- 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 ... communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work...skills to make an impact** **Required Qualifications** + Licensed Registered Nurse ( RN ) with no… 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...various social systems. **Qualifications:** _Required_ + State of MA Registered Nurse ( RN ) + 3-5… more
- Beth Israel Lahey Health (Boston, MA)
- …people's lives.** Position Summary: In conjunction with the admitting/attending physician, the Utilization Review RN assists in determining the appropriate ... billed. Conducts concurrent reviews as directed in the hospital's Utilization Review Plan and review ...required and directed. **Qualifications:** _Required_ + Licensure as a Registered Nurse ( RN ), Massachusetts +… more
- Highmark Health (Boston, MA)
- …and Sunday required in addition to 3 weekdays** This job implements effective utilization management strategies including: review of appropriateness of ... and offers interventions and/or alternatives. **ESSENTIAL RESPONSIBILITIES** + Implement care management review processes that are consistent with established… more
- Beth Israel Lahey Health (Cambridge, MA)
- …annually. c. Maintains BLS, ACLS certification d. Attends Emergency Department RN Competency Review Course annually. e. Attends hospital-based Education ... difference in people's lives.** Join our team as a key Emergency Department nurse in our renovated and expanded department, caring for approximately 34,000 patients… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …medical necessity criteria and BCBSMA policies and procedures + Focus on efficient utilization management with emphasis on discharge planning + Understand and ... to obtain and/or share information relating to benefits and the BCBSMA utilization management process + Collaborate with members/families, providers, medical… more
- Brockton Hospital (Brockton, MA)
- …responsibilities. EDUCATION: + RN with Master's Degree + Current License as Registered Nurse in the Commonwealth of Massachusetts EXPOSURE CATEGORY: It is ... management experience Proven experience in coordinating discharge planning and utilization review experience required. Prior management experience… more
- Brockton Hospital (Brockton, MA)
- …of five years clinical experience in an acute care facility required. Prior experience in case management , utilization review or discharge planning required. ... Provides medical-surgical pediatric and obstetrical case management services to Brockton Hospital patients. Responsible for assuring continuity of care for patients… more
- Intermountain Health (Boston, MA)
- …REGISTRATION, LICENSE (*indicates primary source verification requirement) Required: + Active Registered Nurse License Preferred: + Certified Healthcare Access ... Associate (CHAA) EXPERIENCE Required: + Licensed Registered Nurse + Minimum of 2 years'...experience in acute clinical nursing setting + Knowledge of utilization management and case management … more
- Cambridge Health Alliance (Cambridge, MA)
- …a business card. * Integrates the discharge planning/coordination and utilization review functions in the case management role. * Refers appropriate cases ... Center **Work Days:** Generally Mon-Fri days 8-4:30 and one evening/wk **Category:** Registered Nurse **Department:** Office Based Opioid Grant **Job Type:**… more
- Guardian Life (Boston, MA)
- …services. Act as a liaison between all parties required in case management to facilitate collaboration toward RTW goals. Utilization of independent ... **Position Summary** The RN Clinical Consultant serves as a clinical resource...issues, when possible, to enhance the customer experience. **Activity** Review and assess claimant subjective reports and objective medical… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …health care settings (Inpatient, outpatient, or differing levels of care). + Utilization Management experience, preferred + Active licensure in Massachusetts is ... standards to create, follow and appropriately document comprehensive care management plans. + Review medication list and...required, appropriate to position ( RN /PT) + Licensure in additional states a plus. +… more
- Erickson Living (Hingham, MA)
- …of medical practice; insurance benefit structures and related legal/medical issues; and utilization review and quality assurance procedures. Please note that ... + Researches and selects care options as appropriate. The nurse care coordinator may utilize a range of alternative,...available. **What you will need** + Active Professional Licensed RN required. CCM certification or working toward. + Minimum… more
- East Boston Neighborhood Health Center (East Boston, MA)
- …range planning and determining staffing needs. + Assists Home Care Manager/Residential Nurse manager to monitor utilization and processes for stocking Nursing ... in policy review and revision. Works with Home Care Director/Residential Nurse Manager to update policies, procedures and workflows as needed to ensure… 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
- Beth Israel Lahey Health (Charlestown, MA)
- …and familiarity with CPT/HCPCs/DRG coding experience required. . Clinical education and/or utilization review experience strongly preferred. . Requires minimum 2 ... aspects of clinical appeals, audits, and compliance issues to management . . Participates in complex projects related to denial...managers are involved. . Assist in the tracking and review of payer audit and denial results. Prepare appeal… 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 ... Working under the direction of the Sr. Director, TPA Management and Claims Compliance, Healthcare Medical Claims Coding Sr....regulations. The role will also be responsible for timely review and research, as necessary on all new and… more
- Commonwealth Care Alliance (Boston, MA)
- …market, and evolve with our company's capabilities. + Sales Strategy & Management : Develop and implement sales strategy, consistent sales processes, effective daily ... management systems, and methodology for sizing opportunity to drive...that clients are invested in their constituents' adoption and utilization and share performance targets; and that instED has… more