- 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
- Point32Health (MA)
- …utmost importance. **Key** **Responsibilities/Duties** **- what you will be doing** + ** Utilization Management** + Performs clinical review of prospective, ... Summary** In this part-time role, the Behavioral Health Psychologist Reviewer will primarily perform utilization management and...line for peer-to-peer discussions. + Performs clinical review of expedited and standard appeals for… 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
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …of the Senior Medical Director of the Physician Review Unit (PRU), the reviewer also provides clinical leadership in other areas of BCBSMA. The physician ... reviewer is responsible for evaluating pre & post-service clinical service requests made by BCBSMA members and providers....Active clinical practice in order to process appeals + Experience in Utilization Management in… more
- Blue Cross Blue Shield of Massachusetts (Boston, MA)
- …the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer also provides clinical leadership in other areas of BCBSMA. The ... healthcare? Bring your true colors to blue. The Physician Reviewer is responsible for evaluating clinical service...clinical practice in order to participate in panel appeals + Experience in Utilization Management in… 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
- Centene Corporation (Jefferson City, MO)
- …of all appeals requests + Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry ... benefits including a fresh perspective on workplace flexibility. **Position Purpose:** Performs clinical reviews needed to resolve and process appeals by… 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
- CareFirst (Baltimore, MD)
- …This position will support the government programs line of business. The Clinical Appeals Nurse completes research, basic analysis, and evaluation of ... provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical ...**Preferred Qualifications** : + 2 years experience in Medical Review , Utilization Management or Case Management at… more
- Molina Healthcare (Columbus, OH)
- **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within ... compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical /medical reviews of...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
- Centene Corporation (Austin, TX)
- …role. Candidate must posses a compact nursing license. _** Position Purpose: Performs clinical reviews needed to resolve and process appeals by reviewing medical ... the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified,… more
- Healthfirst (NY)
- … 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
- Elevance Health (Richmond, VA)
- …+ Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information. + ... **Title: Grievance/ Appeals Analyst I** **Location:** This position will work...HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of… more
- CVS Health (Salem, OR)
- …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
- US Tech Solutions (Columbia, SC)
- …care issues. **Experience:** + 2 years clinical experience plus 1 year utilization /medical review , quality assurance, or home health, OR, 3 years clinical ... requests including pre-pay and post-payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested… more
- UCLA Health (Los Angeles, CA)
- …or Medicare Advantage setting is highly desired * Experience in handling appeals , grievances, utilization management, or potential quality issues * Knowledge ... Description As the Appeals & Grievances Nurse, you will play a...grievances. You will: + Ensuring timely, accurate, and thorough review of member and provider complaints, working closely with… more