- Catholic Health Services (Melville, NY)
- …ensure timely follow through. | Reviews providers' requests for services and coordinates utilization / appeals management review . | Assist Utilization and ... Health was named Long Island's Top Workplace! Job Details Position Summary: The Utilization and Appeals Coordinator will perform activities to help facilitate … more
- Catholic Health Services (Melville, NY)
- …Long Island's Top Workplace! Job Details Position Summary: The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews and appeals ... from payors for additional clinical documentation. Acts as liaison between the Utilization and Appeals Management Department and the physician of record, as… more
- Catholic Health Services (Melville, NY)
- …Long Island's Top Workplace! Job Details Position Summary: The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews and appeals ... from payors for additional clinical documentation. |Acts as liaison between the Utilization and Appeals Management Department and the physician of record, as… more
- WMCHealth (Valhalla, NY)
- …implementation or investigation of the procedures specified in the Quality Management, Utilization Review and Discharge Planning Program at Westchester Medical ... Asst Utilization Coordinator - Appeals Company: Westchester...of which must have been in the area of utilization review , quality assurance, risk management or… more
- Apex Health Solutions (Houston, TX)
- …a contact and resource person to Health Solutions' members for the utilization review (UR) of healthcare services. The UM Reviewer will be responsible for ... complying with utilization review procedures in accordance with Texas UR Certification requirements, as well as carrying out day today pre-authorization… more
- CareFirst (Baltimore, MD)
- …or similar clinical experience OR 5 years' experience in Medical Review , Utilization Management or Case Management at CareFirst BlueCross BlueShield, or ... **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor directs and coordinates...appeals and reconsiderations, including Regulatory complaints and External review requests. Accountable for quality review and… more
- Corewell Health (Grand Rapids, MI)
- …medicine, and lower per-capita costs; participate in the development of clinical utilization guidelines, health management programs and clinical ... quality programs. + Provide clinical oversight to utilization management. Qualifications Required + Bachelor's Degree + 3 years of relevant experience in … more
- Molina Healthcare (Columbus, OH)
- …every 4 weeks Monday-Thursday and Wed - Saturday._** **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct ... appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical...the specific programs supported by the plan such as Utilization Review , Medical Claims Review ,… more
- VNS Health (Manhattan, NY)
- …and appeals or related area such as medical or utilization management required + Proficient verbal/written communication skills required + Proficient computer ... OverviewResolves grievances, appeals and external reviews for one of the...of the plan's fiduciary responsibilities. Prepares records for physician review as needed. + Conducts review of… more
- CDPHP (Albany, NY)
- …requirements. Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render ... you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering... experience required. + Minimum one (1) year of quality/ utilization review experience required. + Experience with… more
- ManpowerGroup (Columbia, SC)
- …communicate with members and healthcare providers. **Key Responsibilities** ✔ **Medical Review & Utilization Management (80%)** + Perform medical reviews ... + Review interdepartmental requests for medical information to support utilization processes. + Conduct high-dollar forecasting and patient health summaries. +… more
- Healthfirst (AL)
- … practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management. + Demonstrated ... Responsibilities: + Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical...understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual,… more
- VNS Health (Manhattan, NY)
- …You Will Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. ... quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of...Appeals or related area such as medical or utilization management in a Managed Care setting required +… more
- ManpowerGroup (Columbia, SC)
- …to join their team. As an Analyst, Appeals , you will be part of the clinical review department supporting the appeals team. The ideal candidate will have ... School of Nursing. + 2 years clinical experience plus 1 year in utilization /medical review , quality assurance, or home health. + An active, unrestricted RN… more
- CVS Health (Providence, RI)
- …the Quality Review nurses. * IRE monitoring and tracking and Utilization Management Strategy support. * Develop subject matter expertise on Medicare policy for ... the enterprise. * Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management staff. * Participate… more
- Healthfirst (NY)
- …previous work experience such as medical records review ; claims processing; utilization /case management in a clinical practice or managed care organization; ... and improve processes and performance to ensure quality. + Review and investigate appeals and grievances requests...evaluate the quality and effectiveness of case management and/or utilization review decision-making + Additional duties as… more
- CVS Health (Columbus, OH)
- …eg, Clinical Practice and Health Care Industry. *Prior UM ( Utilization Management) experience *Active and current state medical license without encumbrances ... system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. **This is a… more
- Hackensack Meridian Health (Hackensack, NJ)
- …patient population and Hackensack UMC. These include but are not limited to utilization review , hospital reimbursement, clinical compliance, case management, ... **Overview** The Senior Utilization Review Specialist collaborates with the...clinical denials by: I. Peer-to Peer (P2P) Concurrent appeals ii. Written Concurrent appeals iii. Recovery… more
- Premera Blue Cross (Mountlake Terrace, WA)
- …Services (CMS) and other sources. + Liaise with Utilization Management and Clinical Appeals Departments to regularly review data from same specialty ... utilization management (UM) to promote usability. The MP Clinical Specialist monitors and updates policies associated with programs...of the following: pre-service review , post services review , and/or clinical appeals . (Required)… more
- Hackensack Meridian Health (Hackensack, NJ)
- …Hackensack University Medical Center. These include but are not limited to utilization review , hospital reimbursement, clinical compliance, case management, ... **Overview** The Utilization Review Physician collaborates with the...direction and support regarding CMS & NJDOH regulations governing Utilization Management & Clinical documentation. b. Oversight… more