- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- … Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity reviews on ... prior authorization requests in accordance with national standards, contractual requirements,...coverage while working remotely. Primary Responsibilities * Perform prospective utilization reviews and first level determinations for members using… more
- Elevance Health (San Antonio, TX)
- …consumer's treatment journey. **Title:** Utilization Management Representative II - Prior Authorization **Location:** TX-SAN ANTONIO, 4751 HAMILTON WOLF RD, ... impact.** The ** Utilization Management Representative II - Prior Authorization ** is responsible for managing incoming...caller. + Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care. +… more
- Centene Corporation (Sacramento, CA)
- …Standard Hours with occasional weekends and holidays.** **Position Purpose:** Analyzes all prior authorization requests to determine medical necessity of service ... interdepartmental teams, to assess medical necessity of care of member + Escalates prior authorization requests to Medical Directors as appropriate to determine… more
- Actalent (Sunrise, FL)
- …direct utilization and capture data effectively. Responsibilities + Review prior authorization requests for medical necessity and appropriateness, utilizing ... Utilization Management Nurse !Job Description The ...between the Medical Director, physicians, and office staff, resolving prior authorization issues. + Communicate denial determinations… more
- Actalent (Sunrise, FL)
- …satisfaction, safety, and appropriate length of stay. Responsibilities + Review prior authorization requests for medical necessity and appropriateness using ... Actalent is hiring a Utilization Management Nurse ! Job Description The...with the interdisciplinary team to perform reviews of service authorization requests, ensuring the utilization of appropriate… more
- Commonwealth Care Alliance (Boston, MA)
- …clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA ... Utilization Mgmt **Position Summary:** Reporting to the Manager Utilization Management, the Nurse Utilization ...+ Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical… more
- US Tech Solutions (Chicago, IL)
- …as an RN + Registered Nurse in state of residence + Must have prior authorization utilization experience + Experience with Medcompass **Skills:** + MUST ... + Do you have experience with Prior Authorization ? + Do you have experience with Utilization... Review? + Do you have an Active Registered Nurse License? **About US Tech Solutions:** US Tech Solutions… more
- Humana (Richmond, VA)
- …a team **Preferred Qualifications** + Bachelor's degree + Previous experience in prior authorization , claims, and/or utilization management in healthcare, ... a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination,… more
- CVS Health (Sacramento, CA)
- …telephone queue working with providers to secure additional information for prior authorization review. CVS health requires eligible colleagues identified ... by the user up front. **Required Qualifications** * 1 year UM, concurrent review or prior authorization * 5 years of clinical experience required * 5 years… more
- CDPHP (Albany, NY)
- …responsible for the clinical review and documentation for services requiring prior authorization . This includes approval determinations and appropriate ... of acute care experience is required as a Registered Nurse . + Minimum of two (2) years Utilization... Nurse . + Minimum of two (2) years Utilization Management experience is preferred. + Knowledge of coding/claims… more
- US Tech Solutions (May, OK)
- …hospital experience . Registered Nurse in state of residence . Must have prior authorization utilization experience . Able to work in multiple IT ... and Medicare/Medicaid knowledge. . MUST HAVE UM experience, inpatient utilization management review. . MUST HAVE 1 YEAR OF...knowledge of Milliman/MCG. . MUST HAVE 6 months of Prior Authorization . Education: . Active and unrestricted… more
- CVS Health (Austin, TX)
- …and work schedules will include holidays and evening hours **Preferred Qualifications** + Prior Authorization or Utilization Management experience + Managed ... Friday, 10:00am to 7pm EST with occasional holiday rotation. Utilization Management is a 24/7 operation and work schedules...Qualifications** + 3+ years of experience as a Registered Nurse + Must have active current and unrestricted RN… more
- AmeriHealth Caritas (LA)
- …clinical experience in home healthcare or a medical office setting. + Previous prior authorization experience is required.; + Proficiency in Electronic Medical ... direction of a supervisor, the Clinical Care Reviewer - Utilization Management evaluates medical necessity for inpatient and outpatient...Degree in Nursing (BSN) preferred. + An active Registered Nurse (RN) license in good standing is required. +… more
- CVS Health (Carson City, NV)
- …1 year of Utilization Management experience in concurrent review or prior authorization . + Strong decision-making skills and clinical judgment in independent ... high-quality healthcare for members. We are seeking a dedicated Utilization Management (UM) Nurse Consultant to join...+ Experience in a high-volume clinical call center or prior remote work environment. **Education** + Associate's degree in… more
- Humana (Madison, WI)
- …specifically Word, Excel, and Outlook. + At least 3-years experience with prior authorization / utilization management. **Preferred Qualifications** + ... community and help us put health first** The UM/PA Nurse Supervisor plays a key leadership role in overseeing...leadership role in overseeing the daily operations of the Utilization Management and Pre- Authorization nursing teams. This… more
- CVS Health (St. Paul, MN)
- …of residence. + 3+ years of Nursing experience. Preferred Qualifications + Prior authorization utilization management/review experience preferred Outpatient ... and external constituents in the coordination and administration of the utilization /benefit management function. Required Qualifications + Registered Nurse in… more
- Humana (Madison, WI)
- **Become a part of our caring community and help us put health first** The Pre- Authorization Nurse 2 reviews prior authorization requests for appropriate ... and approves services or forward requests to the appropriate stakeholder. The Pre- Authorization Nurse 2 work assignments are varied and frequently require… more
- CVS Health (Springfield, IL)
- …+ Must be willing to work 8-5pm local time. **Preferred Qualifications** + Prior authorization utilization experience preferred + Outpatient Clinical ... opportunities to promote quality effectiveness of Healthcare Services and benefit utilization + Consults and lends expertise to other internal and external… more
- Humana (Atlanta, GA)
- …barriers to helping people achieve their best health. Humana CarePlus is seeking a Pre- Authorization Nurse who reviews prior authorization requests for ... and approves services or forward requests to the appropriate stakeholder. The Pre- Authorization Nurse roles and responsibilities include but are not limited… more
- Molina Healthcare (Albuquerque, NM)
- … Utilization Review RN or LPN in New Mexico. This team reviews the prior authorization requests for our New Mexico Medicaid recipients. Preference will be ... benefits and eligibility for requested treatments and/or procedures. + Conducts prior authorization reviews to determine financial responsibility for Molina… more
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