- Humana (Jefferson City, MO)
- **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
- Sharecare (Jefferson City, MO)
- …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 (Jefferson City, MO)
- …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
- Centene Corporation (Jefferson City, MO)
- …Develop and maintain the audit process and tools related to: authorizations, appeals , quality events, and case management in CCMS; interrater reliability related to ... RESIDE IN MISSOURI **Ideal candidate will be a Licensed Practical Nurse (LPN) with auditing experience.** **Education/Experience:** Bachelor's degree in related… more
- Children's Mercy Kansas City (Kansas City, MO)
- …utilizing InterQual and/or MCG screening guidelines, and clinical denials/ appeals oversight. Participates in department and hospital performance improvement ... One of the following: Licensed RN - MO, Registered Nurse Multistate License Missouri required upon hire + One...One of the following: Licensed RN - Kansas, Registered Nurse Multistate License Kansas required upon hire + RN… more