- Optum (San Juan, PR)
- …and obtain additional information needed to make an appropriate determination Determine if appeal review is clinical or administrative Research and make ... cases Coordinate with business partners to obtain decisions when appropriate Review member benefit information, provider specific information/contracts, claims ,… more
- Highmark Health (Wexford, PA)
- …Reviews pharmacy utilization management (UM) coverage requests and prepares such cases for clinical review by a pharmacist and/or medical director when required. ... medically necessary. (20%) Engages in member and provider outreach to resolve non- clinical issues such as appeal initiation requests, processing errors, and… more
- Kaiser Permanente (Denver, CO)
- …If the claim was denied correctly, forwards to appropriate staff for appeal review or enters authorization to pay correctly if appropriate. Build spreadsheet ... limited to: Macess, SharePoint, Health Connect, DOI issues, emails, review benefit exceptions, visiting member claims , self-funded...be made send info to Harrington Health requesting additional claim information. Daily review of the retro… more
- Hoag Memorial - Red Hill Clinic (Costa Mesa, CA)
- …Client Name Hoag Memorial - Red Hill Clinic Job Type Local Offering Non- Clinical Profession Medical Biller Specialty Hospital Job ID 16776482 Job Title Collector I ... queues. *Obtains the maximum amount of reimbursement by evaluating claims at the contract rate with the use of...(Examples: APC, DRG, APRDRG). *Reviews and initiates the initial appeal for underpayments, observing all timely requirements to secure… more
- Denver Health (Denver, CO)
- …timely follow-up, cash application processes, reconciling payer remittance, denial management and appeal functions for claims to government or grant funded ... and information systems to perform work processes. Essential Functions : Completes claims submissions, performs review of accounts, ensure that work performed… more
- Franciscan Missionaries of Our Lady Health System (Baton Rouge, LA)
- …placement. g. Collaborates with Centralized Denials Management Department to coordinated appeal efforts to secure claim reimbursed on services provided. ... all job requirements related to prospective, concurrent and retrospective case review and reporting quality issues identified during the utilization review… more
- UPMC (Pittsburgh, PA)
- …established processes. + Collaborate with physician leadership as warranted in preparation of appeal / clinical review responses. + BSN or Bachelors degree ... your career? UPMC is hiring a full-time Revenue Cycle Clinical Review Nurse. This position works Monday...the local care management departments by initiating the retrospective appeal process for acute inpatient clinical denials… more
- Corewell Health (Grand Rapids, MI)
- …+ Resolve appeal requests prior to committee or fair hearing review , when appropriate, including collaboration internally with all levels within the organization ... knowledge of policies and procedures, including medical policies which may impact the appeal and review process Preferred + Intermediate or advanced level using… more
- CVS Health (Hartford, CT)
- …of this Medical Director role include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered ... Medical Director role include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …the most appropriate decision within regulatory timeframes.The TeamAs an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will ... The RoleThe Clinical Appeals Nurse Reviewer is responsible for applying sound clinical judgement to review provider and member appeals for denied services… more
- HCA Healthcare (Dallas, TX)
- …each individual is recognized. Submit your application for the opportunity below: Clinical Denials Coding Review SpecialistParallon. **Benefits** Parallon, offers ... benefits may vary by location._** We are seeking a Clinical Denials Coding Review Specialist for our...as it relates to researching, analyzing, and resolving outstanding clinical denials and insurance claims . This job… 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 ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- Baptist Memorial (Memphis, TN)
- …performing activities related to denied claims such as obtaining authorizations, claims review , patient billing, appeal writing, auditing, and/or denial ... appeal , collaborate with coding/billing for formulation of appeal with corrected claims and denial resolution...Physician Advisor communication may be necessary to provide further clinical review from the physician perspective as… more
- Beth Israel Lahey Health (Plymouth, MA)
- …contract changes as they pertain to level of care determination and the appeal /denial process. + Oversees utilization review workflow processes to ensure timely ... for identified deficiencies. + Facilitates peer-to-peer communication in support of submitted claims . + Participates on the Utilization Review Committee +… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …medical information was provided to the third-party payer. + If necessary, helps clinical team understand denial and coordinates appeal process. + Creates cost ... clinical and/or related experience required. Case Management, Utilization Review and/or Prior Authorization experience is preferred. + **Certification/Licensure/Registration:**… more
- JB Hunt Transport (Lowell, AR)
- …keeping with applicable benefit plan guidelines, and present claim appeals to the Appeal Review Board, providing clinical insight specific to each case + ... with insured member, plan administrators, and provide support for clinical transitions, as necessary, as it relates to benefit...claim cases. + Assist with claim appeal process; gather information and prepare for review… more
- Intermountain Health (West Valley City, UT)
- …governmental insurance appeals using supporting documentation. 2. Assesses the appropriateness of clinical appeal requests by using payer policies and Federal ... **Job Description:** Uses nationally recognized, evidence-based utilization criteria to review medical records and perform clinical assessments for patient… more
- Houston Methodist (Houston, TX)
- …with physicians, revenue cycle personnel, and payers to successfully clear front end claim edits, appeal clinical denials, and address customer service ... + Integrates the payer medical policies, case specific medical documentation, and claims information into a concise appeal letter, including appropriate medical… more
- Molina Healthcare (Houston, TX)
- …of a formal appeal being submitted. + Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and...specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long… more
- City and County of San Francisco (San Francisco, CA)
- …2574 positions + All City departments with open permanent positions can review your application Under general supervision, conducts professional-level work in ... clinical psychology; carries out psychodiagnostic examinations and psychotherapy of...on the application form the language(s) in which they claim proficiency. Important Note: Please make sure it is… more
