- CVS Health (Hartford, CT)
- …team player to manage Risk Adjustment National Programs for the Aetna Better Health Medicaid Plans. Reporting to the Lead Director of Medicaid Risk Adjustment ... to revenue integrity excellence. This position will contribute to Medicaid RAF performance through the delivery of measurable and...for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed… more
- Medical Mutual of Ohio (OH)
- …may include precertification review, concurrent review, prospective review, retrospective review and discharge planning, or clinical quality improvement. ... Oversees production and quality data to identify individual/unit performance. Establishes program targets and monitors overall performance. Develops and implements a… more
- The Cigna Group (Bloomfield, CT)
- …facilitate appropriate healthcare outcomes for members. Ensures that case management program objectives are met by evaluating the effectiveness of alternative care ... and utilization management to members. Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select… more
- CVS Health (Hartford, CT)
- …affordable. Position SummaryCVS Health has an exciting opportunity for a Senior Informatics Manager to join our dynamic Medicaid Risk Adjustment Analytics team! ... analysis to identify and prioritize members outreached for prospective and retrospective programs - Identify opportunities to optimize risk scores, while maintaining… more
- AmeriHealth Caritas (Newark, DE)
- …reporting/analytics for UM DE, and serves as SME for clinical components DE Medicaid Utilization Management Program . Works in close collaboration with all ... **Utilization Management Plan Oversight Manager , Registered Nurse (must reside in DE)** Location: Newark, DE Primary Job Function: Medical Management ID**: 34207… more
- Virginia Mason Franciscan Health (Bremerton, WA)
- …market(s) development, implementation, evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care ... department processes authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity;… more
- LA Care Health Plan (Los Angeles, CA)
- …to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and ... retrospective claims medical review. Monitors and oversees the collection...the department's continuous quality improvement activities. Communicates to UM Manager and supervising RN, barriers to completing assignments or… more
- Trinity Health (Syracuse, NY)
- …outliers and audit risks. Perform provider targeted and focused prospective and retrospective audits of documentation compared to services billed for new and ... issues detected through audits/reviews and compliance monitoring to their Regional Manager . Responsible for writing reports that document the findings from… more
- Trinity Health (Farmington Hills, MI)
- …denial management processes (Clinical and Administrative/Technical accounts, focusing upon retrospective follow-up and appeal processing) with the objective of ... manner possible: + Supports Supervisor Clinical Payment Resolution or Manager Clinical/Coding Payment Resolion with communication and follow-up processes related… more
- The Cigna Group (Bloomfield, CT)
- …job family. Handles moderately-complex cases. Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and ... select outpatient services. Ensures that case management program objectives are met by evaluating the effectiveness of alternative care services and that cost… more
- LA Care Health Plan (Los Angeles, CA)
- …to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and ... retrospective claims medical review. Monitors and oversees the collection...Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM… more
- Fallon Health (Worcester, MA)
- …to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid , and PACE ( Program of All-Inclusive Care for the ... with appeals regarding filing limit appeals, claim denials, claim payment, retrospective referrals, administrative inpatient days and other issues for which the… more
- Northwell Health (Bay Shore, NY)
- …make referrals to the Supervisor and the department involved. + * Performs retrospective reviews as required. + * Participates in the maintenance of Utilization ... Acts as a liaison with patient's insurance carrier (case manager , utilization reviewer) to coordinate post hospital services and...* Assists in identifying patient incidents through the NYPORTS program . + * Performs any and all related duties… more
- CareOregon (Portland, OR)
- …Wisconsin. Job Title Senior Clinical Pharmacist Exemption Status Exempt Department Pharmacy Manager Title Director of Pharmacy - Clinical Services Direct Reports n/a ... quality improvement programs related to medication use and other pharmacy program activities as assigned. Essential Responsibilities + Prepare drug utilization… more
- UNC Health Care (Rocky Mount, NC)
- … retrospective or prospective review, ie - Medicare and Medicaid RA (Recovery Auditor) programs. **Responsibilities:** + Ensuring compliant billing guidelines ... + Assistance with hospital denial management program + Assistance with hospital audit response ...Healthcare/Medical setting + 1 year of HealthCare/Medical - Case Manager in Case Management, UR, Hospital Billing, Compliance, Charge… more