- Catholic Health Services (Melville, NY)
- …why Catholic Health was named Long Island's Top Workplace! Job Details The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews ... from payors for additional clinical documentation. Acts as liaison between the Utilization and Appeals Management Department and the physician of record, as… more
- LA Care Health Plan (Los Angeles, CA)
- Manager , Customer Solution Center Appeals and Grievances Job Category: Management/Executive Department : CSC Appeals & Grievances Location: Los Angeles, ... net required to achieve that purpose. Job Summary The Manager , Customer Solution Center Appeals and Grievances...in a manner consistent with regulatory requirements from the Department of Managed Health Care, Department of… more
- BronxCare Health System (Bronx, NY)
- Overview The Appeals Manager is responsible to assist in the analysis and preparation of response to denial notification letters that arrive in letter and ... to best respond to all hospital denials notification and documentation efforts. The Appeals Manager will provide timely tracking and trending of all denials… more
- Molina Healthcare (Midvale, UT)
- …Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/ Appeals . + Provides training, leadership and mentoring for less ... internet connectivity of high speed required._ **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical...has been made or upon request by another Molina department to reduce the likelihood of a formal appeal… more
- Munson Healthcare (Traverse City, MI)
- …customer service/interpersonal skills 6. Monitors and sorts incoming communication to the Utilization Management and Appeals department , including faxes, ... verbal communication skills. ORGANIZATIONAL RELATIONSHIP . Report to the Manager of Utilization Management and works closely... Utilization Management and works closely with the Utilization Management and Appeals team . Interacts… more
- Beth Israel Lahey Health (Burlington, MA)
- …Officer as part of an integrated Revenue Cycle model. + Ensures the Utilization Review department maintains documented, up-to-date policies and procedures and ... a job, you're making a difference in people's lives.** Manages the Utilization Management (UM) team, maintaining effective and efficient processes for determining… more
- Mount Sinai Health System (New York, NY)
- …Nurse denial phone calls for UM Nurse to follow + Prioritizes work as per department protocol (IPRO Discharge Appeals / Insurance requests) + Support Appeals ... **Job Description** **Insurance Specialist Mount Sinai West Utilization Mgmt FT Days EOW** To maintain front...To maintain front end operations of the Case Management Department by monitoring all incoming correspondence and ensuring it… more
- Children's Mercy Kansas City (Kansas City, MO)
- …review functions utilizing InterQual and/or MCG screening guidelines, and clinical denials/ appeals oversight. Participates in department and hospital performance ... to integrated inpatient teams; assists Director in the management of department ; including personnel and fiscal management and development of, and training… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** Manages the utilization of referral services. Enhances quality of care by assuring compliance with policies, including safety, ... **ESSENTIAL FUNCTIONS:** + Trains staff on standards of practice of Utilization Management and reimbursement methodologies and treatment coding. + Manages policies… more
- Children's Hospital Boston (Boston, MA)
- …Posting Title:Per Diem RN Case Manager , Utilization Management/ReviewDepartment:Patient Services-Patient Care OperationsAutoReqId:80451BRStatus:Part-TimeStandard ... experience required, pediatric experience preferred. + Experience as a Case Manager (Discharge Planning and or Utilization Management) preferred. Licensure/… more
- AdventHealth (Glendale Heights, IL)
- …and financial indicators including LOS, cost per case, avoidable days, resource utilization , readmission rates, concurrent denials, and appeals . *Uses data to ... 60139 **The role you'll contribute:** The role of the Utilization Management (UM) Registered Nurse (RN) is to use...UM RN is responsible to document findings based on department and regulatory standards. When screening criteria does not… more
- Molina Healthcare (Vancouver, WA)
- …(such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services ... The Pharmacist, UM will be responsible for reviewing coverage determinations and appeals in a timely, compliant, and accurate manner. The Pharmacist, UM will… more
- Cleveland Clinic (Beachwood, OH)
- …with one of the most respected healthcare organizations in the world. As a Utilization Management RN, you will provide a high level of patient care and clinical ... coordinating and obtaining prior authorizations for medication coverage, managing appeals , reviewing patient charts, conducting follow-up assessments to monitor… more
- Ochsner Health (Lafayette, LA)
- …the daily operations of all assigned divisions within the case management department in collaboration with the case management and social services leadership. ... systems (CMS) regulations, compliance and quality metrics. Experience managing denials and appeals of all payer cases in a timely and organized manner. Preferred… more
- Sharp HealthCare (San Diego, CA)
- …documents as appropriate in the electronic medical record and provides information to the department head as indicated. + Utilization review and utilization ... **Facility:** Sharp Memorial Hospital **City** San Diego ** Department ** **Job Status** Regular **Shift** Day **FTE** 1...1 **Shift Start Time** **Shift End Time** Certified Case Manager (CCM) - Commission for Case Manager … more
- Mount Sinai Health System (New York, NY)
- …homecare, long term care or utilization review preferred. + Discharge Planner or Case Manager preferred. + Manager or a minimum of 3-5 years? experience as a ... **Job Description** **RN/Case Manager MSH Case Management FT Days** The Case...length of stay (LOS), improved efficiency, quality and resource utilization . Assignment will be by units/clinical areas of practice… more
- Mount Sinai Health System (New York, NY)
- …homecare, long term care or utilization review preferred. + Discharge Planner or Case Manager preferred. + Manager or a minimum of 3-5 years? experience as a ... **Job Description** **RN/Case Manager Inpatient Mount Sinai West FT Days 8a-4p...length of stay (LOS), improved efficiency, quality and resource utilization . Assignment will be by units/clinical areas of practice… more
- LifePoint Health (Rutherfordton, NC)
- …through the appeals process; including RAC chart audit reviews. Emergency Department (ED) Case Management1. Serves as a gatekeeper of patients being admitted to ... the hospital by facilitating initiation of care starting.2. The ED Case Manager starts initiation and utilization process, encouragement of use of reimbursable… more
- LifePoint Health (Hickory, NC)
- *Registered Nurse (RN), Clinical Case Manager * PRN * * *Your experience matters* At Frye Regional Medical Center, we are driven by a profound commitment to ... technology to directly impact patient wellbeing. ** * * * Department /Unit Summary* * * Monday-Friday 7:30a-4:00p/8:00a-4:30p Accountable for the execution,… more
- State of Colorado (Denver, CO)
- …ten (10) calendar days from your receipt of notice or acknowledgement of the department 's action. For more information about the appeals process, the official ... Assistant Nurse Manager - Nurse III - Colorado Mental Health...Job Type Full Time Job Number IIC 05943 06/06/2025 Department Colorado Department of Human Services Division… more