- 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
- Humana (Boston, MA)
- …guidelines/procedures **Use your skills to make an impact** **Required Qualifications** + Licensed Registered Nurse ( RN ) with no disciplinary action in the ... put health first** Humana Healthy Horizons in Ohio is seeking a Utilization Management Nurse 2 who utilizes clinical nursing skills to support the coordination,… 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 ... delays through problem resolution and follow-up. Monitors on-site case managers and utilization review staff to ensure compliance with Signature Healthcare… more
- Beth Israel Lahey Health (Plymouth, MA)
- …to enable them to negotiate various social systems. **Qualifications:** _Required_ + State of MA Registered Nurse ( RN ) + 3-5 years acute care nursing + Two ... Decreasing unit cost, 4) reducing readmissions. **Functions and Responsibilities:** **A. Utilization Management** + Performs review of anticipated admissions… more
- Cambridge Health Alliance (Cambridge, MA)
- …Center **Work Days:** Generally Mon-Fri days 8-4:30 and one evening/wk **Category:** Registered Nurse **Department:** Office Based Opioid Grant **Job Type:** ... OBOT RN Case Manager **Date Posted:** 01/16/2025 **Requisition Number:**...a business card. * Integrates the discharge planning/coordination and utilization review functions in the case management… 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
- 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
- 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 ... managers are involved. . Assist in the tracking and review of payer audit and denial results. Prepare appeal...Registration . Applicable clinical or professional certifications/licenses such as RN , LPN, CPC, RT, MT, RPH are highly desirable.… 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 ... regulations. The role will also be responsible for timely review and research, as necessary on all new and...applicable)), an OIG Report and verification of a valid MA/ RN license (if applicable). Commonwealth Care Alliance is an… more
- Highmark Health (Boston, MA)
- …Sunday required in addition to 3 weekdays** This job implements effective utilization management strategies including: review of appropriateness of health care ... services, application of criteria to ensure appropriate resource utilization , identification of opportunities for referral to a Health Coach/case management, and… more
- Brockton Hospital (Brockton, MA)
- …preferred. Must have current license from Commonwealth of Massachusetts to practice as a Registered Nurse . Minimum of five years clinical experience in an acute ... care facility required. Prior experience in case management, utilization review or discharge planning required. more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …Bring : + Behavioral Health professional with an active independent Massachusetts license: Registered Nurse , LICSW, LMHC, BCBA + 3-5 years of clinical experience ... transform healthcare? Bring your true colors to blue. The Role The Clinical Utilization Reviewer is responsible for facilitating care for members who may have… more
- Intermountain Health (Boston, MA)
- …REGISTRATION, LICENSE (*indicates primary source verification requirement) Required: + Active Registered Nurse License Preferred: + Certified Healthcare Access ... **Job Description:** The Pre-Access Prior Authorization RN provides timely review of authorization...Associate (CHAA) EXPERIENCE Required: + Licensed Registered Nurse + Minimum of 2 years'… more
- Guardian Life (Boston, MA)
- **Position Summary** The RN Clinical Consultant serves as a clinical resource for the investigation and assessment of medical information regarding disability by ... medical reviews and analysis of long-term disability claims. The RN Clinical Consultant identifies restrictions, limitations and duration impacting functional… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …to create, follow and appropriately document comprehensive care management plans. + Review medication list and educate members with complex pharmacy needs, and ... care settings (Inpatient, outpatient, or differing levels of care). + Utilization Management experience, preferred + Active licensure in Massachusetts is required,… 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)
- …for the overall operation of care transitions discharge planning and/or utilization management departments through oversight of daily and long-term activities at ... **Job Description:** **PLANNING:** Plans department's clinical services and operations including review of tracking and trending data to assess need for performance… more
- Tufts Medicine (Quincy, MA)
- …Support duties: Provides basic care services to patients, but does not have an RN or LPN license. Positions in this nursing support work under the direction of ... physicians, mid-level practitioners, and may work under the direction of registered nurses depending on their unit. A clinical technologist role that has specialized… more
- Commonwealth Care Alliance (Boston, MA)
- …administrative delays; that clients are invested in their constituents' adoption and utilization and share performance targets; and that instED has the widest window ... for the department based on the organization's strategic goals. Responsible to review and improve existing sales incentive plans to ensure alignment with sales… more