- Commonwealth Care Alliance (Boston, MA)
- …timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role ... Utilization Management , the Nurse Utilization Management (UM) Reviewer is...**Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior authorization in a variety… more
- Commonwealth Care Alliance (Boston, MA)
- …member experience. - Address provider inquiries related to care coordination, utilization management , and program participation, collaborating with internal ... does not have direct reports. Essential Duties & Responsibilities: Provider Relationship Management - Serve as the primary relationship manager and point of contact… more
- Parexel (Boston, MA)
- …mitigations and drive resolution with cross-functional stakeholders as part of the Risk Management Plan. + Review and analyze metrics to derive meaningful ... practices like version control and literate programming. + BSN, RN , RPh, Pharm D, PA, MPH, or other applicable...project-level resourcing of staff and staff assignments. + Regularly review and update Data Management resources to… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- Ready to help us transform healthcare? Bring your true colors to blue. The RoleThe RN Utilization Management Reviewer is responsible for facilitating ... benefit to provide the best quality care. The TeamThe RN Utilization Management Reviewer...+ Licensure in additional states a plus. + For registered nurses only: a bachelor's degree in (BSN) preferred.… more
- CenterWell (Boston, MA)
- … RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to ... put health first** Conviva Care Solutions is seeking a RN who will collaborate with other health care givers...DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous… more
- Elevance Health (Woburn, MA)
- ** Nurse Reviewer I** **Virtual:** This role...hospital setting or minimum of 1 year of prior utilization management , medical management and/or ... time,** **with rotating weekends.** **New Grads are encouraged to apply!** The ** Nurse Reviewer I** will be responsible for conducting preauthorization, out… more
- Beth Israel Lahey Health (Cambridge, MA)
- …SKILLS, AND ABILITIES REQUIRED** 1. RN with experience in risk management , quality assessment, or utilization management . 2. Strong spreadsheet, ... on the key performance indicators and quality measures, the RN specialist also aims to foster a culture of...reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review … more
- Beth Israel Lahey Health (Burlington, MA)
- …the medical necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue integrity, these specialized ... Analyst works with physicians, the payers and inpatient case management team to validate the medical necessity of the...necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …true colors to blue. The Role:The Compliance Program Consultant will focus on utilization management compliance and audit readiness activities such as evaluating ... Medical Management 's (HMM) and delegate's compliance with the applicable NCQA utilization management standards and state and federal regulations. The Team:… more
- Massachusetts Institute of Technology (Cambridge, MA)
- …patients, families, providers, and community agencies. PREFERRED: two years of case management , utilization review , and discharge planning experience. ... Registered Nurse , Care Coordinator + Job... Registered Nurse , Care Coordinator + Job Number: 25320 +...Graduate of an accredited nursing program; bachelor's degree; current RN license in Massachusetts; CPR Certified; a minimum of… more
- Beth Israel Lahey Health (Burlington, MA)
- …**Essential Duties & Responsibilities including but not limited to:** 1) Performs utilization review and discharge planning to inpatient admissions. 2) Applies ... to meet the needs of the department. **Minimum Qualifications:** Education: * Registered Nurse , Bachelors Degree or commensurate experience preferred. Licensure,… more
- Tufts Medicine (Melrose, MA)
- …role is essential in developing and maintaining an infrastructure for the systematic review and management of complex patients. The position will work closely ... managers, TMIN Practice Optimization Coaches (POMs) and primary care providers to review patient records, analyze data, and identify practice and patient outlier … more
- Lawrence General Hospital (Methuen, MA)
- … experience in an acute care setting with discharge planning, continuing care, care management , and utilization review preferred. ? Strong verbal and written ... Job Description: The RN Care Coordinator is responsible for overseeing the...of the Hospital on a rotating basis to perform utilization reviews and other UM activities, as needed, to… more
- Fresenius Medical Center (Lowell, MA)
- …and acts as the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member eligibility. Facilitate timely ... workup of patients for access management , dialysis services, patient education, hospitalizations, and kidney transplantation as appropriate, and ensures coordination… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …and 3-5 years in a managed care health plan setting. + Strong understanding of Utilization Review , Care Management and Medical Polices. + Knowledge of APR ... concerns Key Qualifications + Strong clinical skills and understanding of HMM's Utilization Management , Case Management and operational procedures, Medical… more
- Fresenius Medical Center (Peabody, MA)
- …auditing activities. + Accountable for completion of the Annual Standing Order Review and Internal Classification of Disease (ICD) coding. + Manages clinic ... financials including efficient utilization of supplies or equipment and regular profits and...of supplies or equipment and regular profits and loss review . + Responsible for all required network reporting and… more
- Lawrence General Hospital (Methuen, MA)
- … experience in an acute care setting with discharge planning, continuing care, care management , and utilization review preferred. + Strong verbal and written ... below the top of the range to support future salary growth. The RN Care Manager collaborates with physicians, nurses, and other clinical staff/directors to… more
- Beth Israel Lahey Health (Needham, MA)
- …practice model. **Job Description:** **Essential Responsibilities:** 1. Performs utilization management , care coordination, and discharge planning ... third weekend & rotating holiday required) Job Summary: The RN Case Manager (CM) facilitates the coordination of care.... 4. Knowledge of discharge planning practices, understanding of utilization review practices including third party payer… more
- Commonwealth Care Alliance (Boston, MA)
- …member experience. * Address provider inquiries related to care coordination, utilization management , and program participation, collaborating with internal ... does not have direct reports. Essential Duties & Responsibilities: Provider Relationship Management * Serve as the primary relationship manager and point of contact… more
- Evolent (Boston, MA)
- …the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
