- Beth Israel Lahey Health (Plymouth, MA)
- …a job, you're making a difference in people's lives.** Full Time **Job Description:** ** Utilization Review & Denials management manager - Full Time** **Who We ... Our Team of Experts and Serve Your Community!** **In your role as a Utilization Review & Denials Management Manager, you will:** + Directs staff performance… more
- Children's Hospital Boston (Boston, MA)
- …Hours per Week:40 Job Posting Category:NursingJob Posting Description:The Utilization Review Nurse will be ... with established procedures, guidelines and criteria + Focusing on high priority utilization review activity including: conducting emergency admission level of… 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
- Evolent (Providence, RI)
- …+ Performs other duties as assigned. **Qualifications: Required and Preferred:** + Licensed registered nurse or LVN/LPN (current and unrestricted) + Minimum of ... direct clinical patient care + **Minimum one year of experience with Utilization Review (UM) in a managed care environment** + Cardiology and Oncology Healthcare… 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
- Highmark Health (Providence, RI)
- …+ Experience in UM/CM/QA/Managed Care **LICENSES or CERTIFICATIONS** **Required** + United States Registered Nurse ( RN ) license + Delaware RN ... Health **Job Description :** **JOB SUMMARY** This job implements effective utilization management strategies including: review of appropriateness of health… 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 (Providence, RI)
- …Inc. **Job Description :** **JOB SUMMARY** 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,… 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
- 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
- Humana (Providence, RI)
- …**Required Qualifications:** **Must meet** **one** **of the following:** + Active unrestricted registered nurse license in the state of Virginia or reside ... case manager required. **Additional Information:** **Workstyle:** Remote work at Home **Location for Registered Nurse :** must reside in the state of Virginia or… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …products and benefits, as well as regulatory and NCQA requirements. + Refer to RN or PT Clinical Utilization reviewer for more complex cases as appropriate ... Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and… more
- Beth Israel Lahey Health (Plymouth, MA)
- …using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal clinical denials related to the care provided to ... job that may reasonably be required._ **Education/Experience Required:** + Current MA RN licensure + Bachelor's Degree in Nursing or advanced degree in healthcare… more
- Sedgwick (Providence, RI)
- …to work. Great Place to Work(R) Most Loved Workplace(R) Forbes Best-in-State Employer RN Medicare Compliance **We are growing and looking for nurses who have their ... clinical data; to complete complex submissions revisions/updates in preparation for Medicare review and act as an internal resource regarding Centers for Medicare &… more
- Tufts Medicine (Boston, MA)
- …**Job Description** **Minimum Qualifications** **:** 1. Master's degree in Nursing (MSN). 2. Registered Nurse ( RN ) license. 3. Advanced Practice ... **Job Overview** This position is responsible for the direction of Nurse Practitioners, including arrangement of schedules, staffing during vacations, direction of… more
- State of Massachusetts (Wrentham, MA)
- …have at least (A) four years of full-time or equivalent part-time experience as a registered nurse in a recognized hospital, clinic, or medical facility and (B) ... from an approved school of nursing must have applied for the first available registered nurse examination. Based on assignment, possession of a current and valid… more
- Commonwealth Care Alliance (Boston, MA)
- …skills to improve CCA enrollee outcomes by impacting care access and utilization , closing care quality gaps, and optimizing member connection to medical, behavioral ... role in reducing high emergency department (ED) and inpatient utilization related to unmet social needs, including housing, food,...manner; promote and enforce the CCA compliance program + Review the Code of Conduct at least annually and… more
- Dana-Farber Cancer Institute (Boston, MA)
- …protocol under which the patient is treated. In conjunction with RN transplant coordinators, Cell Therapy Coordinators provide extensive direction to patients, ... the assigned patient population to achieve patient safety, flow and the resource utilization goals of the organization + Responsible for ensuring filing or reporting… 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