- The Cigna Group (Bloomfield, CT)
- …Job Requirements include, but not limited to: + Must have experience in Medicare Appeals , Utilization Case Management or Compliance in Medicare Part C + Ability ... Cigna Medicare Part C Appeals Reviewer: Appeals Processing Analyst We...accurately; e) prepare case files for submission to Independent Review Entity, which also include writing required case summary… more
- BronxCare Health System (Bronx, NY)
- …the analysis and preparation of responses to payor denials and develop strong appeals for the purpose of securing reimbursement for acute care services provided to ... identification of patterns and trends identified during the course of appeals preparation. Conduct departmental performance improvement audits, analyze findings and… more
- LA Care Health Plan (Los Angeles, CA)
- …Nurses and Medical Directors to appropriately investigate, review and resolve clinical appeals and grievances. Prepares Nurse Summary for MD review and ... Customer Solution Center Appeals and Grievances Nurse Specialist LVN...review of medical records related to grievances and appeals . Responsible for handling member and provider appeals… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes regarding ... adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical skills and knowledge...**Preferred Qualifications** : + 2 years experience in Medical Review , Utilization Management or Case Management at… more
- UCLA Health (Los Angeles, CA)
- Description As the Appeals & Grievances Nurse , you will play a key role in managing and resolving New Century Health Plan member appeals and grievances. You ... will: + Ensuring timely, accurate, and thorough review of member and provider complaints, working closely with...Advantage setting is highly desired * Experience in handling appeals , grievances, utilization management, or potential quality… more
- CareFirst (Baltimore, MD)
- …of appeals and reconsiderations, including Regulatory complaints and External review requests. Accountable for quality review and interpretation of the ... or similar clinical experience OR + 5 years experience in Medical Review , Utilization Management or Case Management at CareFirst BlueCross BlueShield,… more
- Dayton Children's Hospital (Dayton, OH)
- …years of acute care experience in a hospital required + 3-5 years as progressive utilization review nurse and knowledge of payers and managed care contracts ... Facility:Work From Home - OhioDepartment: Utilization Review TeamSchedule:Full timeHours:40Job Details:Reporting to the Manager of Utilization Management and… more
- CareFirst (Baltimore, MD)
- …Master's in Science Nursing or related field, Legal Nurse Consultant, Utilization Management, and Government Program experience with Appeals and Grievance, ... with dynamic goals resulting in the full and fair review of appeals and designed to achieve...Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems… more
- VNS Health (Manhattan, NY)
- …Do + Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department. + Manages ... of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of service or clinical...Appeals or related area such as medical or utilization management in a Managed Care setting required +… more
- VNS Health (Manhattan, NY)
- …and appeals or related area such as medical or utilization management required + Proficient verbal/written communication skills required + Proficient computer ... OverviewResolves grievances, appeals and external reviews for one of the...of the plan's fiduciary responsibilities. Prepares records for physician review as needed. + Conducts review of… more
- CDPHP (Albany, NY)
- …(3) years of clinical experience required. + Minimum one (1) year of quality/ utilization review experience required. + Experience with research, data retrieval, ... Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations… more
- State of Connecticut, Department of Administrative Services (East Hartford, CT)
- Utilization Review Nurse Coordinator (40 Hour) Office/On-site Recruitment # 241106-5613FP-001 Location East Hartford, CT Date Opened 11/7/2024 12:00:00 AM ... (https://portal.ct.gov/dds/searchable-archive/northregion/north-region/welcome-to-the-north-region?language=en\_US) - is accepting applications for a full-time Utilization Review Nurse Coordinator… more
- Ascension Health (Tulsa, OK)
- …planning needs with healthcare team members. + May prepare statistical analysis and utilization review reports as necessary. + Oversee and coordinate compliance ... **Additional Preferences** + 2+ years of bedside nursing experience + 2+ years of Utilization Review experience **Why Join Our Team** Ascension St. John has been… more
- Ascension Health (Manhattan, KS)
- …Provide health care services regarding admissions, case management, discharge planning and utilization review . + Review admissions and service requests ... planning needs with healthcare team members. + May prepare statistical analysis and utilization review reports as necessary. + Oversee and coordinate compliance… more
- UCLA Health (Los Angeles, CA)
- …leader with: + Current CA LVN licensure required + Two or more years of utilization review / utilization management experience in an HMO, MSO, IPA, or health ... and guidelines in the issuance of adverse organization determinations. You will review for appropriate care and setting while working closely with denial… more
- University of Virginia (Charlottesville, VA)
- Under general direction: The Utilization Management RN serves as a leader resource in the Utilization Management process. They collaborate with physicians and ... RN conducts initial concurrent and retrospective medical necessity reviews. All Utilization Management activities are performed in accordance with the mission vision… more
- Stanford Health Care (Palo Alto, CA)
- …records to ensure the necessity and appropriateness of care provided. 3. Utilization Review : Conduct thorough utilization reviews, applying evidence-based ... hybrid Stanford Health Care job.** **A Brief Overview** The Utilization Management Registered Nurse (UM RN) will...utilization management principles. + Experience in case management, utilization review , or related healthcare roles. +… more
- Elevance Health (Washington, DC)
- The Utilization Management Nurse is responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member ... in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Primary duties may include, but are not limited to:… more
- Mount Sinai Health System (New York, NY)
- **Job Description** The Utilization Review Manager for the Selikoff Centers for Occupational Health is responsible for the management of program operations ... records, and internal and external regulatory and survey requirements. + The Utilization Review Manager collaborates with multiple professionals to support and… more
- AdventHealth (Glendale Heights, IL)
- …Behavioral Health RN experience strongly preferred + Experience in utilization review strongly preferred + Registered Nurse credentialed from the Illinois ... Provides health care services regarding admissions, case management, discharge planning and utilization review . **The value you'll bring to the team:** +… more