- BlueCross BlueShield of Tennessee (Chattanooga, TN)
- …review , special review requests, and UM pre\-certifications and appeals , utilizing medical appropriateness criteria, clinical judgement, and contractual ... Health and Withdrawal Management\. + Present cases confidently and effectively during clinical rounds\. + Work independently with minimal supervision\. + Excel in a… 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 ...and mandates. + Organizes the appeal case for physician review by compiling clinical , contractual, medical policy… 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** + ... FTE + 100% Remote + Days **POSITION HIGHLIGHTS** The Clinical Appeals and Disputes Nurse ...and communicated payer decisions in a timely manner + Review clinical denials and initiate appeals… more
- Guthrie (Cortland, NY)
- …than one year of experience) Summary The LPN Utilization Management (UM) Reviewer , in collaboration with Care Coordination, Guthrie Clinic offices, other physician ... associated with UM processes and operations. Experience Minimum of five years clinical experience in an acute health care setting. Must possess strong communication… more
- Elevance Health (Indianapolis, IN)
- ** Nurse Appeals ** **Location: Indiana** **Virtual:** This role enables associates to work virtually full-time, with the exception of required in-person training ... an accommodation is granted as required by law. The ** Nurse Appeals ** is responsible for investigating and...appealed service and forwards to Medical Director for final review and decision. + Ensures that appeals … 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...work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators… more
- St. Luke's University Health Network (Allentown, PA)
- …serve, regardless of a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- CVS Health (Columbus, OH)
- …utilizing templates in Word, and typing on the computer. + Responsible for the review and resolution of clinical appeals . + Reviews documentation and ... day. **Position Summary** CVS Aetna is seeking a dedicated ** Appeals Nurse Consultant** to join our remote...3+ years clinical experience. **Preferred Qualifications** + Appeals , Managed Care, or Utilization Review experience.… more
- BJC HealthCare (St. Louis, MO)
- …and VitalWare to review documentation to write a compelling appeal. The Clinical Appeals Specialist must be able to identify trends and escalate them ... Information About the Role** BJC HealthCare is seeking a Clinical Appeals Specialist to assist with infusion... clinical denials and sending them to a nurse to review and appeal and then… 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...of Care cases and forwards to Medical Director for review and determination. + Ensures grievances are resolved timely… more
- CareFirst (Baltimore, MD)
- …a compliant appeal process with dynamic goals resulting in the full and fair review of appeals and designed to achieve corporate objectives and advance ... Federal and accreditation requirements. Ensures appropriate and complete resolution of appeals , Regulatory complaints and External review requests. Performs… more
- CareFirst (Baltimore, MD)
- …leading in a managed care or health insurance environment with a focus on Clinical Medical Review and Appeals and Grievances. **Preferred Qualifications:** + ... services and provider types. + Understanding of the interdependencies between Medical Policy, Clinical Medical Review and Appeals and Grievances. + Ability… 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 ... critical part in preventing payment denials by providing timely and accurate clinical information to all payers, while ensuring compliance with CMS requirements,… 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... unit. This position is responsible for the quality review of complex and/or escalated clinical A&G… 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 ... decisions and billing status and ensures compliance with the Utilization Review standard and regulations. + Performs concurrent and retrospective utilization… 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 ... and billing status and ensures compliance with the Utilization Review standard and regulations. Performs concurrent and retrospective utilization management… more
- Baystate Health (Springfield, MA)
- …Minimum - Midpoint - Maximum $87,859.00 - $100,984.00 - $119,412.00 **UM Outpatient Clinical Review Nurse - Baystate Health, Health New England** **This ... **Current States Eligible MA and CT** The **UM Outpatient Clinical Review Nurse ** contributes to...management on referral of members, as appropriate + Performs clinical reviews for member and provider appeals … more
- Gentiva (Mooresville, NC)
- … Nurse RN, Hospice Authorization, Home Care Authorization, Eligibility Review , Medicare, Medicaid, Commercial Payers, Claims Appeals , Hospice Nursing ... **Overview** **Ensuring Compliance. Streamlining Authorizations. Supporting Patient Care.** The Clinical Authorization Nurse plays a key role in supporting our… more
- State of Colorado (Pueblo, CO)
- NURSE III - Clinical Specialist - Pueblo Regional Center Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5186234) Apply NURSE III - ... minimum staffing standards. This includes covering as a team nurse as needed. This position exists as a unit...and Health Care Technicians/QMAP. + Through direct observations and review of documentation determines if nurses are practicing critical… more
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