- Medical Mutual of Ohio (OH)
- …Nursing Board. Bachelor's degree preferred. + 3 years as a Registered Nurse with a combination of clinical and or utilization/case management experience, preferably ... care in Medical/Surgical/Critical Care/ ambulatory care experience preferred. + Registered Nurse with current State of Ohio unrestricted license. + Intermediate… more
- Blue Cross and Blue Shield of Louisiana (Baton Rouge, LA)
- …responsible for completing the Medical Policy activities outlined in BCBSLA's Medicare Advantage Medical Policy Development Policies & Procedures locating, tracking ... heavy workloads accurately. **Licenses and Certifications** + Health Services\RN - Registered Nurse - State Licensure And/or Compact State Licensure to practice in… more
- Elevance Health (South Portland, ME)
- **Clinical Review Nurse I - Medicare Part A** National Government Services is a proud member of Elevance Health's family of brands. We administer government ... pm EST or CST. Hours are flexible.** The **Clinical Review Nurse I** is responsible for reviewing...experience is a plus. + Prior experience with claim review of Medicare helpful. + CMS (Centers… more
- LA Care Health Plan (Los Angeles, CA)
- Utilization Management Clinical Quality Nurse Reviewer RN II Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 ... required to achieve that purpose. Job Summary The Utilization Management Clinical Quality Nurse Reviewer RN II, under the purview the Utilization Management (UM)… more
- Zelis (Morristown, NJ)
- Position Overview: The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical ... billing and coding rules, plan policy exclusions, and payment errors/overpayments. Conduct review of facility and outpatient bills as it compares with medical… more
- Commonwealth Care Alliance (Boston, MA)
- …clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA ... procedures, and facilities under the provisions of CCA's benefits plan. The Nurse Utilization Management (UM) Reviewer is responsible for day-to-day timely… more
- CDS Life Transitions (Webster, NY)
- Summary: Utilization Management Reviewer (UR) is the critical evaluation of health care services provided to members using an integrated approach to determine the ... costs and monitoring quality of care. The Utilization Management Reviewer will play a key role in conducting these...and medical necessity of those services + Compile and review the necessary documents and clinical records to effectively… more
- Centers Plan for Healthy Living (Margate, FL)
- …For Healthy Living is currently accepting applications for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer works ... UM Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063,...to enroll eligible individuals who are either Medicaid or Medicaid/ Medicare recipients and optimize their ability to remain in… more
- Zelis (TX)
- Position Overview: The Inpatient DRG Reviewer will be primarily responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG reviews ... AHA Coding Clinic and client specific coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest savings for… more
- Molina Healthcare (Long Beach, CA)
- …the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the ... medical director, and quality improvement staff. + Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements. + Reviews quality referred… more
- The Cigna Group (Bloomfield, CT)
- …effective and sufficient support of all Utilization Management activities to include review of inpatient and outpatient medical services for medical necessity and ... Medical Directors when services do not meet criteria or require additional review . + Participation in staff meetings, regular trainings and other collaborative… more
- State of Connecticut, Department of Administrative Services (Middletown, CT)
- Utilization Review Nurse Coordinator (40 Hour) Office/On-site Recruitment # 240830-5613FP-001 Location Middletown, CT Date Opened 9/5/2024 12:00:00 AM Salary ... - is accepting applications for one (1) full-time Utilization Review Nurse Coordinator (https://www.jobapscloud.com/CT/specs/classspecdisplay.asp?ClassNumber=5613FP&R1=&R3=) position, in Middletown,… more
- InnovaCare (San Juan, PR)
- …to the business. MMM Holdings, Inc.Job Description Inpatient Unit POSITION: Concurrent Review Nurse (CRN) POSITION DESCRIPTION Manages the inpatient utilization ... visits to Acute, SNF, and Rehabilitation Inpatient facilities to concurrently review admissions and continued stay to determine appropriate Utilization, Quality… more
- The County of Los Angeles (Los Angeles, CA)
- UTILIZATION REVIEW NURSE SUPERVISOR II Print (https://www.governmentjobs.com/careers/lacounty/jobs/newprint/2784979) Apply UTILIZATION REVIEW NURSE ... administrative and technical supervision over the nursing staff engaged in utilization review activities at Los Angeles General Medical Center, one of the largest… more
- US Tech Solutions (Chicago, IL)
- …experience with Utilization Review ? + Do you have an Active Registered Nurse License? **About US Tech Solutions:** US Tech Solutions is a global staff ... clinical policy, regulatory and accreditation guidelines. + Responsible for the review and evaluation of clinical information and documentation. + Reviews… more
- Hackensack Meridian Health (Hackensack, NJ)
- **Overview** **The Hackensack University Medical Center Night Shift RRT Nurse Practitioner or Physician Assistant performs the role utilizing the patient-centered ... practice. 5. Participates in APRN interviewing, credentialing, and peer review process as requested. 6. Participates in a minimum...staff leaders to support nursing-led protocols to enhance the nurse 's ability to function at their highest level of… more
- Molina Healthcare (Long Beach, CA)
- **Job Description** **Job Summary** The Clinical Correspondence Review Nurse is responsible for performing quality reviews of written clinical determination ... regulatory guidelines or requirements, and NCQA accreditation standards, for assigned Medicare , Medicaid or Marketplace programs. **We are seeking a candidate with… more
- US Tech Solutions (May, OK)
- …clinical policy, regulatory and accreditation guidelines. . Responsible for the review and evaluation of clinical information and documentation. . Reviews ... Care cases across all lines of business (Commercial and Medicare ). . Independently coordinates the clinical resolution with internal/external.... 1+ years of inpatient hospital experience . Registered Nurse in state of residence . Must have prior… more
- Actalent (St. Louis, MO)
- Clinical Review Nurse - Concurrent Review (**Remote**) 100% REMOTE, MONDAY - FRIDAY 8-5 (regardless of timezone) Job Description Acute Care Utilization ... Management Nurse . You will virtually manage facilities for acute care...Surgical) + Utilization Management, Utilization Review , Concurrent Review + Knowledge of Medicare and Medicaid… more
- State of Maine, Bureau of Human Resources (ME)
- MaineCare Quality Review Nurse Maine, USA | Nursing | Full-time Apply by: Sept. 20, 2024 Apply with Linkedin Apply Department of Health and Human Services ... yes and you are licensed as a Registered Professional Nurse in the State of Maine as issued by...this position, please contact Sue Pinette, Asst. Director, Division Medicaid/ Medicare Services at ### or by e-mail at ###@maine.gov.… more