- Humana (Boston, MA)
- **Become a part of our caring community and help us put health first** The Appeals Nurse 2 resolves clinical complaints and appeals . The Appeals Nurse ... and independent determination of the appropriate courses of action. The Appeals Nurse 2 reviews documentation and interprets data obtained from clinical records… more
- Beth Israel Lahey Health (Cambridge, MA)
- …to the Director of Quality & Patient Safety, the Quality and Patient Safety nurse specialist plays a role in reviewing publicly reported quality data by leading the ... processes to reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review clinical charts, interpret data, and… more
- Sharecare (Boston, MA)
- …enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited to medical, ... 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status +...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- CVS Health (Boston, MA)
- …accordance with contract. + Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) ... incoming correspondence and internal referrals. + Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management. Performs… more
- Fallon Health (Worcester, MA)
- …authorization information in QNXT because of determinations made by Authorization Coordinators, Nurse Reviewers and/or Nurse Care Specialists. + Handles an ... contract information, benefits, etc.), including authorization details when requested for appeals . + Distributes departmental facsimiles; checks Right Fax no less… more