- Molina Healthcare (Atlanta, GA)
- JOB DESCRIPTION **Job Summary** The Medical Claim Review Nurse provides support for medical claim review activities. Responsible for ensuring ... clinical/ medical reviews of retrospective medical claim reviews, medical claims and...hospital setting, including at least 1 year of utilization review , medical claims review… more
- Molina Healthcare (Atlanta, GA)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... schedule) Looking for a RN with experience with appeals, claims review , and medical coding....clinical/ medical reviews of retrospective medical claim reviews, medical claims and… more
- State of Georgia (Fulton County, GA)
- …additional experience in the analysis of medical services documentation and related claims 2) Utilization Review 3) Case Management 4) Analysis of CPT codes ... Nurse Investigator Georgia - Fulton - Atlanta (https://ga.referrals.selectminds.com/jobs/64040/other-jobs-matching/location-only)...clinical experience AND one (1) year experience working with medical claims . Preference will be given to… more
- Humana (Atlanta, GA)
- …guidance where needed. Follows established guidelines/procedures. **KEY ACCOUNTABILITIES** + Review medical documentation, obtain additional information that may ... community and help us put health first** The Appeals Nurse 2 resolves clinical complaints and appeals. The Appeals...TRICARE, all HGB policies and procedures as well as medical necessity review criteria and privacy requirements… more
- CVS Health (Atlanta, GA)
- …the US with virtual** **training.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, ... Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.… more
- Cognizant (Atlanta, GA)
- …. Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with ... to Friday - Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced level work related to clinical… more
- Elevance Health (Atlanta, GA)
- … medical necessity. + Extrapolates and summarizes medical information for medical director, consultants and other external review . + Research to determine ... to apply for denied services. + Utilizes guidelines and review tools to assess, analyze, interpret the medical...+ 3 years of clinical experience as a Registered Nurse is strongly preferred. + Experience reviewing medical… more
- CVS Health (Atlanta, GA)
- …implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness. + ... + Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit...and multiple diagnoses that impact functionality. + Reviews prior claims to address potential impact on current case management… more
- Evolent (Atlanta, GA)
- …+ Determines medical necessity and appropriateness of services using clinical review criteria. + Accurately documents all review determinations and contacts ... for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are… more
- Sedgwick (Atlanta, GA)
- …to Work(R) Fortune Best Workplaces in Financial Services & Insurance Nurse Allocator- RN Medicare Compliance **Prior Medicare-set-aside (MSA) experience highly ... **PRIMARY PURPOSE OF THE ROLE:** To perform provider outreach, specialized document review , and analysis and interpretation of interventions for the preparation of… more
- Elevance Health (Atlanta, GA)
- …and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to payment. Researches new healthcare-related questions ... **Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU**...Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Clinical Fraud Investigator II** is responsible… more
- Elevance Health (Atlanta, GA)
- **Telephonic Nurse Case Manager I** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager I** is responsible for telephonic care...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisor's on the development of… more
- Elevance Health (Atlanta, GA)
- **Telephonic Nurse Case Manager II** **Location** : This role enables associates to work virtually full-time, with the exception of required in-person training ... different states; therefore Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager II** is responsible for performing care management within… more
- Elevance Health (Atlanta, GA)
- **Telephonic Nurse Case Manager Senior** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training ... in different states; therefore, Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager Senior** is responsible for care management within the… more
- Elevance Health (Atlanta, GA)
- **Telephonic Nurse Case Manager II** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Elevance Health (Atlanta, GA)
- **Telephonic Nurse Case Manager II** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Travelers Insurance Company (Alpharetta, GA)
- …Utilizes evaluation documentation tools in accordance with department guidelines. + Proactively review Claim File Analysis (CFA) for adherence to quality ... negotiating and resolving assigned General Liability related Bodily Injury and Property Damage claims . Provides quality claim handling throughout the claim … more
- Lincoln Financial (Atlanta, GA)
- …mental health disability claims . You will act as a resource to review , analyze, and interpret medical information as well as assess ongoing interventions ... Protection Clinical organization. You will collaborate with Independent Consulting Physicians, Claims Specialists, and Nurse Disability Consultants to assist… more
- GE Vernova (Atlanta, GA)
- …responsible for analyzing Projects risk to develop mitigation plans and support claim development / resolution. Project Controller is also responsible to perform an ... based on allocated weightage + Participate in the Constructability review to make sure project schedule is aligned with...deliverables and ensure no impact to contract dates. + Claims (EOT, etc.); perform delay analysis to support extension… more
- Molina Healthcare (Atlanta, GA)
- … claims with corresponding medical records to determine accuracy of claims payments. + Review of applicable policies, CPT guidelines, and provider ... policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or… more