- Evolent (Raleigh, NC)
- …scheduled. + Determines medical necessity and appropriateness of services using clinical review criteria. + Accurately documents all review ... for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks… more
- Elevance Health (Durham, NC)
- ** Nurse Reviewer I** A proud member...reviews that are routine having limited or no previous medical review experience requiring guidance by more ... Hours:** **Monday through Friday, 9:30AM - 6PM (CST).** The ** Nurse Reviewer I** is responsible for conducting...+ Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request… more
- Fresenius Medical Center (Garner, NC)
- …or federal surveys. + Participates in the completion of the FMS Administrative Clinical Review . **PHYSICAL DEMANDS AND WORKING CONDITIONS:** + The physical ... requirements. Ensure provision of quality patient care while maintaining cost-effective clinical operations in accordance with all legal, compliance, and regulatory… more
- Fresenius Medical Center (Garner, NC)
- **About this role:** As a Clinical Manager with Fresenius Medical Care, you will ensure that quality patient care is delivered while maintaining clinical ... kidney disease. **Training and advancement:** You will enter our Clinical Leadership Program that creates and supports a culture...a tremendous asset that sets us apart. At Fresenius Medical Care, you will truly make a difference in… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …(UM) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting ... or change at any time, with or without notice. Primary Responsibilities + Independently review and analyze pre and post service medical necessity, benefit, and… more
- Elevance Health (Durham, NC)
- ** Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU** **Location:** This role requires associates to be in-office 1 - 2 ... Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The ** Clinical Fraud Investigator II** is responsible… more
- Humana (Raleigh, NC)
- …Manager, Fraud and Waste Investigator: Nurse Audit/ Review performs clinical audit/validation processes to ensure that medical record documentation and ... approach, resources, schedules and goals. The Manager, Fraud and Waste Investigator: Nurse Audit/ Review validates and interprets medical documentation to… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …Medical and Case Management services for Workers' Compensation. The Workers' Compensation Nurse Case Reviewer collaborates with medical care providers, ... and the evaluation of coverage under the Plan. The Nurse Case Manager reports to the Casualty Department Manager.... review , continued stay reviews, and based on clinical judgment and state WCB Medical Treatment… more
- UNC Health Care (Raleigh, NC)
- … nursing care consistent with professional standards. Reporting and accountable to the Nurse Manager/Director, the Clinical Nurse is responsible for ... date: September 2025 - March 2026, the New Graduate Nurse Program will offer varied start dates based on...and confidence in the professional role. In addition to clinical orientation on the unit, the Residency program provides… more
- Dispatch Health (Cary, NC)
- …recovery, as necessary. + Chart Review with aim to promote evidence based medical practice and adherence toDispatchHealth clinical pathways + Work as part of ... Lead Nurse Practitioner or Physician Assistant FNP PA-C **How...in Deck. + In collaboration with Market Manager and Medical Director, conduct monthly clinical meetingswith all… more
- PruittHealth (Durham, NC)
- ** CLINICAL COMPETENCY COORDINATOR / NURSE EDUCATOR.** **Join the PruittHealth family, where the health and safety of our workforce is our top priority!** We're ... reviewing medical records and documentation. **KEY RESPONSIBILITIES:** 1. Coordinates clinical competency assessment and training needs of clinical staff,… more
- Veterans Affairs, Veterans Health Administration (Durham, NC)
- Summary The Licensed Practical Nurse will serve as the Clinical Care Coordinator to manage all administrative and clinical preparation for the General ... Surgery team at the Durham VA Medical Center. The Surgical service will screen patients for...patient information. Completed work should need only a general review by a registered nurse (RN) or… more
- Sunrise Senior Living (Raleigh, NC)
- …NAME** Sunrise of Raleigh **Job ID** 2025-234120 **JOB OVERVIEW** The Wellness Nurse is responsible for monitoring the health and well-being of our residents ... administration, communication with resident support services and families, and maintaining clinical quality assurance while leading and demonstrating the Mission for… more
- Humana (Raleigh, NC)
- …needs and by providing guidance along the healthcare continuum. You will perform clinical case review on members during an inpatient hospital admission. You ... us put health first** The NICU Care Manager, Telephonic Nurse 2, in a telephonic environment, assesses and evaluates...+ Bilingual is a plus - preferably Spanish + Clinical claim review experience **Additional Information** +… more
- BAYADA Home Health Care (Raleigh, NC)
- …as necessary. + Coordinate and/or deliver in-services for field staff. **Qualifications for a Clinical Nurse Manager:** + Registered Nurse (RN) with 2or more ... Nurse (RN) to fill the position of **RN Clinical Manager** for our Raleigh, NC Medicare Certified Senior...Facilitate new hire orientation of field staff + Documentation review , including OASIS + Monitoring quality assurance + Managing… more
- Elevance Health (Durham, NC)
- …Supports legal, management, and executive leadership by managing State Fair Hearing and External Medical Review requests. + Acts as a resource for both ... ** Nurse Appeals - Litigation & Legal Support** **Location:**...clinical and non- clinical teams, by managing and...accurate entry, investigation, and analysis of state appeals; summarizing medical information for review by medical… more
- Insight Global (Sanford, NC)
- …for a strong Nurse practitioner to assist in coordination of clinical operations, including medical surveillance, OSHA recordkeeping, facility operations and ... They should be comfortable with documenting patient data in electronic medical database(s), as per standard protocols ORGANIZATIONAL RELATIONSHIPS * Will work… more
- Highmark Health (Raleigh, NC)
- …over a specified panel of members that range in health status/severity and clinical needs; and assesses health management needs of the assigned member panel and ... utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent conducts… more
- CenterWell (Lillington, NC)
- …policies and standards. + Assesses staff education needs based on own the review of clinical documentation in addition to feedback and recommendations by ... on-site at our Lillington, NC branch location.** The **RN Clinical Manager** coordinates and oversees all direct care patient...Utilization Review staff. Upon completion of the assessment, creates and… more
- UNC Health Care (Chapel Hill, NC)
- …no Holidays, and no on-call. Surgical Center at UNC Chapel Hill is looking for Clinical Support Tech II candidates with a team building and positive attitude. As a ... the health and well-being of the unique communities we serve. Summary: The Clinical Support Technician II is responsible for assisting the professional caregiver in… more