- BlueCross BlueShield of Tennessee (Chattanooga, TN)
- …retrospective claim review, special review requests, and UM pre\-certifications and appeals , utilizing medical appropriateness criteria, clinical judgement, and ... Health and Withdrawal Management\. + Present cases confidently and effectively during clinical rounds\. + Work independently with minimal supervision\. + Excel in a… more
- Highland Hospital (Rochester, NY)
- … clinical documentation, forms/paperwork requested by patients, prior authorization appeals , sign home care orders + Coordinate with other providers, home ... sessions may be done from home via telemedicine dependent on clinical availability, personal preference, and insurance guidelines for telemedicine coverage… 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 of all applicable State and Federal… more
- University of Washington (Seattle, WA)
- …**UW Medicine's Patient Financial Services Department** has an outstanding opportunity for a ** Clinical Appeals and Disputes Nurse .** **WORK SCHEDULE** + ... 100% FTE + 100% Remote + Days **POSITION HIGHLIGHTS** The Clinical Appeals and Disputes Nurse ensures that payers are prepared to reimburse the UW Medicine… more
- Elevance Health (Indianapolis, IN)
- ** Nurse Appeals ** **Location: Indiana** **Virtual:** This...or BS in Nursing preferred. + 3 years of clinical experience as a Registered Nurse is ... for employment, unless an accommodation is granted as required by law. The ** Nurse Appeals ** is responsible for investigating and processing and medical… more
- Evolent (Springfield, IL)
- …to Standard processing, documenting accordingly. + Works closely with the appeals -dedicated Clinical Reviewers to ensure timely adjudication of processed ... for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a...be able to exercise independent and sound judgment in clinical decision making. - **Preferred** + Able to navigate… more
- CVS Health (Columbus, OH)
- …with heart, each and every day. **Position Summary** CVS Aetna is seeking a dedicated ** Appeals Nurse Consultant** to join our remote team. In this role, you ... typing on the computer. + Responsible for the review and resolution of clinical appeals . + Reviews documentation and interprets data obtained from clinical … more
- BJC HealthCare (St. Louis, MO)
- …work experience) **Additional Information About the Role** BJC HealthCare is seeking a Clinical Appeals Specialist to assist with infusion appeals for ... government and commercial plans. This individual will be handling clinical denials and sending them to a nurse...clinical denials for BJC hospitals and payors. The Clinical Appeals Specialist must be able to… more
- Elevance Health (Indianapolis, IN)
- ** Nurse Appeals RN-Quality of Care** **Hybrid 1:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, ... an accommodation is granted as required by law._ The ** Nurse Appeals ** is responsible for investigating and...grievances/quality of care issues and is a resource for clinical and non- clinical team members in expediting… more
- CareFirst (Baltimore, MD)
- …of members for Commercial lines of business. Ensures quality management of the clinical appeal process to reduce the risk of State and Federal Regulatory fines ... for Care Management. We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who...goals resulting in the full and fair review of appeals and designed to achieve corporate objectives and advance… more
- St. Luke's University Health Network (Allentown, PA)
- …regardless of a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, claims data ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- BronxCare Health System (Bronx, NY)
- …arrive in letter and electronic format. Collaborating with the Department Denial and Appeals Coordinators, Physician Advisors, and the clinical staff, the Appeal ... Overview The Appeals Manager is responsible to assist in the...for timely response by the department physician advisors and clinical staff. Qualifications - NYS Registered Nurse … more
- Nuvance Health (Danbury, CT)
- *Description* *Summary:* The purpose of the Denial Prevention Nurse is to ensure that all patient admissions are appropriately status within the first 12-24 hours ... in preventing payment denials by providing timely and accurate clinical information to all payers, while ensuring compliance with...notice of conversion, etc. * Tracking and trending all appeals and communicating on a daily/regular basis with the… more
- LA Care Health Plan (Los Angeles, CA)
- …in Nursing for Registered Nurses Experience Required: At least 8 years of clinical appeals and grievances experience in a managed care, utilization management ... Lead Customer Solution Center Appeals and Grievances RN Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, 90017… more
- Northwell Health (Melville, NY)
- …+ Ensures compliance with current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect ... retrospective utilization management using evidenced-based medical necessity criteria; conducts clinical reviews and formulates appeal letters to support appropriateness… more
- Northwell Health (Melville, NY)
- …stay. Ensures compliance with current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately ... retrospective utilization management using evidenced-based medical necessity criteria; conducts clinical reviews and formulates appeal letters to support appropriateness… more
- CareFirst (Baltimore, MD)
- …with the overall Corporate Strategic Plan through direction and oversight of the Clinical Medical Claims Reviews, Clinical Appeals and Analysis programs ... in a managed care or health insurance environment with a focus on Clinical Medical Review and Appeals and Grievances. **Preferred Qualifications:** + Significant… more
- McLaren Health Care (Mount Pleasant, MI)
- …outcomes and fulfills the obligation and responsibilities of the role to support the clinical team. 3. Collaborates with the Denials Appeals RN to ensure payer ... . Provides support to both internal and external customers for denial/ appeals activities and audits. Assists with monitoring and auditing activities, reviews… more
- Gentiva (Mooresville, NC)
- **Overview** **Ensuring Compliance. Streamlining Authorizations. Supporting Patient Care.** The Clinical Authorization Nurse plays a key role in supporting our ... to ensure compliance and smooth claims processing. **As a Clinical Authorization Nurse , You Will:** + Perform...+ Manage and communicate with the team regarding the appeals process for claims + Collaborate with Directors of… more
- State of Colorado (Pueblo, CO)
- NURSE III - Clinical Specialist - Pueblo...if your application is eliminated. You will find the appeals process, the official appeal form, and how to deliver ... Regional Center Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5186234) Apply NURSE III - Clinical Specialist - Pueblo Regional Center… more
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