- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …(Inpatient, outpatient, or differing levels of care). + Utilization Management experience, preferred + Experience with Medicare Advantage, preferred + ... help us transform healthcare? Bring your true colors to blue. The RoleThe Clinical Utilization Reviewer is responsible for facilitating care for our Medicare … more
- Evolent (Boston, MA)
- …clinical objectives **Desired Skill Set** + Understanding of regulatory framework for utilization management in Medicare , Medicaid, and Commercial contexts ... of physician, nursing, and shared services staff in the utilization management value chain + Owns clinical...and implementation of new strategies to make the clinical review process more efficient through people, processes, and technology… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …to coverage decisions and final determinations regarding coverage in the BCBSMA utilization management system (MHK), so that decisions and medical reasoning ... request of the Senior Medical Director of the Physician Review Unit (PRU), the reviewer also provides...practice in order to process appeals + Experience in Utilization Management in a managed-care or risk… more
- Blue Cross Blue Shield of Massachusetts (Boston, MA)
- …Active clinical practice in order to participate in panel appeals + Experience in Utilization Management in a managed-care environment (as a clinician or in ... of the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer also provides clinical...to evaluate clinical service requests + Practice anticipatory case management for members whose cases come for review… more
- Evolent (Boston, MA)
- …Doing:** As a Physician Clinical Reviewer you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
- Humana (Boston, MA)
- …and help us put health first** Humana Healthy Horizons in Ohio is seeking a Utilization Management Nurse 2 who utilizes clinical nursing skills to support the ... and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and… more
- Humana (Boston, MA)
- …and interpretation skills with prior experience leading teams focusing on quality management , utilization management , discharge planning and/or home health ... of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Represents Humana at Administrative… more
- Evolent (Boston, MA)
- …Doing:** As a Cardiology, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
- Humana (Boston, MA)
- … management . + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or ... conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Highmark Health (Boston, MA)
- …OVERVIEW: * Receive, review and make determinations regarding physician reviewer assignments for medical management decisions. Cases requiring physician ... agencies' standards including the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Committee (URAC), Pennsylvania Department of… more
- Humana (Boston, MA)
- … management . + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or ... conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements and will...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Humana (Boston, MA)
- … management . + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or ... and other sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements, and will...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Commonwealth Care Alliance (Boston, MA)
- …claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required + 7+ years experience with Optum Claims ... research, as necessary on all new and revised coding logic, related Medicare /Medicaid policies for review /approval through the Payment Integrity governance… more
- Beth Israel Lahey Health (Plymouth, MA)
- …3) Decreasing unit cost, 4) reducing readmissions. **Functions and Responsibilities:** **A. Utilization Management ** + Performs review of anticipated ... This role is structured around four major functions + Utilization Management + Care Coordination + Discharge...assess for appropriate level of care assignment. + Certifies Medicare admissions and utilizes Code 44 when appropriate +… more
- Lawrence General Hospital (Lawrence, MA)
- …Specialist Works collaboratively with the Complex Care Nurse Managers, Social Workers, and Utilization Review Nurses, in coordinating and providing care that is ... as an advocate for clients. + Ensures Important Message (IM) notices for Medicare patients have been distributed and completes all required IM documentation MINIMUM… more
- CenterWell (Pittsfield, MA)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and ... delivery, and documentation requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking for performance … more
- Beth Israel Lahey Health (Wakefield, MA)
- …making a difference in people's lives.** The Care Manager, RN provides care management services to the BILHPN primary care physicians focusing on at risk, high ... on their at-risk patient population through care coordination, condition management education and community resource support. Responsibilities include working with… more
- Beth Israel Lahey Health (Cambridge, MA)
- …Responsible for the overall operation of care transitions discharge planning and/or utilization management departments through oversight of daily and long-term ... advisors. 4. Ensures regulatory compliance and monitoring of key systems, including review and actions towards key performance management indicators related to… more
- United Therapeutics (Boston, MA)
- …with superior financial performance and our communities with earth-sensitive energy utilization . Our company was founded by an entrepreneur whose daughter was ... to support decisions regarding policy and reimbursement landscape + Support senior management in all financial, sales, and new business modeling + Provide data… more
- Beth Israel Lahey Health (Burlington, MA)
- …manager. . Assists Utilization Managers with all aspects of utilization review /discharge planning/performance improvement processes. . Functions as liaison ... including Interqual, Rightfax, NaviHealth, Change Healthcare, Epic, etc. . Manages all utilization management work queues by researching and following up on… more