- Centers Plan for Healthy Living (Margate, FL)
- UM Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063, USA Req #664 Monday, December 2, 2024 Centers Plan for Healthy Living's goal is to create the ... applications for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer works within a multidisciplinary team to help… more
- Sutter Health (Sacramento, CA)
- …years of recent relevant experience. * 2 years experience in Utilization Management ( UM ) and Clinical Denial Management Preferred **SKILLS AND KNOWLEDGE:** * ... Office-Valley **Position Overview:** Manages the operations of the centralized Utilization review department for Sutter Health entities in accordance with current… more
- CVS Health (Hartford, CT)
- … Clinical Operations, Clinical Account Management, Formulary Administration, and Clinical Affairs. The UM Clinical Development pharmacist may be ... each and every day. **Position Summary** The Utilization Management ( UM ) clinical development pharmacist will develop clinically...support of prior authorization, step therapy, quantity and formulary review programs for CVS Health. The UM … more
- Elevance Health (Indianapolis, IN)
- …necessary quality behavioral healthcare in a cost effective setting in accordance with UM Clinical Guidelines and contract. + Refers cases to Peer Reviewers ... companies, Carelon Behavioral Health, formerly Beacon Health Options, offers superior clinical mental health and substance use disorder management, a comprehensive… more
- Elevance Health (Indianapolis, IN)
- …make an impact:** + Coordinating utilization management process including appropriate use of UM Clinical Guidelines to refer cases to Peer Reviewers. + ... companies, Carelon Behavioral Health, formerly Beacon Health Options, offers superior clinical mental health and substance use disorder management, a comprehensive… more
- Fallon Health (Worcester, MA)
- …relevant clinical information from medical care providers as needed for the clinical review process + Conducts clinical reviews of retrospective and ... eligibility, and network contract status criteria to a physician reviewer for consideration, ensuring the timely review ...applies CMS always INPT and SDS CPT codes during UM clinical reviews + Collaborates with Fallon… more
- Apex Health Solutions (Houston, TX)
- …Solutions' members for the utilization review (UR) of healthcare services. The UM Reviewer will be responsible for complying with utilization review ... Summary: The UM Reviewer serves as a contact...review /precertification requirements. Collects and/or documents all required enrollee clinical and co-morbidity information during the pre-authorization process to… more
- University of Miami (Coral Gables, FL)
- …CTO is an enterprise level executive and will oversee all IT infrastructure services across UM and UHealth in support of education, clinical care , and research ... detailed plan process involving management staff, senior leadership and members of the UM 's clinical and educational communities. + Strong interpersonal and… more
- Humana (Columbia, SC)
- …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 ... ensuring best and most appropriate treatment, care or services for members. UM Administration Coordinator 2 + Primarily receive calls from Providers, Hospitals,… more
- Humana (Baton Rouge, LA)
- …support assignments. Performs computations. Typically works on semi-routine assignments. The UM Administration Coordinator 2 provides non- clinical support for ... 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
- CVS Health (Springfield, IL)
- …competitors, reduce liquidated damages, and support accreditation activities. Supporting the UM team in predetermination reviews and providing clinical , coding, ... sustainable competitive business advantage by supporting the plan goals. Review , interpret and analyze data and trends at State...expertise. Work closely with UM team and clinical leaders to identify and effectively manage emerging utilization… more
- US Tech Solutions (Canton, MA)
- …possible extension)** Notes: Fully remote, MA license required.** **Job Summary The Clinical Reviewer is a licensed professional -a Registered Nurse preferred- ... clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for making the...functions as a member of the Precert / Outpatient UM team and works under the general direction of… more
- Sharp HealthCare (San Diego, CA)
- …other sources. + Achieves and maintains benchmarked utilization and cost management ( UM ) goals and clinical quality improvement (QI) objectives, in conjunction ... selected utilization/cost and quality outcomes. + Participates in policy review , performs analysis and makes recommendations for updating current...and UM platforms. + Oversees A/G and UM reviews of all clinical reviewers. +… more
- AmeriHealth Caritas (Charleston, SC)
- …perform a thorough medical necessity review . It is within the BH UM Reviewer 's discretion to retain requests for additional information and/or request ... is responsible for completing medical necessity reviews. ;Using clinical knowledge and experience, the clinician reviews provider requests...clarification. The BH UM Reviewer will use his/her professional judgment… more
- Hackensack Meridian Health (Hackensack, NJ)
- …University Medical Center. These include but are not limited to utilization review , hospital reimbursement, clinical compliance, case management, and transitions ... **Overview** The Utilization Review Physician collaborates with the healthcare team in...overall medical management effectiveness, benchmarked utilization and cost management ( UM ) goals clinical improvement objectives f. Interfaces… more
- Point32Health (MA)
- …day in service to our members, partners, colleagues and communities. **Job Summary** The Clinical Reviewer is a licensed Registered Nurse that is expected to ... clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for making the...functions as a member of the Precert / Outpatient UM team and works under the general direction of… more
- University of Maryland, Baltimore (Baltimore, MD)
- …patient care decision making * In collaboration with Oncology Practice Leadership and UM SJMC Leadership teams, develop annual clinical operational goals and ... interventions in alignment with Oncology Clinical Service Line roadmap. * Attend UM ...accord with institutional research processes * Conducts physician peer review activities as requested by medical staff office *… more
- Corewell Health (Grand Rapids, MI)
- …high level of collaboration, patient-centered care and evidence-based medicine. The Physician Reviewer can expect to work approximately 2-4 hours on 1- day holidays, ... medicine, and lower per-capita costs; participate in the development of clinical utilization guidelines, health management programs and clinical quality… more
- Excellus BlueCross BlueShield (Dewitt, NY)
- …the diagnosis and treatment of members' medical health conditions, applying established clinical review criteria, guidelines and medical policies and contractual ... as well as State and Federal Mandates. May perform clinical review telephonically, electronically, or on-site, depending...5 years. + Broad understanding of multiple areas (ie UM and CM). Incumbent is required to know multiple… more
- Hackensack Meridian Health (Hackensack, NJ)
- …and Hackensack UMC. These include but are not limited to utilization review , hospital reimbursement, clinical compliance, case management, and transitions of ... **Overview** The Senior Utilization Review Specialist collaborates with the healthcare team in...overall medical management effectiveness, benchmarked utilization and cost management ( UM ) goals and clinical improvement objectives d.… more