- UNC Health (Chapel Hill, NC)
- …the unique communities we serve.RN Utilization Manager position specifically for a Utilization Manager/Clinical Appeals Nurse . This person is based at ... UNC Health is seeking a Registered Nurse (RN) Care Manager for a nursing job...reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the … more
- The University of Vermont Health Network (Elizabethtown, NY)
- …Medicaid rules, and regulations, clinical practice guidelines, and quality issues related to utilization management with application for appeals and denials ... of employee health documents and reports. The manager is a registered professional nurse manager who is responsible for conducting inpatient Care Management ; and… more
- CHRISTUS Health (Alamogordo, NM)
- …screening, monitoring, and reporting individual cases and/or trends to the infection control nurse . Performs utilization management functions as required by ... of Participation, DNV standards, HIPAA, and reporting requirements. Submits appeals in a timely manner, upon request by the...payer source. Complies with the Utilization Management Plan. Requirements Education Required: Associate… more
- Kepro (Indianapolis, IN)
- …vital partner for health solutions in the public sector. Acentra is currently looking for a Utilization Management Appeals Nurse - LPN/RN to join our ... growing team. Job Summary: Our Utilization Management Appeals Nurse - LPN/RN will help orchestrate the seamless resolution of appeals in line with… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …Role BHPS provides Utilization Management services to its clients. The Utilization Review Appeals Nurse performs daily appeal reviews and clinical ... DME, and Complex Care Needs. Essential Qualifications + Current licensed Registered Nurse (RN) with state licensure. Must retain active and unrestricted licensure… more
- Molina Healthcare (TX)
- …position we are seeking a REGISTERED NURSE (RN) with prior experience in Utilization Review / Utilization Management and knowledge of Interqual / MCG ... be required. + Serves as a clinical resource for Utilization Management , Chief Medical Officer, Physicians, and Member/Provider Inquiries/ Appeals . + Provides… more
- Penn Medicine (Bala Cynwyd, PA)
- …external appeals vendor for government retrospective reviews. + Assists Utilization Management teams with vendor relations regarding Physician Advisory ... hospital based technical coding, billing and medical necessity matters related to utilization management . + Review medical documentation and provide feedback to… more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + Req ... Resource Management issues, other issues including concerns involving under/over utilization , avoidable days and quality issues. 13. Responsible for all incoming… more
- Trinity Health (Farmington Hills, MI)
- …regulations, healthcare financing and managed care. Knowledge of and experience in case management and utilization management . Knowledge of insurance and ... rejection, denial and appeal activities with Ministry Organization (MO) based Utilization Review/Case Management departments; + Reviews and understands … more
- LA Care Health Plan (Los Angeles, CA)
- …Skills Required: Knowledge of state, federal and regulatory requirements in Appeals /Care/Case/ Utilization Management /Quality. Strong verbal and written ... Supervisor, Appeals and Grievances Clinical Operations RN Job Category:...a lead/supervisory experience. Equivalency: Completion of the LA Care Management Certificate Training Program may substitute for the supervisory/… more
- Centene Corporation (Columbus, OH)
- …Knowledge of NCQA, Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. **License/Certification:** + LPN - ... 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, national organization offering competitive… more
- CareFirst (Baltimore, MD)
- …**Knowledge, Skills and Abilities (KSAs)** + Knowledge of NCQA requirements of utilization review, Case Management standards and guidelines, appeal rights and ... of the Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs and Quality of Care Complaint Unit. May lead… more
- Rush Copley Medical Center (Aurora, IL)
- …+ Organized, attentive to details, and self-motivated. **Experience** + Knowledge/experience in utilization management , denials and/or appeals management ... **Position Summary** : The Appeals Specialist RN reviews inpatient hospital denials, clinical...and works collaboratively with physician advisor team (PAT), providers, utilization management , coders, insurance companies and revenue… more
- Penn Medicine (Philadelphia, PA)
- … appeals correspondence. + Maintains database for the department and the utilization management requirements for the hospital information system and within ... Clinical Appeals Coordinator in all phases of the Clinical Quality and Utilization Management functions including but not limited to data entry, obtaining… more
- Henry Ford Health System (Troy, MI)
- …experience . + Minimum of two (2) years of experience working on utilization management platform-processing authorizations. + Minimum of two (2) years of ... prompt and thorough investigation of medical, transportation, and pharmacy member appeals and grievances for Health Alliance Plan's (HAP's): Commercial, Medicare… more
- Trinity Health (Farmington Hills, MI)
- …in the timeliest manner possible: + Coordinates follow-up activities with Utilization Review/Case Management /Coding/ Nurse Liaison to provide required ... as part of the payment resolution team that receives, analyzes, and appeals denials received for an assigned PBS location. Reviews, researches and resolves… more
- LA Care Health Plan (Los Angeles, CA)
- Utilization Management Nurse Specialist LVN II Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 ... net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist LVN...experience in a patient care setting and/or combination in utilization management , appeals and grievances,… more
- McLaren Health Care (Detroit, MI)
- **Department: Utilization Management ** **Daily Work Times: 7:00am-3:30pm** **Shift: Days** **Scheduled Bi-Weekly Hours: 40** **Position Summary:** Responsible ... as Assigned:** 1. Performs a variety of concurrent and retrospective utilization management -related reviews and functions to ensure that appropriate… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …BHPS provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity ... with or without notice. Primary Responsibilities * Perform prospective utilization reviews and first level determinations for members using...of services and care. * Provides referrals to Case management , Disease Management , Appeals &… more
- Beth Israel Lahey Health (Burlington, MA)
- …Functions and Responsibilities:** Performs a variety of concurrent and retrospective utilization management -related reviews and functions to ensure that ... payer certification, and denied cases. Monitors effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics,… more
