- UCLA Health (Los Angeles, CA)
- …is responsible for reviewing and evaluating clinical documentation related to prior authorization requests for medical services. The UM Review Nurse ... Description At UCLA Health, the Utilization Management ( UM ) Review Nurse plays a vital...of resources. Key Responsibilities: + Conducts clinical reviews of prior authorization requests to evaluate medical necessity… more
- Healthfirst (NY)
- …oversight and operational management for all utilization management functions, including prior authorization , concurrent review , and service requests ... accredited institution or equivalent work experience NYS RN Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care… more
- Dignity Health (Bakersfield, CA)
- …to ensure appropriate and cost-effective care. Key functions involve: - Authorization Review : Proactively, concurrently, or retroactively reviewing referral ... to patient information, PHI and HIPAA regulations. **Preferred Qualifications:** - Prior Utilization Management ( UM ) experience strongly preferred. - Bachelors… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …UM Coordinator is responsible for coordinating all aspects of the prior authorization process, including member eligibility and benefit verification, ... in medical record review . + Knowledge of CPT codes, preferred. + Prior knowledge of JIVA, preferred. + Excellent customer service and communication skills. +… more
- Fallon Health (Worcester, MA)
- …to outpatient and inpatient, utilization management operations, including but not limited to prior authorization , concurrent review and discharge planning. + ... activities. + Recommends and implements innovative process improvements for the prior authorization and utilization management processes + Develops and… more
- LA Care Health Plan (Los Angeles, CA)
- …Preferred: Experience in Medi-Cal managed care. 1 year of experience in UM / Prior Authorization . Skills Required: Demonstrated proficiency in Medical ... support the safety net required to achieve that purpose. Job Summary The Authorization Technician II supports the Utilization Management ( UM ) Specialist by… more
- CVS Health (Baton Rouge, LA)
- …day. **Position Summary** The Utilization Management Nurse Consultant (UMNC) for Prior Authorization conducts high-acuity, timely, and comprehensive clinical ... regulatory compliance and organizational goals. Key Responsibilities: * Perform prior authorization clinical reviews of acute admissions...* Resident of Louisiana preferred. * Working knowledge of UM review tools (eg, InterQual, MCG) and… more
- CVS Health (Baton Rouge, LA)
- …+ Lead, coach, and develop a multidisciplinary team responsible for utilization review , prior authorization , and case management functions. + ... heart, each and every day. **Position Summary** The Utilization Management Manager of Prior Authorization oversees a team of clinical professionals to ensure the… more
- Integra Partners (Troy, MI)
- …queue-based workflow with daily review expectations + Familiarity with electronic UM systems and authorization platforms + Experience with DMEPOS reviews + ... This full-time, salaried role functions within a structured, high-volume authorization review queue and requires adherence to...Experience with NCQA UM accreditation standards + Prior … more
- Integra Partners (Troy, MI)
- …with administrative and non-clinical tasks related to processing Utilization Management prior authorization sand appeals. JOB RESPONSIBILITIES + Monitor incoming ... faxes + Enter UM authorizations review requests in ...+ Verify all necessary documentation has been submitted with authorization requests + Contact requesting providers to obtain medical… more
- Point32Health (MA)
- …prioritization of authorization requests + Achievement of expected productivity goals + Review of all assigned prior authorization requests including but ... referrals, outpatient procedures, VNA or outpatient therapies as specified in the prior authorization list using specified clinical criteria sets. + Concurrent… more
- Molina Healthcare (NM)
- …compact license who resides in New Mexico or Texas. This team reviews the prior authorization requests for our New Mexico Medicaid recipients. Preference will be ... given to those whose UM experience is within another MCO like Molina; experience...and eligibility for requested treatments and/or procedures. + Conducts prior authorization reviews to determine financial responsibility… more
- Point32Health (Canton, MA)
- …responsible for reviewing, processing and managing the daily caseload of pharmacy prior authorization (PA) requests for coverage determinations (CD), and ... consults as required with THP Medical Directors (MD) on prior authorization that fails to meet drug...pharmacy technicians and confer with other clinical pharmacist on review questions + Communicate with UM staff… more
- Martin's Point Health Care (Portland, ME)
- …prevent or reduce hospital admissions where appropriate. Job Description Key Outcomes: + Review prior authorization requests ( prior authorization ... a need for inpatient/ outpatient authorizations. This position receives and reviews prior authorization requests for specific inpatient and outpatient medical… more
- Healthfirst (NY)
- …to UM leaders and teams executing department functions including prior authorizations, concurrent reviews, and service requests + Develop strong operational and ... Medicaid and//or Managed Long-Term Care Plan (MLTCP). + Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care… more
- Molina Healthcare (Sparks, NV)
- …* At least 2 years experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination of ... MCG guidelines. At least 2 years of experience with inpatient concurrent review , prior authorization and managed care; Acute care hospital experience with… more
- US Tech Solutions (Chicago, IL)
- …as an RN + Registered Nurse in state of residence + Must have prior authorization utilization experience + Experience with Medcompass **Skills:** + MUST HAVE ... MANAGED CARE exp and Medicare/Medicaid knowledge. + MUST HAVE UM experience, inpatient utilization management review . +...knowledge of Milliman/MCG. + MUST HAVE 6 months of Prior Authorization . **Education:** + Active and unrestricted… more
- Molina Healthcare (Yonkers, NY)
- …* At least 2 years experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination of ... stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its members. *… more
- Molina Healthcare (North Las Vegas, NV)
- …* At least 2 years experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination of ... stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its members. *… more
- Molina Healthcare (Louisville, KY)
- …in KY or have a compact RN license. The Care Review Clinician Inpatient Review BH will provide prior authorization for outpatient and inpatient services ... of stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization / financial responsibility for Molina and its members. *… more