- Kepro (CA)
- …to being a vital partner for health solutions in the public sector. Acentra seeks a Utilization Clinical Reviewer to join our growing team in California. Job ... Summary As a Utilization Clinical Reviewer , you'll harness...the accuracy and consistency of the Psychiatric Inpatient Concurrent Review process in alignment with the California Mental Health… more
- Guthrie (Sayre, PA)
- …needs for clinical knowledge to leverage payors. Position Summary: The Utilization Management (UM) Reviewer , in collaboration with other internal and ... Teamwork Flexibility to meet the Monday through Friday needs for life balance. Roles: Utilization review to status the patient to the appropriate level of care… more
- Commonwealth Care Alliance (Boston, MA)
- …the provisions of CCA's benefits plan. The Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization ... review for medical necessity and decision-making. The Utilization Management Reviewer has a key role...Be Doing:** **Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior… more
- Commonwealth Care Alliance (Boston, MA)
- …provisions of CCA's benefits plan. The Nurse Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization ... review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA meets CMS compliance standards in… more
- Point32Health (MA)
- …who we are at Point32Health, click here (https://youtu.be/S5I\_HgoecJQ) . **Job Summary** The Clinical Reviewer is a licensed Registered Nurse that is expected ... for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for making the determination of medical… more
- Prime Therapeutics (Columbus, OH)
- …fuels our passion and drives every decision we make. **Job Posting Title** Physician Clinical Reviewer - GI- REMOTE **Job Description Summary** Key member of the ... utilization management team, and provides timely medical ...clinical determinations cannot be made by the Initial Clinical Reviewer . + Discusses determinations with requesting… more
- Evolent Health (Columbus, OH)
- …for the mission. Stay for the culture. **What You'll Be Doing:** As a Cardiology, Physician Clinical Reviewer you will be a key member of the utilization ... when available, within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the… more
- Evolent Health (Columbus, OH)
- …Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer you will be a key member of the utilization ... provides clinical rationale for standard and expedited appeals. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the MD… more
- Trinity Health (Livonia, MI)
- …Type:** Part time **Shift:** Rotating Shift **Description:** **JOB SUMMARY** The Clinical Nurse Reviewer 's chief responsibility is to collect and submit ... database of all eligible cases for the hospital. The Clinical Nurse Reviewer also works closely with...software (Microsoft Word, Excel, PowerPoint) and web-based applications. + Clinical chart review and abstraction experience required… more
- Point32Health (MA)
- …of utmost importance. **Key** **Responsibilities/Duties** **- what you will be doing** ** Utilization Management** + Performs clinical review of prospective, ... and concerns. + Supports the provider inquiry line for peer-to-peer discussions. + Performs clinical review of expedited and standard appeals for all lines of… more
- WTW (Boston, MA)
- …issues or impact to timeline proactively to Project Manager + Complete initial review of carrier responses for parity projects + Draft comparative analysis based on ... and client specific responses + Collaborate with MHPAEA senior reviewer and Project Manager to conduct follow up calls/emails...a manner consistent with WTW work processes and peer review standards (eg, filing of drafts, deliverables, client and… more
- Evolent Health (Columbus, OH)
- …matter expert in meetings, as assigned with practices and/or payers. + Perform all peer clinical review activities while located in a state or territory of the ... Oncology you will be a key member of the utilization management team. We can offer you a meaningful...to make a difference in patients lives, in a non- clinical environment. You can enjoy better work- life balance… more
- Brighton Health Plan Solutions, LLC (New York, NY)
- …work. + Provides utilization review , continued stay reviews, and utilization management based on clinical judgment and state WCB Medical Treatment ... About The Role Brighton Health Plan Solutions (BHPS) provides Utilization Review /Medical and Case Management services for Group Health and Workers' Compensation… more
- AdventHealth (Bolingbrook, IL)
- …department/clinic or with clinical research or medical records. . Clinical chart review and abstraction experience. **_LICENSURE, CERTIFICATION OR ... annual thereafter) follow-up data components for the program through the effective utilization of the hospital medical record systems and through a coordinated… more
- Elevance Health (Olathe, KS)
- …of our Kansas Pulse Point locations in Topeka or Olathe. The **Psychologist Reviewer - Kansas** is responsible for collaborating with providers and Medical Directors ... UR staff and external Behavioral Health Providers to ensure appropriate and consistent utilization of plan benefits, out of network services, and clinical … more
- US Tech Solutions (Columbia, SC)
- …decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. + May provide any of ... sets/qualities: I would love to have someone with prior insurance/ utilization review experience, but I know that...and our medical policies. The nurse would read through clinical information, ensuring that all requirements are met based… more
- Kelsey-Seybold Clinic (Pearland, TX)
- **Responsibilities** The Utilization Review Specialist (LVN) is responsible for conducting medical reviews, benefit verification, and applying criteria to ... authorization prior to services being rendered for members. The Utilization Review Specialist (LVN) serves as a...plan, ACO, IPA, or provider group or 3 years clinical nursing experience Preferred: N/A **License(s)** Required: TX LVN… more
- Beth Israel Lahey Health (Burlington, MA)
- …in utilization review and medical necessity activities Key responsibilities: Utilization review and inpatient clinical optimization: (include all ... **Job Type:** Regular **Time Type:** Part time **Work Shift:** Day (United States of...payor provider representatives, participation in the observation escalation process, clinical reviews of utilization review … more
- Centene Corporation (Sacramento, CA)
- …facilities + Partners with interdepartmental teams on projects within utilization management as part of the clinical review team + Partners and works ... and concurrent review findings + Provides education to providers on utilization processes to ensure high quality appropriate care to members + Partners with… 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 ... medical specialty and subspecialty. In addition to its direct clinical services, DHS also runs the Emergency Medical Services...and technical supervision over the nursing staff engaged in utilization review activities at Los Angeles General… more