- Elevance Health (Miami, FL)
- …RN license in the state of Florida. + Requires minimum of 5 years acute care clinical experience, utilization management or managed care experience; ... Senior RN Utilization Review /Management (Acute InPatient) JR116937 **Location:**...through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and… more
- Highmark Health (Camp Hill, PA)
- …**ESSENTIAL RESPONSIBILITIES** + Performs as the clinical subject matter expert for clinical , quality, care , utilization , high cost claim and population ... and accounts after customer discussions.Participate in ad-hoc and annual clinical review meetings as needed to provide...as quarterly and annual outcomes and trends for al clinical strategies for all current and emerging care… more
- Commonwealth Care Alliance (Boston, MA)
- …This Role is Important to Us:** The Nurse Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization ... review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role...and organizational determinations. The Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical … more
- Kepro (Los Angeles, CA)
- …culture is fueled by passion and driven by purpose. Position Overview As a Utilization Clinical Reviewer , you'll harness your expertise to meticulously ... programs with experience navigating similar projects. + Ability to develop level-of- care recommendations based on clinical medical records and evaluations.… more
- Guthrie (Sayre, PA)
- …(UM) processes and requirements for prior authorization/certification for reimbursement of patient care services. The Utilization Reviewer : * Secures ... Position Summary: The Utilization Management (UM) Reviewer , in collaboration...eligibility for licensure required Experience: Minimum of five years clinical experience in an acute health care … more
- Prime Therapeutics (Columbus, OH)
- …fuels our passion and drives every decision we make. **Job Posting Title** Physician Clinical Reviewer , MRx - Oncology - REMOTE **Job Description Summary** Key ... member of the utilization management team, and provides timely medical ...clinical determinations cannot be made by the Initial Clinical Reviewer . + Discusses determinations with requesting… more
- Evolent Health (Columbus, OH)
- …for the mission. Stay for the culture. **What You'll Be Doing:** As a Cardiology, Physician Clinical Reviewer you will be a key member of the utilization ... when available, within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the… more
- Evolent Health (Columbus, OH)
- …Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer you will be a key member of the utilization ... provides clinical rationale for standard and expedited appeals. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the MD… more
- Evolent Health (Columbus, OH)
- …staff. Initial clinical reviewers are supported by Physician clinical review staff (MDs) in the utilization management determination process. + Reviews ... the culture. **What You'll Be Doing:** As an Initial Clinical Reviewer , you will be a key...**What You Will Be Doing:** + Functions in a clinical review capacity to evaluate all cases,… more
- Centers Plan for Healthy Living (Margate, FL)
- …currently accepting applications for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer works within a ... in their home to improve their quality of life. Utilization Management Clinical Reviewer will...care managers and believe that coordinating high quality clinical and social services will result in better … more
- Centers Plan for Healthy Living (Margate, FL)
- RN - Grievance and Appeals Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063, USA Req #461 Monday, April 29, 2024 Centers Plan for Healthy Living's goal is ... plans they need for healthy living. JOB SUMMARY: The Grievance & Appeal Clinical Reviewer performs complex medical necessity reviewed on Initial Adverse… more
- Kepro (Richmond, VA)
- …Our Behavioral Health Clinical Reviewer RN/LCSW will use clinical expertise to review medical records against appropriate criteria in conjunction ... in the public sector. Acentra seeks a Behavioral Health Clinical Reviewer RN/LCSW to join our growing...assessment and critical thinking skills. + 1+ year of Utilization Review (UR) and/or Prior Authorization or… more
- Magellan Health Services (Evanston, WY)
- …an acceptable format to ensure accurate documentation and reporting. + May process utilization review requests received by phone, fax or mail within established ... Assists in processing difficult behavioral case management utilization requests in a timely manner according to...applicable field (eg, psychiatric field). General Job Information Title Clinical Reviewer , RN, LCPC, LCSW, LAC Grade… more
- Kepro (Richmond, VA)
- …appeals process with our client. UM Clinical Reviewer : + Using clinical knowledge and nursing experience, to review and interpret patient records and ... reviewer role - you will utilize clinical expertise for the review of medical...of Virginia. + 2+ years of experience in healthcare/managed care , preferably with experience in Utilization Management… more
- AdventHealth (Maitland, FL)
- …addressing areas of need.Collaborates with Senior Medical Officers with contracted managed care payers regarding utilization review management activities and ... efficiency in the inpatient setting.Performs other duties as assigned.Develops clinical care pathways and utilization ...the organization and collaborates with all levels of managed care team, utilization review management,… more
- Adelante (Goodyear, AZ)
- …health outcomes reporting, clinical audits, and programmatic evaluation. + Assist in clinical care by providing utilization of resources, and development ... Medical Assistant ( Care Today) - Goodyear Job Details Job Location...to patients regarding obtaining and collecting of specimens. + Review patient plan and educates patient on discharge instructions… more
- Carle (Urbana, IL)
- …Arts (LPHA) authorizing Integrated Assessment and Treatment Plans. Will complete thorough review of each document, provide clinical guidance to team members, ... Licensed Practitioner of the Healing Arts (LPHA) Reviewer + Department: Cert Comm BH Clinic -...or a related field CERTIFICATION & LICENSURE REQUIREMENTS Licensed Clinical Social Worker (LCSW) upon hire or Licensed … more
- Elevance Health (Walnut Creek, CA)
- **Nurse Reviewer I** **Location:** Within 50 miles of a pulse point in the following states: + California + Washington + Nevada **Shift** : An 8-hour shift from 9:30 ... am - 6 pm **P** **ST** The **Nurse Reviewer I** is responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for… more
- Penn Medicine (Plainsboro, NJ)
- …is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field ... Working for this leading academic medical center means collaboration with top clinical , technical and business professionals across all disciplines. Today at Penn… more
- Kepro (Lombard, IL)
- …leadership and clinical expertise to operations relating to the peer review process, utilization review activities, and other activities requiring ... Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver… more