- Garden Place Healthcare (Attleboro, MA)
- …*Minimum of two years health care experience. *Experience with MDS completion, reimbursement, clinical resource utilization and/or case management is highly ... Medicare/Managed Care Assessments. *Tracks Skilled (MRA/HMA/HMO) customers utilizing Case Management Tools to determine continued and appropriate Medicare/Managed Care… more
- Lifespan (Taunton, MA)
- …director in review of financial reports, as needed. Budget Management Demonstrates appropriate utilization of staff resources, including overtime evaluation ... director in effectively managing the department within budgetary constraints. II. Leadership/ Management Skills Management , Operational, Clinical , Technical… more
- NavitsPartners (Boston, MA)
- …or case management role Demonstrated experience in discharge planning and utilization review within the past 4 years Working knowledge of InterQual(R) ... or financial needs and refer to appropriate resources Perform utilization reviews and respond to third-party payers with timely,...or equivalent clinical review system Case Management … more
- Lifespan (North Dartmouth, MA)
- …and implements corrective strategies to optimize drug use in compliance with clinical usage guidelines. Participates in quality management and quality ... Manager as applicable. Under the supervision of the Pharmacist-In-Charge, Senior Clinical Pharmacist Specialist, or Clinical Coordinator as appropriate… more
- US Tech Solutions (Canton, MA)
- …of clinical decision making and support needed to perform utilization management , medical necessity determinations and benefit determinations using ... remote, but Massachusetts RN license required.** **Job Summary The Clinical Reviewer is a licensed professional -a...unrestricted Massachusetts license required + Minimum of five years clinical experience in utilization management ,… more
- Commonwealth Care Alliance (Boston, MA)
- … Utilization Management reports to the Director of Utilization Management * Oversees clinical decision review for services requiring prior ... for overseeing and managing the daily operation of the Utilization Management Review Nurse and... Nurse and Specialist staff responsible for conducting centralized clinical review and authorization creation for centrally… more
- Evolent (Boston, MA)
- …from providers per guidelines. + Utilizing clinical guidelines approved by the Utilization Management Committee (UMC), the URN has the authority to authorize ... cost-effective care. **Collaboration Opportunities** : As a Radiation Technologist in the Utilization Management department, you will work closely with other… more
- Commonwealth Care Alliance (Boston, MA)
- … and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA ... Manager Utilization Management , the Nurse Utilization Management (UM) Reviewer is...direct reports. **Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …us transform healthcare? Bring your true colors to blue. The Role The RN Utilization Management Reviewer is responsible for facilitating care for members ... provide the best quality care. The Team The RN Utilization Management Reviewer is part...and retrospective reviews with emphasis on utilization management , discharge planning, care coordination, clinical outcomes,… more
- Actalent (Boston, MA)
- …with all company policies and standards. Essential Skills + Proficiency in clinical review , case management , utilization review , and utilization ... Clinical Review Clinician Job Description As... Clinical Review Clinician Job Description As a Clinical...Medicare, and Medicaid regulations is preferred. + Familiarity with utilization management processes is preferred. + State… more
- Commonwealth Care Alliance (Boston, MA)
- …local regulatory guidelines. + Serve as the lead for CCA's Utilization Review functions working closely with other medical management team members. + Support ... review findings, actions, and outcomes in accordance with Utilization + Management policies; meets health plan...a clinical resource and coach for the utilization management team + Is available and… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …business expert for member and provider submitted appeals. Working collaboratively with Physician review unit, Utilization Management , Case Management , ... Nurse Reviewer is responsible for applying sound clinical judgement to review provider and member...Member appeals and Grievance, Provider Service, Claims, Network Management , and Medical Policy teams. This role is eligible… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …the Home Infusion Therapy, Specialty Pharmacy Network and Medical Utilization Management for pharmaceuticals programs + Partner with clinical and non- ... the Retail Pharmacy, Medicare Advantage Part D, Home Infusion Therapy, and Medical Utilization Management benefits. This position is eligible for the Flex… more
- Evolent (Boston, MA)
- …the mission. Stay for the culture. **What You'll Be Doing:** **Cardiovascular Utilization Management Reviewer (Interventional Cardiologist)** Are you ready ... make a meaningful impact on patient care in a non- clinical setting? Join our Utilization Management...within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure… more
- Evolent (Boston, MA)
- …clinical expertise in developing cardiovascular programs that include improvements to clinical effectiveness of utilization management (UM) and risk-based ... critical role in **Performance Suite risk arrangements with payers and strategic utilization management initiatives.** This is an opportunity for a… more
- Beth Israel Lahey Health (Plymouth, MA)
- …a job, you're making a difference in people's lives.** Full Time **Job Description:** ** Utilization Review & Denials management manager - Full Time** **Who ... and Serve Your Community!** **In your role as a Utilization Review & Denials Management ...UR and the analysis, resolution, monitoring & reporting of clinical denials. + Maintains current knowledge of payer contract… more
- Humana (Boston, MA)
- …Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a medical ... their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Humana (Boston, MA)
- …Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a medical ... daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Humana (Boston, MA)
- …Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a medical ... their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical ...with prior experience participating in teams focusing on quality management , utilization management , case … 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
