- Humana (Madison, WI)
- …of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... determination of the appropriate courses of action. The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent… more
- Cognizant (Madison, WI)
- …+ Educational background - Registered Nurse (RN) + 2-3 years combined clinical and/or utilization management experience with managed health care plan ... Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced...care revenue cycle or clinic operations + Experience in utilization management to include Clinical … more
- Molina Healthcare (Madison, WI)
- …hearing officer during fair hearings as may be required. * Serves as a clinical resource for utilization management , chief medical officer, physicians, and ... JOB DESCRIPTION **Job Summary** The RN Clinical Appeals Nurse provides support for...officer on denial decisions. * Resolves escalated complaints regarding utilization management and long-term services and supports… more
- Evolent (Madison, WI)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- Fresenius Medical Center (Fitchburg, WI)
- …requirements. Ensure provision of quality patient care while maintaining cost-effective clinical operations in accordance with all legal, compliance, and regulatory ... and FMS patient care and administrative policies as the clinical leader, has the authority to make daily decisions...the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member… more
- Molina Healthcare (Madison, WI)
- …including 5 years of clinical practice experience, 3 years utilization /quality program management experience, and 2 years managed care experience, ... and data analysts to produce tools to report, monitor and improve utilization management . * Actively participates in regulatory, professional and community… more
- Evolent (Madison, WI)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and ... accomplishments. **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to company… more
- CVS Health (Madison, WI)
- …- 3+ years of acute experience as a Registered Nurse - 1+ years of Utilization Management experience - Must have experience using MS Office suites - Must be ... of high performing teams. Works closely with functional area management to ensure consistency in clinical interventions...Occasional travel less than 5% to complete audits/meetings - Utilization Management is a 24/7 operation and… more
- Select Medical (Madison, WI)
- …focus on resource management . + Demonstrating compliance with facility-wide Utilization Management policies and procedures. + Coordinating UR compliance with ... doing what is right. As the Director of Case Management **,** you will use your clinical ...growth of the department, including, but not limited to: Utilization Review (UR) and resource management , discharge… more
- Molina Healthcare (Madison, WI)
- …of health care services provided to plan members. * Supports plan utilization management program and accompanying action plan(s), which includes strategies ... the most appropriate care at the most effective setting. *Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and… more
- Molina Healthcare (Madison, WI)
- …key health care services (HCS) functions: care management , care transitions, utilization management , behavioral health and/or nurse advice line. ... professionals, in some or all of the following functions: utilization management , care management , care...(RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW),… more
- Select Medical (Madison, WI)
- … within the plan of care. + Demonstrates compliance with facility-wide Utilization Management policies and procedures. + Coordinates UR compliance with ... **Case Manager (PRN)** _Requires a current licensure in a clinical discipline either as a Nurse or...what is right. The Case Manager is responsible for utilization reviews and resource management , discharge planning,… more
- Molina Healthcare (Madison, WI)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for...Preferred Experience Previous experience in managed care Prior Auth, Utilization Review / Utilization Management … more
- Oracle (Madison, WI)
- …of analysts providing support for operationally required changes and enhancements to clinical applications, and aa group of analysts leading projects that will ... These include, but are not limited to, multiple Essential Clinical Dataset (ECD) alignments, Critical Care workflow implementation, Multi-Disciplinary Rounding,… more
- Molina Healthcare (Madison, WI)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is...and medical coding. JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying… more
- Molina Healthcare (Madison, WI)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... RN license required_** JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that… more
- Highmark Health (Madison, WI)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... data to assure appropriate level of payment and resource utilization . It is also used to identify issues which...- 5 years of related, progressive experience in a clinical setting **Preferred** + 1-3 years of experience in… more