- Highmark Health (Buffalo, NY)
- …**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
- 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
- Kepro (Los Angeles, CA)
- …partner for health solutions in the public sector. Acentra seeks aUtilization Clinical Reviewer - LCSW/LMFT/LPCC/LCPC (Remote within California) to join our ... programs with experience navigating similar projects. + Ability to develop level-of- care recommendations based on clinical medical records and evaluations.… more
- Prime Therapeutics (Columbus, OH)
- …fuels our passion and drives every decision we make. **Job Posting Title** Physician Clinical Reviewer - GI- 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
- Kepro (IL)
- …to join our growing team. Job Summary: Our Behavioral Health Clinical Reviewer will coordinate program services and review activities associated with the ... Quality Improvement Organization (QIO) contract. The Child/Adolescent Behavioral Health Clinical Reviewer performs eligibility determination, residential treatment… 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
- 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 1, 2024 Centers Plan for Healthy Living's goal is to ... plans they need for healthy living. JOB SUMMARY: The Grievance & Appeal Clinical Reviewer performs complex medical necessity reviewed on Initial Adverse… more
- Trinity Health (Livonia, MI)
- **Employment Type:** Full time **Shift:** Rotating Shift **Description:** HMS collaborative reviewer The Clinical Nurse Reviewer 's chief responsibility is to ... database of all eligible cases for the hospital. The Clinical Nurse Reviewer also works closely with...projects as may be identified. **PERFORMANCE DUTIES** **Documenting Patient Care ** + Responsible for the identification of patients for… more
- Kepro (Richmond, VA)
- …UM Clinical Reviewer (RN, LCSW,LPC, and/or LBA) will use clinical expertise to review medical records against appropriate criteria in conjunction with ... the public sector. Acentra seeks a Behavioral Health UM Clinical Reviewer (PRN, Remote within Virginia) with...in the State of Virginia. + 1+ year of Utilization Review (UR) and/or Prior Authorization or… 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
- Elevance Health (Las Vegas, NV)
- …you a check, or ask you for payment as part of consideration for employment. **Nurse Reviewer I** + Job Family: MED > Licensed Nurse + Type: Full time + Date ... VEGAS + MN, MENDOTA HEIGHTS + TX, HOUSTON + TN, KNOXVILLE **Description** **Nurse Reviewer I** **Location:** Within 50 miles of a pulse point **Shift** : Sunday -… more
- Elevance Health (San Juan, PR)
- …you a check, or ask you for payment as part of consideration for employment. **Nurse Reviewer I (NCLEX)** + Job Family: MED > Licensed Nurse + Type: Full time + Date ... providing information technology and business operations services for health plans._ **Nurse Reviewer I** **Location:** This position will work on-site on Carelon PR… 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
- 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
- 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
- Elevance Health (Columbus, GA)
- … Care Management staff by assisting in training, attending utilization management rounds, and serving on interdepartmental initiatives; assists in developing ... neuropsychological testing. Position requirements: + Requires Ph.D. or Psy.D in clinical /counseling psychology and managed care experience which includes… more
- Adelante (Peoria, AZ)
- …but not limited to POCT items (flu, strep, UA, HCG testing) + Helps evaluate clinical care , utilization of resources, and development of new clinical ... clinical decision support tools for the adult primary care , OB, and Peds populations. + Participate in team...reporting, clinical audits, and programmatic evaluation. + Review and take action on care team… more
- Centene Corporation (Baton Rouge, LA)
- …the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, ... fresh perspective on workplace flexibility. **Position Purpose:** Authorize, direct and monitor care for behavioral health and substance abuse problems according to … more