- Commonwealth Care Alliance (Boston, MA)
- …timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role ... Utilization Management , the Nurse Utilization Management (UM) Reviewer is...**Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior authorization in a variety… more
- Commonwealth Care Alliance (Boston, MA)
- … Management is responsible for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible ... reports to the Director of Utilization Management * Oversees clinical decision review for...reviews). * Hire, train and mentor UM staff, including nurse reviewers and support personnel. * Act as liaison… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …TeamAs an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will serve as a liaison and business expert for member and ... your true colors to blue. The RoleThe Clinical Appeals Nurse Reviewer is responsible for applying sound...provider submitted appeals. Working collaboratively with Physician review unit, Utilization Management ,… more
- US Tech Solutions (Canton, MA)
- …all aspects of clinical decision making and support needed to perform utilization management , medical necessity determinations and benefit determinations using ... criteria through participation in the IMPAC. + Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM… more
- Beth Israel Lahey Health (Burlington, MA)
- …you're making a difference in people's lives.** Joint role of Case Manager and Utilization Review Nurse **Job Description:** The Inpatient Registered ... the multidisciplinary team to ensure a timely process. Registered Nurses (RNs) with utilization review experience, case management experience, and med/surg… more
- Children's Hospital Boston (Boston, MA)
- …Posting Title:Per Diem RN Case Manager, Utilization Management /ReviewDepartment:Patient Services-Patient Care OperationsAutoReqId:80451BRStatus:Part-TimeStandard ... + Experience as a Case Manager (Discharge Planning and or Utilization Management ) preferred. Licensure/ Certifications: + Current Massachusetts license… more
- Elevance Health (Woburn, MA)
- …Finder and follows up with provider on referrals given. + Refers cases requiring clinical review to a nurse reviewer ; and handles referrals for specialty ... ** Utilization Management Representative II** **Virtual:** This...+ Processes incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and… more
- Beth Israel Lahey Health (Burlington, MA)
- …taking a job, you're making a difference in people's lives.** Manages the Utilization Management (UM) team, maintaining effective and efficient processes for ... collaboration with the Physician Advisors, Collaborates and helps facilitate the Utilization Review Committee. Continuously monitors processes for opportunities… more
- Sharecare (Boston, MA)
- …appropriate resource utilization and desired clinical outcomes. The Disease Management Nurse is also responsible during their interactions with participants ... learn more, visit www.sharecare.com . **Job Summary:** The Disease Management Nurse has the responsibility for supporting...and to take the pre and post tests to review competency during orientation. Yearly competency tests are required… more
- Humana (Boston, MA)
- …and Physical Therapy utilization review + Previous experience in utilization management , case management , discharge planning and/or home health or ... community and help us put health first** The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care... depending on case findings. + Educates providers on utilization and medical management processes. + Enters… more
- Beth Israel Lahey Health (Wakefield, MA)
- …system considered in lieu of degree. + Active, unrestricted Massachusetts Registered Nurse License required. Certification in Case Management (CCM) preferred. NH ... making a difference in people's lives.** The Care Manager, RN provides care management services to the BILHPN primary care physicians focusing on at risk, high… more
- Beth Israel Lahey Health (Wakefield, MA)
- …system considered in lieu of degree + Active, unrestricted Massachusetts Registered Nurse License required. Certification in Case Management (CCM) preferred. NH ... of population health and is responsible to ensure that quality, efficient care management services are provided to the BILHPN provider's risk populations. The Care… more
- Cambridge Health Alliance (Cambridge, MA)
- …team leader in multi-disciplinary team discussion regarding treatment planning, treatment review , quality assurance and utilization review ... Nurse Practitioner - Clinical Specialist II (APRN), Psychiatry...to nursing policy and procedure. + Communicate effectively with management , peers, and health team members. + Interact effectively… more
- Brockton Hospital (Brockton, MA)
- … management experience Proven experience in coordinating discharge planning and utilization review experience required. Prior management experience ... delays through problem resolution and follow-up. Monitors on-site case managers and utilization review staff to ensure compliance with Signature Healthcare… more
- WTW (Boston, MA)
- …reviewed including master templates and client specific responses + Collaborate with health management senior reviewer and Project Manager to conduct follow up ... + Health analytics experience preferred + Understanding of health plan utilization /case management processes, network management , credentialing, quality… more
- Beth Israel Lahey Health (Boston, MA)
- …daily schedule to expedite surgical cases or personnel. Works in collaboration with the Nurse in Charge and Anesthesia, but is ultimately responsible to the OR ... Nurse Manager. **Job Description:** PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:...during which hours, the substitution of cases and the utilization of specific rooms for specific cases. + Assures… more
- Molina Healthcare (Boston, MA)
- …integrated) performing one or more of the following activities: care review / utilization management (prior authorizations, inpatient/outpatient medical ... including 3 or more years in one or more of the following areas: utilization management , case management , care transition and/or disease management… more
- Humana (Boston, MA)
- …leader, with responsibility for evolving Humana's Utilization Management of medical review by physician or nurse , with a focus on our 5+ million Medicare ... members. The Director, Physician leadership will lead Medical Directors performing utilization management for Medicare inpatient and behavioral medicine case… more
- Children's Hospital Boston (Boston, MA)
- …concurrent review process for acute psychiatric care + Possessing experience in Utilization Management / Utilization Review + Demonstrating the ability ... + Experience as a Case Manager (Discharge Planning and or Utilization Management ) preferred. Licensure/ Certifications: + Current Massachusetts license… more
- East Boston Neighborhood Health Center (East Boston, MA)
- …range planning and determining staffing needs. + Assists Home Care Manager/Residential Nurse manager to monitor utilization and processes for stocking Nursing ... in policy review and revision. Works with Home Care Director/Residential Nurse Manager to update policies, procedures and workflows as needed to ensure… more