- Medical Mutual of Ohio (OH)
- …Advantage, Medicare Supplement, and individual plans. Under limited supervision, the Medicare Nurse Reviewer applies medical necessity guidelines in ... for applicants that have a strong clinical utilization management background. Medicare experience is a plus. **Responsibilities** + Evaluates clinical information… 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
- Chenega Corporation (NM)
- …Services** ' company, is looking for a fully remote **Clinical Quality Reviewer ** to ensure compliance with the contract, and program requirements for Clinical ... national, TRICARE, and URAC standards for consistency. Supports activities of peer review and quality and safety committees. Our company offers employees the… more
- MetroHealth (Cleveland, OH)
- …of additional comorbid conditions. Conducts concurrent and retrospective medical record review on defined patient populations to identify opportunities to improve ... minimum of 3 years of CDI experience or; - CDI Second Level Reviewer with a strong understanding of disease processes, clinical indications and treatments, provider… more
- Medical Mutual of Ohio (OH)
- …insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans. **Under general ... supervision,** **performs administrative functions in support of assigned utilization review or case management department. Receives and reviews correspondence from… 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
- The Cigna Group (Bloomfield, CT)
- This position, the Nurse Case Manager Senior Analyst, through the case management process, will promote the improvement of health outcomes to members and assist ... for the transplant members assigned to their caseload. This will require review of clinical information and correspondence with facilities to make determinations on… more
- State of Connecticut, Department of Administrative Services (East Hartford, CT)
- Utilization Review Nurse Coordinator (40 Hour) Office/On-site Recruitment # 241106-5613FP-001 Location East Hartford, CT Date Opened 11/7/2024 12:00:00 AM Salary ... - is accepting applications for a full-time Utilization Review Nurse Coordinator (https://www.jobapscloud.com/CT/specs/classspecdisplay.asp?ClassNumber=5613FP&R1=&R3=) position, located… 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
- Hackensack Meridian Health (Little Falls, NJ)
- …for coding, OASIS and Hospice, and other clinical assessment tools as needed. + Review every Medicare and Managed Medicare admission chart to determine ... in the system if inappropriate codes are identified. + Review each Hospice assessment to assure each CTI, 485...of the certified operation, Hospice Clinical Director, and the Nurse Manager for the appropriate operation. Demonstrates the ability… more
- Hackensack Meridian Health (Brick, NJ)
- …for coding, OASIS and Hospice, and other clinical assessment tools as needed. + Review every Medicare and Managed Medicare admission chart to determine ... in the system if inappropriate codes are identified. + Review each Hospice assessment to assure each CTI, 485...of the certified operation, Hospice Clinical Director, and the Nurse Manager for the appropriate operation. Demonstrates the ability… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The role of the Quality Review Nurse (RN) is to evaluate clinical quality and procedures within the Clinical Appeals & ... Utilization Management, Case Management, Claims, Quality Management and Compliance. The Nurse , Quality Review position develops procedures and reinforce quality… more
- Martin's Point Health Care (Portland, ME)
- …has been certified as a "Great Place to Work" since 2015. Position Summary The Utilization Review Nurse works as a member of a team responsible for ensuring the ... reviews for retrospective authorization requests as well as claims disputes. The Utilization Review Nurse will use appropriate governmental policies as well as… 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
- CareFirst (Cumberland, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Medical Review Nurse handles day to day review of professional and institutional claims and provider ... processing and/or adjudication. The incumbent will handle pre and post claim medical review for Commercial, FEP and Medicare Advantage Plans. This position… 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
- UCLA Health (Los Angeles, CA)
- Description As the Utilization Management & Quality Review Nurse , you will be responsible for: + Ensuring appropriate, cost-effective, and high-quality care for ... * Two or more years of experience in utilization management, preferably in Medicare Advantage or managed care * Knowledge of Medicare Advantage regulatory… more
- Dayton Children's Hospital (Dayton, OH)
- Facility:Work From Home - OhioDepartment:Utilization Review TeamSchedule:Full timeHours:40Job Details:Under the supervision of the Manager of Utilization Management, ... the Utilization Review RN conducts medical record review for...meet medical criteria, complex cases, appropriate level of care, Medicare cases as required, and the need for Peer-to-Peer… more