- Katmai (Fort Carson, CO)
- **SUMMARY** Provide a comprehensive utilization review (UR) and utilization management ( UM ) program for all TRICARE eligible beneficiaries within the CMHS. ... years as a registered nurse in utilization management. + One (1) year of experience in UR/ UM and three (3) years of clinical nursing experience. + Must be able… more
- BlueCross BlueShield of Tennessee (Chattanooga, TN)
- …Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews\. + Lead and serve on various committees in order to ... **Job Responsibilities** + Develop and administer inter\- reviewer reliability methodology to ensure medical necessity determinations are consistent with CMS… more
- Premera Blue Cross (Mountlake Terrace, WA)
- …the Medical Policy Implementation Workgroup to ensure cross-functional collaboration between Clinical Review , Healthcare Services, and other departments on ... our Healthsource blog: https://healthsource.premera.com/ . **_About the role of Clinical Policy Coding Administrator_** The **_Clinical Policy Coding Administrator_**… more
- Premera Blue Cross (Mountlake Terrace, WA)
- …serve through our Healthsource blog: https://healthsource.premera.com/ . The **Senior Clinical Pharmacist,** **Oncology Program** will lead and help develop ... appropriate and cost-effective use of medication, aligning with and supporting Premera's clinical and financial goals. Join us to shape and lead a pioneering… more
- Katmai (Fort Carson, CO)
- …design, analyze, update and record data. + Facilitate the development and integration of UM review policies and procedures into operations. + Perform Right of ... and ancillary healthcare workers. + Apply principles of utilization review (UR) and utilization management ( UM ) in...Must have a minimum of three (3) years of clinical experience. + Must have working knowledge of computers,… more
- ERP International (Luke AFB, AZ)
- …and Care Coordination meetings. Shares knowledge and experiences gained from own clinical nursing practice and education relevant to nursing and case management. - ... Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); CAMH; (AAAHC); Health Services Inspection… more
- Stony Brook University (Stony Brook, NY)
- …Case Manager** is a valuable member of our team, who provides clinical services to our patient population. Qualified candidates will demonstrate superior patient ... may include the following but are not limited to:** + Completes Utilization review screen for inpatient and observation cases. Activity includes UR from the… more
- Healthfirst (NY)
- …institution or equivalent work experience + NYS RN + Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care ... management for all utilization management functions, including prior authorization, concurrent review , and service requests + Lead, coach, and develop UM… more
- Centers Plan for Healthy Living (Margate, FL)
- …applications for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer works within a multidisciplinary team to help ... in their home to improve their quality of life. Utilization Management Clinical Reviewer will assess and process all authorization requests to determine medical… more
- UCLA Health (Los Angeles, CA)
- …clinical documentation related to prior authorization requests for medical services. The UM Review Nurse applies clinical judgment, regulatory standards, ... Description At UCLA Health, the Utilization Management ( UM ) Review Nurse plays a vital...benefit coverage. + Applies UCLA Health protocols and national clinical guidelines (eg, InterQual, Milliman) in review … more
- Dignity Health (Bakersfield, CA)
- …superior customer service in line with CommonSpirit's values. You will function as a UM nurse reviewer , applying clinical expertise to ensure appropriate ... reviewing medical records, authorizing services, and preparing cases for physician review . You'll work closely with both Pre-Service and In-Patient Utilization… more
- Integra Partners (Troy, MI)
- …Oversight + Provide day-to-day clinical leadership and oversight to the Utilization Review Medical Director(s) and clinical UM team. + Ensure consistent, ... clinical quality monitoring. + Serve as the clinical reviewer for audit findings and contribute...case review + Prior leadership experience overseeing clinical staff or UM operations + Experience… more
- Evolent (Lansing, MI)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. ... policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member...medical management activities in a managed care environment + UM /UR experience + Clinical experience in Oncology,… 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 ... determination depends, making reasonable efforts to obtain relevant information via UM clinical reviewers, peer-to-peer outreach, and/or direct provider EMR… more
- Point32Health (Canton, MA)
- …issues with pharmacy technicians and confer with other clinical pharmacist on review questions + Communicate with UM staff and providers when issues arise ... . **Job Summary** Under the direction of the Pharmacy Utilization Management ( UM ) Supervisor, the Clinical Pharmacist is responsible for reviewing, processing… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- About The Role BHPS provides Utilization Review services to its clients. The UM Denials Coordinator supports the Utilization Management function by reviewing ... obtain additional information, or resolve discrepancies prior to letter release. The UM Denials Coordinator reports to the Clinical Services team and… more
- Humana (St. Paul, MN)
- …a part of our caring community and help us put health first** The UM Administration Coordinator 2 provides non- clinical support for the policies and procedures ... a part of our caring community and help us put health first** The UM Administration Coordinator 2 contributes to administration of utilization management. The UM … more
- RxBenefits (Charlotte, NC)
- …the effects this has on formulary tier changes, specialty designations, LDD designations, UM components, clinical outcomes, and MCAP outcomes and their relation ... GTM documents with ease and a delivery that exudes confidence around pricing, UM caveats, Clinical Products, and formulary disruption down to the single… more
- CareFirst (Baltimore, MD)
- …**PURPOSE:** The role of the Nurse, Quality Review Utilization Management ( UM ) is to evaluate clinical quality and procedures within the Utilization ... and maintains systematic audit tools to measure compliance with UM Standard Operating Procedures, regulatory requirements and accreditation standards. Utilizes… more
- Insight Global (New York, NY)
- …fully remote Physician Reviewers for a leading health insurance company. The Physician Reviewer will review requests for care before, during, and after treatment ... we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/. Skills and… more
