- UNC Health (Chapel Hill, NC)
- …unique communities we serve.RN Utilization Manager position specifically for a Utilization Manager/ Clinical Appeals Nurse. This person is based at the Hedrick ... quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met… more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist...continued stay using evidence from the medical record and clinical review tools, as well as input from ... and executes the appeal process for all AHS facilities clinical appeals and third party audits. **DUTIES...ensure effective resource utilization and an appropriate level of care . 5. Coordinates all utilization review functions,… 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, June 3, 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
- 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 ... clinical determinations cannot be made by the Initial Clinical Reviewer . + Discusses determinations with requesting...as needed to discuss cases and problems. + Utilizes medical/ clinical review guidelines and parameters to assure… more
- Evolent Health (Columbus, OH)
- …of the request and provides clinical rationale for standard and expedited appeals . + Utilizes medical/ clinical review guidelines and parameters to assure ... and costly health conditions. Working across specialties and primary care , we seek to connect the pieces of fragmented...the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer you will be a key… more
- Evolent Health (Columbus, OH)
- …for the mission. Stay for the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer , Hematology and Medical Oncology you will be a key member of ... **What You Will Be Doing:** + Serve as the Clinical Reviewer in Oncology cases, that do...within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure… more
- Independent Health (Buffalo, NY)
- …consistent review and investigation of provider and/or member complaints and/or appeals . The Contractual Reviewer -Senior will be required to rely on their ... to collaborate with multiple departments and associates to properly investigate appeals /complaints. The Contractual Reviewer -Senior will also be responsible for… more
- Guthrie (Sayre, PA)
- …processes and requirements for prior authorization/certification for reimbursement of patient care services. The Utilization Reviewer : * Secures authorization as ... eligibility for licensure required Experience: Minimum of five years clinical experience in an acute health care ...to track and monitor the status for denials and appeals . c) Collects and aggregates clinical , financial,… more
- Cleveland Clinic (Stuart, FL)
- …UM Team Manager to perform UM activities which include admission review , concurrent review , retrospective chart review and clinical systems review to ... patient's hospital stay or visit. Some of your responsibilities include medical record review , providing clinical information to the payer, UM data collection… more
- Banner Health (AZ)
- …a Registered Nurse and your knowledge of Case Managment and Utilization Management to review clinical records to ensure patients are in the correct status. Your ... balance, and boosting employee engagement. As a Registered Nurse Reviewer , you will work a critical part of the...find many options for contributing to our award-winning patient care . POSITION SUMMARY This position reviews clinical … more
- Trinity Health (Farmington Hills, MI)
- …length of stay, level of care , missing pre-certification, or other clinical reasons and constructing warranted appeals for defined populations as directed ... causes of clinical denials. Responsible for leveraging clinical knowledge and standard procedures to track appeals...nursing experience, to include two (2) years of utilization review /case management, managed care or comparable patient… more
- Molina Healthcare (TX)
- …details to be discussed during our interview process._** **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct ... for appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical /medical reviews of… more
- R1 RCM (Salt Lake City, UT)
- …AI, intelligent automation, and workflow orchestration. As our ** Clinical Coding Appeals Nurse** , you will help review and interpret medical records ... position. **Here's what you will experience working as a Clinical Coding Appeals Nurse:** + Review...only does that drive customer success and improve patient care , but that same enthusiasm is applied to giving… more
- CareFirst (Baltimore, MD)
- … Medical Claims Review , Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs and Quality of Care Complaint Unit. May lead ... FUNCTIONS:** + Directs the Medical Review and Appeals units and manages multiple strategic clinical ...Licensure And/or Compact State Licensure. **Experience:** + 8 years clinical experience in care management. + 3… more
- Penn Medicine (Philadelphia, PA)
- …your life's work? **Summary:** Responsible for coordinating office activities for the Clinical Appeals Coordinators to assist the department in accomplishing the ... our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future...continuity of communication. + Supports the activities of the Clinical Appeals Coordinator in all phases of… more
- Texas Health Resources (Arlington, TX)
- …**Work location:** Remote **Work hours:** Monday - Friday from 8:00am - 4:30pm ** Clinical Review and Denials Department highlights:** + Flexible schedule + ... ** Clinical Reviews, Denial and Appeals RN**...necessary research for appealing denied days/stays through electronic record review . Requires access to Care Connect patient… more
- Martin's Point Health Care (Portland, ME)
- …and third-party administrators. + Prepares case files on clinical member and provider appeals for review by clinical team, including medical director. + ... the Medicare subject matter expert for the Medicare Managed Care Manuals pertaining to Part C appeals ...Managed Care Manuals pertaining to Part C appeals + Responsible and accountable to meeting 100% timeliness… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …provides Utilization Management services to its clients. The Utilization Review Appeals Nurse performs daily appeal reviews and clinical quality oversite. ... and policy review . + 2+ years' experience in a UM team/ Appeals within managed care setting. + 3+ years' experience in clinical nurse setting preferred.… 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 ... $87,342.00 (Mid.) - $107,498.00 (Max.) Established in 1997, LA Care Health Plan is an independent public agency created...evaluation by the Management Team. Duties Focus on quality review of grievance and appeals cases for… more
- Universal Health Services (Chicago, IL)
- … Appeals , External Independent Reviews, Retrospective Reviews, and State Fair Hearings. Review clinical information for all appeals utilizing nationally ... experience in mental health/psychiatry preferred. Knowledge: Possesses knowledge of utilization review , insurance and managed care procedures. Current knowledge… more
