- Evolent (Springfield, IL)
- …Evolent for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- Cardinal Health (Springfield, IL)
- …both scheduled outbound calls and inbound call queue. + Meets regularly with Clinical Supervisor and/or Senior Nurse , Individualized Care to discuss feedback ... who need them-faster.** **_What Individualized Care contributes to Cardinal Health_** Clinical Operations is responsible for providing clinical specialties… more
- Oracle (Springfield, IL)
- …+ Excellent communication, stakeholder engagement, and leadership skills. **Preferred Qualifications:** + Clinical experience as a nurse or physician with a deep ... **Job Description** The Clinical Note AI Agent Product Management Leader will...Gather and analyze information to define product specifications and review design specifications. Envision and communicate product strategy and… more
- Humana (Springfield, IL)
- **Become a part of our caring community and help us put health first** The Appeals Nurse 2 resolves clinical complaints and appeals. The Appeals Nurse 2 work ... and independent determination of the appropriate courses of action. The Appeals Nurse 2 reviews documentation and interprets data obtained from clinical … more
- Humana (Springfield, IL)
- …a part of our caring community and help us put health first** The Nurse Auditor 2 performs clinical audit/validation processes to ensure that medical record ... complete, compliant and accurate to support optimal reimbursement. The Nurse Auditor 2 work assignments are varied and frequently... clinical and coding experience to conduct a clinical validation review of the inpatient medical… more
- CenterWell (Springfield, IL)
- …regarding Home Health, Hospice, and Palliative Care Services. + Assist with clinical eligibility review for alternate services + Participates in special ... **Become a part of our caring community and help us put health first** Clinical call center. High volume. Fast paced. **Shift details:** + **Full time 40 hours a… more
- Highmark Health (Springfield, IL)
- …:** Allegheny Health Network **Job Description :** **GENERAL OVERVIEW:** This job performs clinical review and data abstraction of patient records to support ... compliance with nationally recognized quality initiatives and the network's clinical process improvement and patient safety initiatives. The incumbent requires… more
- Datavant (Springfield, IL)
- …realize our bold vision for healthcare. **What We're Looking For:** As a Clinical Documentation Quality Improvement (CDQI) Specialist, you will play a pivotal role ... Collaborate with physicians and caregivers to ensure appropriate reimbursement and clinical severity for DRG-based payer patients. + Demonstrate understanding of… more
- CenterWell (Springfield, IL)
- …actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that ... Compact Nursing License + A minimum of three years clinical RN experience; + Prior clinical experience,...three years clinical RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience… more
- Fujifilm (Springfield, IL)
- **Position Overview** The Clinical Consultant, MI - I shall be responsible for providing clinical consulting for the project, report configuration (CV), workflow ... go-live support to Synapse PACS/MI projects. In addition, provide clinical support for sales and company team members with...in: + MPI + MUGA + PET + (CV)Registered Nurse Cardiac experience in: + Cath, Peripheral Angiography, Electrophysiology… more
- Fresenius Medical Center (Springfield, IL)
- …effective dialysis therapy for patients under the direct supervision of a licensed nurse in accordance with FMCNA policies procedures and training and in compliance ... last treatment. Report any complaints or observations to the nurse supervisor. + Evaluate vascular access for patency and...activities. + Enters all treatment data into the designated clinical application accurately and in a timely manner. +… more
- Datavant (Springfield, IL)
- …Prevention Specialist is to effectively defend utilization of available health services, review of admissions for medical necessity and necessity of continued stay ... recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully. Ideal candidate should be a Licensed… more
- Fresenius Medical Center (Springfield, IL)
- …dialysis therapy for patients under the direct supervision of a licensed nurse in accordance with organization policies, procedures, and training and in compliance ... and/or change in patient condition directly to the registered nurse or supervisor. + Observe patient and conduct machine...activities. + Enters all treatment data into the designated clinical application in an accurate and timely manner. +… more
- Oracle (Springfield, IL)
- …(ECD) alignments, Critical Care workflow implementation, Multi-Disciplinary Rounding, and various nurse chart review and documentation optimizations. The ideal ... of analysts providing support for operationally required changes and enhancements to clinical applications, and aa group of analysts leading projects that will… more
- CenterWell (Springfield, IL)
- …in care, ensuring timeless access to important medications and solving urgent clinical needs. This Virtual Physician Collaborator shares in our vision to innovate ... in care, ensuring timeless access to important medications and solving urgent clinical needs. This Virtual Physician Collaborator shares in our vision to innovate… more
- Highmark Health (Springfield, IL)
- …of the claim rejection and the proper action to complete the retrospective claim review with the goal of proper and timely payment to provider and member ... Payment Integrity strategies on a pre-payment and retrospective claims review basis. Review process includes a ...- 5 years of related, progressive experience in a clinical setting **Preferred** + 1-3 years of experience in… more
- Veterans Affairs, Veterans Health Administration (Springfield, IL)
- …These operations are carried out with assistance from staff members from other clinical and support services that are supervised by their clinical service ... adequate and comprehensive services and communicates these to staff physicians, nurse practitioners, physician assistants and other members of Ambulator Care.… more
- Highmark Health (Springfield, IL)
- …**JOB SUMMARY** This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria ... interventions and/or alternatives. **ESSENTIAL RESPONSIBILITIES** + Implement care management review processes that are consistent with established industry and… more
- CVS Health (Springfield, IL)
- …as appropriate, utilizes internal tools to determine required steps to ensure proper review based on clinical requirements as well as established plan ... care service delivery as required based on outcomes/reviews noted by the nurse or medical director** **Performs non-medical research pertinent to the establishment,… more
- CVS Health (Springfield, IL)
- …referrals. + Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management. Performs review of member claim history to ... with contract. + Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target… more