- Evolent (Raleigh, NC)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks ... cost effective care delivery. **What You'll Be Doing:** + Performs utilization review of outpatient procedures and ancillary services. + Fulfills on call… more
- Humana (Raleigh, NC)
- …and help us put health first** The Manager, Fraud and Waste Investigator: Nurse Audit/ Review performs clinical audit/validation processes to ensure that medical ... is complete, compliant and accurate to support optimal reimbursement. The Manager, Nurse Audit/ Review works within specific guidelines and procedures; applies… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …and Case Management services for Workers' Compensation. The Workers' Compensation Nurse Case Reviewer collaborates with medical care providers, employers, ... and the evaluation of coverage under the Plan. The Nurse Case Manager reports to the Casualty Department Manager....timely return to work. + Provides case management, utilization review , continued stay reviews, and based on clinical judgment… more
- UNC Health Care (Raleigh, NC)
- …Nurses **Next program start date: September 2025 - March 2026, the New Graduate Nurse Program will offer varied start dates based on graduation and NCLEX dates.** ... General Program Overview: The twelve-month UNC Health Rex Nurse Residency program supports the transition from academia to practice for new graduate nurses. The… more
- Sharecare (Raleigh, NC)
- …To learn more, visit www.sharecare.com . **Job Summary:** The Disease Management Nurse has the responsibility for supporting the goals and objectives of the ... manner while ensuring high quality care. The Disease Management Nurse works with participating members to become empowered and...and to take the pre and post tests to review competency during orientation. Yearly competency tests are required… more
- Humana (Raleigh, NC)
- …community and help us put health first** The NICU Care Manager, Telephonic Nurse 2, in a telephonic environment, assesses and evaluates members' needs and ... for the care and wellbeing of members. The NICU Care Manager, Telephonic Nurse 2 work assignments are varied and frequently require interpretation and independent… more
- Veterans Affairs, Veterans Health Administration (Durham, NC)
- …and record relevant patient information. Completed work should need only a general review by a registered nurse (RN) or physician (MD/DO) for appropriateness ... Summary The Licensed Practical Nurse will serve as the Clinical Care Coordinator...completed work may require routine or detailed higher level review depending upon the complexity of the duties involved.… more
- CVS Health (Raleigh, NC)
- …medical necessity reviews. **Required Qualifications** + 5+ years' experience as a Registered Nurse with at least 1 year of experience in a hospital setting. + ... A Registered Nurse that holds an active, unrestricted license in their...levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC recognized accreditation preferred.… more
- BAYADA Home Health Care (Raleigh, NC)
- **BAYADA Home Health Care** is seeking a Registered Nurse (RN) to fill the position of **RN Clinical Manager** for our Raleigh, NC Medicare Certified Senior Living ... and geriatric clients living in Senior Living Communities. **Responsibilities for a Nurse Manager:** + Lead, inspire and motivate others to provide exceptional care.… 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 ... Resident Assessment/Evaluation process in accordance with state/provincial regulatory requirements + Review Physician Reports of all new residents as directed by… more
- Dispatch Health (Cary, NC)
- Lead Nurse Practitioner or Physician Assistant FNP PA-C **How You'll Make an Impact** DispatchHealth is looking for a Lead Nurse Practitioner/Physician Assistant ... Participate in APP coaching and service recovery, as necessary. + Chart Review with aim to promote evidence based medical practice and adherence toDispatchHealth… 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 not ... based on patient conditions and acuity. 7. Meets regularly with DHS to review learning needs, coordinate training and to implement plans for education and follow-up.… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in ... change at any time, with or without notice. Primary Responsibilities + Independently review and analyze pre and post service medical necessity, benefit, and quality… 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 days ... opportunities for fraud and abuse prevention and control. + Review and conducts analysis of claims and medical records...Skills, Qualifications, and Experiences:** + Fraud and Abuse experienced Nurse with a CPC are highly desired. For candidates… more
- Insight Global (Sanford, NC)
- …Description A client of Insight Global is looking for a strong Nurse practitioner to assist in coordination of clinical operations, including medical surveillance, ... we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/. Skills and… more
- Fresenius Medical Center (Garner, NC)
- …auditing activities. + Accountable for completion of the Annual Standing Order Review and Internal Classification of Disease (ICD) coding. + Manages clinic ... including efficient utilization of supplies or equipment and regular profits and loss review . + Responsible for all required network reporting and on-site state or… more
- Fresenius Medical Center (Garner, NC)
- …all FMS manuals. + Accountable for completion of the Annual Standing Order Review and ICD coding. + Checks correspondence whether electronic, paper or voice mail, ... surveys. + Participates in the completion of the FMS Administrative Clinical Review . **PHYSICAL DEMANDS AND WORKING CONDITIONS:** + The physical demands and work… more
- Highmark Health (Raleigh, NC)
- …to appropriate resources for additional support. + Implement care management review processes that are consistent with established industry, corporate, state, and ... federal law standards and are within the care manager's professional discipline. + For assigned case load, create care plans to address members' identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help… more
- Elevance Health (Durham, NC)
- …precertification, prior authorization, and post service requests. + Refers cases requiring clinical review to a Nurse reviewer . + Responsible for the ... I** is responsible for coordinating cases for precertification and prior authorization review . **How you will make an impact:** + Managing incoming calls or… more
- GE Vernova (Cary, NC)
- …and provides for cost optimization in all design. Serves as chief reviewer of technical output & solves technical conflicts.-Provides and attends cross discipline ... and prescription drug coverage; access to a Health Coach, a 24/7 nurse -based resource; and access to the Employee Assistance Program, providing 24/7 confidential… more