprehensive member in- home health history and physical assessments, and identifies active and chronic… more
- Sharecare (Madison, WI)
- …/ new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical, ... + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Humana (Madison, WI)
- …others. **Essential Duties and Responsibilities:** + Review PA requests for home health services, durable medical equipment, outpatient therapies, skilled nursing ... inpatient and subacute activity daily for outcomes related to readmission, utilization , quality of care and provider performance in compliance with Humana/iCare… 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...hold a compact license. This is a Remote position, home office with internet connectivity of high speed required… more