- Kepro (Indianapolis, IN)
- …vital partner for health solutions in the public sector. Acentra is currently looking for a Utilization Management Appeals Nurse - LPN/RN to join our ... growing team. Job Summary: Our Utilization Management Appeals Nurse - LPN/RN will help orchestrate the seamless resolution of appeals in line with… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …Role BHPS provides Utilization Management services to its clients. The Utilization Review Appeals Nurse performs daily appeal reviews and clinical ... DME, and Complex Care Needs. Essential Qualifications + Current licensed Registered Nurse (RN) with state licensure. Must retain active and unrestricted licensure… more
- LA Care Health Plan (Los Angeles, CA)
- …and Medicaid Services(CMS), external review organization (QIO or IRE). Work with Utilization Management and PNO to facilitate completion of resolution ... Customer Solution Center Appeals and Grievances Nurse Specialist LVN...Care Health Plan members under the direct supervision and management of the A&G Nurse Specialist, RN… more
- CareFirst (Owings Mills, MD)
- …terminology. + Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management , and systems ... **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Nurse completes research, basic analysis,...**Preferred Qualifications:** + 2 years experience in Medical Review, Utilization Management or Case Management … more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + Req ... Resource Management issues, other issues including concerns involving under/over utilization , avoidable days and quality issues. 13. Responsible for all incoming… more
- Trinity Health (Farmington Hills, MI)
- …regulations, healthcare financing and managed care. Knowledge of and experience in case management and utilization management . Knowledge of insurance and ... rejection, denial and appeal activities with Ministry Organization (MO) based Utilization Review/Case Management departments; + Reviews and understands … more
- LA Care Health Plan (Los Angeles, CA)
- …Skills Required: Knowledge of state, federal and regulatory requirements in Appeals /Care/Case/ Utilization Management /Quality. Strong verbal and written ... Supervisor, Appeals and Grievances Clinical Operations RN Job Category:...a lead/supervisory experience. Equivalency: Completion of the LA Care Management Certificate Training Program may substitute for the supervisory/… more
- Centene Corporation (Sacramento, CA)
- …Knowledge of NCQA, Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. **License/Certification:** + LPN - ... 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, national organization offering competitive… more
- CareFirst (Baltimore, MD)
- …**Knowledge, Skills and Abilities (KSAs)** + Knowledge of NCQA requirements of utilization review, Case Management standards and guidelines, appeal rights and ... of the Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs and Quality of Care Complaint Unit. May lead… more
- Penn Medicine (Philadelphia, PA)
- … appeals correspondence. + Maintains database for the department and the utilization management requirements for the hospital information system and within ... Clinical Appeals Coordinator in all phases of the Clinical Quality and Utilization Management functions including but not limited to data entry, obtaining… more
- Trinity Health (Farmington Hills, MI)
- …in the timeliest manner possible: + Coordinates follow-up activities with Utilization Review/Case Management /Coding/ Nurse Liaison to provide required ... as part of the payment resolution team that receives, analyzes, and appeals denials received for an assigned PBS location. Reviews, researches and resolves… more
- Trinity Health (Farmington Hills, MI)
- …in the timeliest manner possible: + Coordinates follow-up activities with Utilization Review/Case Management /Coding/ Nurse Liaison to provide required ... knowledge of state/federal laws as they relate to contracts and the appeals process. Assists in training Payment Resolution Specialist I colleagues upon hire… more
- Northwell Health (Melville, NY)
- … Review standard and regulations. Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria; conducts ... current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect patient's severity of illness… more
- Integra Partners (Troy, MI)
- …experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This individual will play a ... Medical Director to perform benefit and medical necessity reviews and appeals within an NCQA-compliant UM program. Salary: $60,000.00/annual JOB QUALIFICATIONS:… more
- LA Care Health Plan (Los Angeles, CA)
- Utilization Management Nurse Specialist LVN II Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 ... net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist LVN...experience in a patient care setting and/or combination in utilization management , appeals and grievances,… more
- McLaren Health Care (Detroit, MI)
- **Department: Utilization Management ** **Daily Work Times: 7:00am-3:30pm** **Shift: Days** **Scheduled Bi-Weekly Hours: 40** **Position Summary:** Responsible ... as Assigned:** 1. Performs a variety of concurrent and retrospective utilization management -related reviews and functions to ensure that appropriate… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …BHPS provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity ... with or without notice. Primary Responsibilities * Perform prospective utilization reviews and first level determinations for members using...of services and care. * Provides referrals to Case management , Disease Management , Appeals &… more
- Beth Israel Lahey Health (Needham, MA)
- …Functions and Responsibilities:** Performs a variety of concurrent and retrospective utilization management -related reviews and functions to ensure that ... payer certification, and denied cases. Monitors effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics,… more
- Beth Israel Lahey Health (Burlington, MA)
- …Functions and Responsibilities:** Performs a variety of concurrent and retrospective utilization management -related reviews and functions to ensure that ... payer certification, and denied cases. Monitors effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics,… more
- University of Virginia (Charlottesville, VA)
- Inpatient and Outpatient Setting. Under general direction: The Utilization Management RN serves as a leader resource in the Utilization Management ... UM RN conducts initial concurrent and retrospective medical necessity reviews. All Utilization Management activities are performed in accordance with the mission… more