- Molina Healthcare (Louisville, KY)
- …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
- Elevance Health (Louisville, KY)
- **Clinical Review Nurse I - Medicare Part A**...Nurse I** is responsible for reviewing and making medical determinations as to whether a claim meets ... and reasonableness of the items supplied in a valid claim through the use of medical policy...Hospice experience is a plus. + Prior experience with claim review of Medicare helpful. + CMS… more
- Molina Healthcare (Louisville, KY)
- …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... the likelihood of a formal appeal being submitted. + Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge,… more
- Molina Healthcare (Louisville, KY)
- …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
- Elevance Health (Louisville, KY)
- …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
- BrightSpring Health Services (Louisville, KY)
- …for quality and compliance per applicable home health regulations for submission for pre- claim review process of Review Choice Demonstration and/or Targeted ... up as needed with appropriate staff and/or department for correction + Review coding to ensure documentation is completed within Agency's admission timeframe +… more
- Elevance Health (Louisville, KY)
- …prior authorization, and post service requests. + Refers cases requiring clinical review to a Nurse reviewer. + Responsible for the identification ... I** will be responsible for coordinating cases for precertification and prior authorization review . **How you will make an impact:** + Managing incoming calls or… more