- UPMC (Pittsburgh, PA)
- …and full remote role._ Responsibilities: + Actively participates in the daily utilization management and quality improvement review processes, including ... MD or DO for a fully remote Medical Director, Utilization Management role. The Medical Director, ...and potential quality of care concerns. + Provide expedited review and determination of medically pressing issues in accordance… more
- CVS Health (Harrisburg, PA)
- …experience in a hospital setting required for either BH or RN -1+ years of utilization review / utilization management required (ie concurrent review , ... clinical skills to coordinate, document and communicate all aspects of the utilization /benefit management program. Applies critical thinking and is knowledgeable… more
- Humana (Harrisburg, PA)
- …MDS Coordinator or discharge planner in an acute care setting + Previous experience in utilization management / utilization review for a health plan or ... of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination,… more
- CenterWell (Harrisburg, PA)
- …RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability ... Therapy, DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare… more
- Wellpath (Lemoyne, PA)
- …care support. **How you make a difference** The Medical Director of Utilization Management leads and oversees utilization review , case management , ... appropriate utilization of medical services. The Medical Director of Utilization Management serves as a key liaison with external partners and stakeholders,… more
- Centene Corporation (Harrisburg, PA)
- …IS REMOTE/WORK FROM HOME SUPPORTING PENNSYLVANIA HEALTH & WELLNESS BEHAVIORAL HEALTH UTILIZATION MANAGEMENT .** **APPLICANTS MUST EITHER HOLD AN ACTIVE PA ... and substance abuse preferred. Knowledge of mental health and substance abuse utilization review process preferred. Experience working with providers and… more
- Prime Healthcare (Philadelphia, PA)
- … utilization review and appeals process as part of the denial management initiatives. Utilization review tech is responsible for coordinating phone ... Organizations, the nation's oldest and largest hospital accreditation agency. Responsibilities The Utilization review tech essentially works to coordinate the… more
- Guthrie (Sayre, PA)
- …experience: five (5) years of experience in an acute care setting with strong care management , utilization review , and payer knowledge. A Case Management ... for alternate levels of care. The Acute Case Manager also performs Utilization Management throughout the continuum of care in collaboration with other internal… more
- Evolent (Harrisburg, PA)
- …Reviewer , Interventional Pain Management , you will be a key member of the utilization management team. We can offer you a meaningful way to make a ... Will Be Doing:** + Serve as the Physician Clinical Reviewer for Interventional Pain Management , reviewing cases... and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National… more
- Humana (Harrisburg, PA)
- …. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial ... their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- WellSpan Health (Chambersburg, PA)
- …+ Thoroughly and accurately documents actions/communication surrounding discharge planning and/or utilization management in the medical record. + (BHU Only) ... Skills (CPI certification) + (BHU Only) Effectively represents BHU on the hospital Utilization Management Committee + (Inpatient Rehab only) Assess patients for… more
- Penn Medicine (Philadelphia, PA)
- …a physician serving the hospital through teaching, consulting, and advising the care management and utilization review departments and the hospital ... documentation and payer requirements. * Facilitate, mentor, and educate case management on the utilization review process where appropriate * Chair, or… more
- Highmark Health (Harrisburg, PA)
- …:** **JOB SUMMARY** This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and ... and DOL regulations at all times. In addition to utilization review , the incumbent participates as the...member of the multidisciplinary team for case and disease management . They will advise the multidisciplinary team on cases,… more
- Centene Corporation (Harrisburg, PA)
- …certified in Family Medicine or Internal Medicine or Emergency Medicine + Utilization Management experience and knowledge of quality accreditation standards ... functions for the business unit. + Provides medical leadership of all for utilization management , cost containment, and medical quality improvement activities. +… more
- Evolent (Harrisburg, PA)
- …the mission. Stay for the culture. **What You'll Be Doing:** **Cardiovascular Utilization Management Reviewer (Interventional Cardiologist)** Are you ready ... on patient care in a non-clinical setting? Join our Utilization Management team as a Field Medical... and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National… more
- UPMC (Pittsburgh, PA)
- …of medical management best practices. + Actively participates in the utilization management and quality improvement review processes, including ... policies of the Health Plan. Contributes to process improvement within the Utilization Management department. + Participates in activities to support policy… more
- The Cigna Group (Philadelphia, PA)
- …data, systems, and applications for claims payment, enrollment, benefit design, and utilization management . + Familiarity with data mining and reporting tools, ... **Provider Data Management Analyst** Are you ready to make a...assigned markets, ensuring accuracy and compliance. + Lead monthly review sessions with the contracting team to ensure the… more
- Evolent (Harrisburg, PA)
- …Doing:** As a Cardiology, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
- Evolent (Harrisburg, PA)
- …As a Vascular Surgery, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
- RxBenefits (Philadelphia, PA)
- …channel management , B/G classifications, specialty designations, rebate eligibility, utilization trend, Utilization Management (UM) implications, ... prospect member size, marketing agreements, broker commissions, and drug utilization . + Be the SME on dozens of medical...closed won groups into a client record for Account Management (AM) and Implementation including the initial gathering of… more