- Christus Health (Bellaire, TX)
- …liaison and point of contact for clinical denials and appeal inquiries. The Clinical Appeals Nurse will review each case identified/referred for appeal ... of the appeal, and manage the appeal process. The Clinical Appeals Nurse is responsible for appealing...be reported to the facility. Responsibilities: Focuses on the review and analysis of governmental denial rationales and provides… more
- MetroPlusHealth (New York, NY)
- …medical costs through timely prospective, concurrent, and retrospective review activities. Work Shifts9:00AM-5:00PMDuties & ResponsibilitiesPerforms telephonic ... medical delivery system through departmental UM proceduresCollects all pertinent clinical information and documents within CareConnectPromotes alternative care programs… more
- eviCore healthcare (New York, NY)
- …so delegated.Provides timely peer-to-peer discussions with referring physicians to clarify clinical information and to explain review outcome decisions.Maintains ... Provides timely expert medical review for requests to evaluate the medical necessity...in a state or territory of the United States.Reviews appeals for denied services related to current relevant medical… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …managing medical denials by conducting a comprehensive review of relevant clinical documentation. The Clinical Appeals Specialist will write compelling ... clinical prior authorization review and preparing and managing clinical appeals . **KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:** + Knowledge of… more
- Centene Corporation (Salem, OR)
- …that all appeal letters generated comply with both State and NCQA requirements. + Review clinical information for all appeals utilizing nationally recognized ... Time is strongly preferred RN or LPN with utilization review , case management, and appeals experience in...report verbal and written information regarding member and provider clinical appeals , including information follow up +… more
- AmeriHealth Caritas (Philadelphia, PA)
- **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with ... appeals , ensuring compliance with all regulatory milestones + Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation,… more
- Robert Half Accountemps (Ontario, CA)
- Description We are looking for a detail-oriented Clinical Appeals Reviewer to join our team in Ontario, California. In this role, you will be responsible for ... coordinating and managing documentation related to clinical appeals , ensuring compliance with health plan timelines. This is a long-term contract position… more
- Cognizant (Phoenix, AZ)
- …, and retro-authorization as well as timely filing deadlines and processes. . Review clinical denials including but not limited to referral, preauthorization, ... cycle or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and concurrent reviews .… more
- CommonSpirit Health (Englewood, CO)
- …We are seeking a highly skilled individual to develop and submit clinical appeals , expertly crafting physician-aligned letters based on federal and ... regulations, including CMS rules and the Two-Midnight Rule, while leveraging clinical criteria and prioritizing medical necessity to defend inpatient status. This… more
- Beth Israel Lahey Health (Charlestown, MA)
- …important role in a high-profile team tasked with handling all commercial and government clinical appeals and audit processes. The Clinical Analyst will ... to gather information that would support submitted charges. Prepare clinical appeals relevant to the audits in...review of denials by hospital departments, and provide clinical improvement initiatives. * Draft, revise, and enforce BILH… more
- Northwell Health (Melville, NY)
- …plus specialized certifications as needed. Preferred Skills 3-5 years experience in Utilization Review , Case Management, and Clinical Appeals . 3-5 years of ... stay. Ensures compliance with current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately… more
- Centene Corporation (New York, NY)
- …of all appeals requests + Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry ... **Hours: 8:30am-5pm EST Monday - Friday.** **Position Purpose:** Performs clinical reviews needed to resolve and process appeals...analyzing the basis for the appeal + Ensures timely review , processing, and response to appeal in accordance with… more
- University of Michigan (Ann Arbor, MI)
- Clinical Denials Prevention & Appeals Specialist...posted for a minimum of seven calendar days. The review and selection process may begin as early as ... **Job Summary** The Clinical Denials Prevention & Appeals Specialist role is entirely remote. The Clinical... Appeals Specialist role is entirely remote. The Clinical Denials Prevention & Appeals Specialist plays… more
- Catholic Health (Buffalo, NY)
- …with varied hours based on role of management and oversight of team Summary: The Clinical Denials and Appeals , Clinical Supervisor is responsible for the ... people, carrying out and documenting the appeals process for denied claims denied due to reasons...and internal stakeholders including, but not limited to, Utilization Review , Case Management, Clinical Documentation Integrity, Health… more
- LA Care Health Plan (Los Angeles, CA)
- …(A&G) & General Operations ( Clinical ) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals & Grievances ... for accuracy, clarity, and cultural appropriateness and sensitivity. + Review and monitor procedures for identifying quality of care...appeals & grievance process. Create a best in clinical appeals process that is efficient and… more
- McLaren Health Care (Grand Blanc, MI)
- …activities and commercial appeals beyond the first level, requiring complex clinical review and appeal letter writing. Responsible for collecting, analyzing, ... Medicaid, and commercial insurance. 8. Educates health team colleagues about complex clinical appeals , utilization review , including role, responsibilities… more
- Nuvance Health (Danbury, CT)
- …critical part in preventing payment denials by providing timely and accurate clinical information to all payers, while ensuring compliance with CMS requirements, ... behaviors to internal leadership for assistance in resolution. *Responsibilities:* * Review all inpatient admission and observation cases using InterQual, or… more
- Catholic Health Services (Melville, NY)
- … clinical expertise/reference for specialty services as needed to adequately prepare clinical review and/or appeal. + Demonstrates aptitude and skill in ... Long Island's Top Workplace! Job Details The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews...care to MCC in response to physician order, or review of updated clinical information + Acts… more
- LA Care Health Plan (Los Angeles, CA)
- …Desktop Procedures, in a consistent and accurate manner. This position will focus on quality review of non- clinical grievance and appeals cases for all line ... executing, tracking, and assessing targeted and random audits for non- clinical grievance and appeal case documentation. Ensure A&G Non-...evaluation by the Management Team. Duties Focus on quality review of grievance and appeals cases for… more
- CVS Health (Columbus, OH)
- …managed care. **Key Responsibilities** + Administers review and resolution of clinical complaints and appeals . + Interprets data obtained from clinical ... Nurse Consultant plays a key role in resolving clinical complaints and appeals by reviewing medical...**Required Qualifications** + 3+ years Utilization Management or Utilization Review experience. + 3+ years clinical nursing… more
