- US Tech Solutions (Canton, MA)
- …extension)** Notes: Fully remote , MA license required.** **Job Summary The Clinical Reviewer is a licensed professional -a Registered Nurse preferred- that ... for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for making the determination of medical… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …and benefits, as well as regulatory and NCQA requirements. + Refer to RN or PT Clinical Utilization reviewer for more complex cases as appropriate or when ... Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical … more
- VNS Health (Manhattan, NY)
- … review of all components related to requests for services which includes a clinical record review and interviews with members, clinical staff, medical ... team, or care manager generated requests for medical services and renders clinical determinations in accordance with healthcare policies as well as applicable state… more
- AmeriHealth Caritas (Charleston, SC)
- …**Responsibilities:** Under the direction of the Supervisor, the Behavioral Health Utilization Management Reviewer is responsible for completing medical ... necessity reviews. ;Using clinical knowledge and experience, the clinician reviews provider requests...all information necessary to perform a thorough medical necessity review . It is within the BH UM Reviewer… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …to help us transform healthcare? Bring your true colors to blue. The RoleThe Clinical Utilization Reviewer is responsible for facilitating care for members ... Mobile, and Resident personas. This position can be fully remote , with a 1-2x/month meeting in our Hingham, MA...Hours of work: 8:30a - 4:30p EDT. The TeamThe Clinical Utilization Reviewer is part… more
- Elevance Health (Rancho Cordova, CA)
- …or requires physician review or override. + Clearly and concisely documenting clinical review and other case interactions in online database in adherence to ... **JR144792 Genetic Counselor Reviewer ** The genetic counselor reviewer (GCR)...for authorization requests and determining their appropriateness per designated clinical guidelines, clinical policies, and client rules.… 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
- Sanford Health (SD)
- …to the work of health and healing across our broad footprint.** **Facility:** Remote SD (Central Time) **Location:** Remote , SD **Address:** **Job Schedule:** ... time **Weekly Hours:** 40.00 **Salary Range:** $26.00 - $41.50 **Job Summary** Provides clinical support to the MCHS revenue cycle for denial management and … more
- Henry Ford Health System (Troy, MI)
- …system-wide improvements and operational processes to ensure optimal and compliant utilization review strategies. Under minimal supervision from the Manager ... GENERAL SUMMARY: The Supervisor of Utilization Management has an important role in a...and team member engagement daily. 2. Working with key clinical , operational, and payer stakeholders, manages day to day… more
- CommonSpirit Health Mountain Region (Centennial, CO)
- …with resources to help you flourish and leaders who care about your success. The Utilization Review RN is responsible for the review of medical records ... Coordination staff utilizing evidence-based guidelines and critical thinking. Additionally, as a Utilization Review RN, you will collaborate with the Concurrent… more
- MD Anderson Cancer Center (Houston, TX)
- …to peer or appeals to mitigate denials KEY FUNCTIONS Standards of Practice a₠" Utilization Review Concepts Applies approved clinical criteria and payer ... employees and the public. The primary purpose of the Utilization Review Nurse position is to: Evaluate...receives care Ensure appropriate payment of services that includes review of the appropriate patient class, providing clinical… 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 ... to medical review according to policy and procedure + Documents clinical , functional, psychosocial information in the Core System as well as communications… more
- Intermountain Health (Murray, UT)
- …regulatory requirements. + Occasional travel to provider locations within Select Health region. ** Utilization Review and Care Management:** + ** Review and ... and experience in behavioral health. + Knowledge of healthcare insurance and utilization review processes. + Excellent communication and interpersonal skills. +… more
- CareFirst (Washington, DC)
- …with non- clinical administrative tasks and responsibilities related to pre-service, utilization review , care coordination and quality of care. **ESSENTIAL ... documentation. + Reviews authorization requests for initial determination and/or triages for clinical review and resolution. + Provides general support and… more
- BayCare Health System (Clearwater, FL)
- …that's built on a foundation of trust, dignity, respect, responsibility and clinical excellence. **The Utilization Review Specialist Senior responsibilities ... discounts and more _Equal Opportunity Employer Veterans/Disabled_ **Position** Utilization Review Spec Sr **Location** Clearwater:Morton Plant | Clinical |… more
- Spectrum Billing Solutions (Skokie, IL)
- …is a remote or office/home hybrid position. Responsibilities include: + Review patient admission and clinical information to ensure medical necessity and ... for healthcare organizations. We are looking to add a Utilization Review (UR) Specialist to our growing...will utilize his or her knowledge and skills to review clinical information and obtain initial and… more
- Elevance Health (Columbus, GA)
- …outpatient precertification, prior authorization, and post service requests. + Refers cases requiring clinical review to a Nurse reviewer . + Responsible for ... **Title: Utilization Management Representative I** **Location:** This position will work a remote model. Ideal candidates will live within 50 miles of one of our… more
- Elevance Health (Richmond, VA)
- …outpatient precertification, prior authorization, and post service requests. + Refers cases requiring clinical review to a Nurse reviewer . + Responsible for ... **Title: Utilization Management Representative I** **Location:** This position will work a remote model. Ideal candidates will live within 50 miles of one of our… more
- Elevance Health (Louisville, KY)
- …Provider Finder and follows up with provider on referrals given. + Refers cases requiring clinical review to a nurse reviewer ; and handles referrals for ... **Title: Utilization Management Representative II** **Location:** This position will work a remote model. Ideal candidates will live within 50 miles of one of… more
- Ochsner Health (New Orleans, LA)
- …(2) Board Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or (3) Physician Advisor Sub-Specialty ... Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or (4) commitment to apply for such certifications +… more