- Waystar (Atlanta, GA)
- **ABOUT THIS POSITION** The Clinical Product Consultant for Utilization Management is a member of the Customer Success Organization who will provide clinical ... best practice workflows. We are specifically seeking an experienced Utilization Review Nurse who will serve as...acute care setting + 2+ years of experience in utilization management + Knowledge and understanding of… more
- Humana (Atlanta, GA)
- …of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are… more
- Cognizant (Atlanta, GA)
- …background - Registered Nurse (RN) + 2-3 years combined clinical and/or utilization management experience with managed health care plan + 3 years' experience ... Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced...care revenue cycle or clinic operations + Experience in utilization management to include Clinical Appeals and… more
- CVS Health (Atlanta, GA)
- …we do it all with heart, each and every day. Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of ... efficient use of healthcare resources. Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of… more
- Molina Healthcare (Atlanta, GA)
- …of health care services provided to plan members. * Supports plan utilization management program and accompanying action plan(s), which includes strategies ... the most appropriate care at the most effective setting. *Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and… more
- Elevance Health (Atlanta, GA)
- …center The **Manager Behavioral Health Services** is responsible for Behavioral Health Utilization Management (BH UM), or Behavioral Health Case Management ... or related behavioral health field or a degree in nursing and minimum of 5 years of clinical experience...and/or outpatient psychiatric and chemical dependency treatment and prior utilization management experience; or any combination of… more
- Molina Healthcare (Atlanta, GA)
- …ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) ... modification of payment decisions. + Serves as a clinical resource for utilization management , CMOs, physicians and member/provider inquiries/appeals. + Provides… more
- Evolent (Atlanta, GA)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and ... **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to company policies and… more
- CVS Health (Atlanta, GA)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... Abuse or Maternity/ Obstetrics experience. **Preferred Qualifications** + 1+ years' Case Management experience or discharge planning, nurse navigator or nurse… more
- Molina Healthcare (Atlanta, GA)
- …key health care services (HCS) functions: care management , care transitions, utilization management , behavioral health and/or nurse advice line. ... professionals, in some or all of the following functions: utilization management , care management , care...and experience. * At least 5 years health care management /leadership required. * Registered Nurse (RN), Licensed… more
- Danaher Corporation (Atlanta, GA)
- …includes some of the following: infection detection/control, sepsis care, decision support, utilization management , case management , ED patient workflow, ... nursing , emergency medicine, pharmacy, quality, patient safety, risk management , IT, infection control, laboratory, and administration is required. This position… more
- Molina Healthcare (Atlanta, GA)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... or emergency room. Preferred Experience Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of… more
- Elevance Health (Atlanta, GA)
- …solving with providers, claims or service issues. + Assists with development of utilization /care management policies and procedures. + Within the medical ... **Transplant Nurse II** **Location:** Virtual: This role enables associates...II** will be responsible for providing case and/or medical management for members receiving transplant services. Continue to learn… more
- Sharecare (Atlanta, GA)
- …/ new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical, ... + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Elevance Health (Atlanta, GA)
- …criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management within the scope of licensure for members with complex and chronic care ... **Telephonic Nurse Case Manager II** **Location:** This role enables...claims or service issues. + Assists with development of utilization /care management policies and procedures. **Minimum requirements:**… more
- Elevance Health (Atlanta, GA)
- …to 8:00 PM EST. The ** Nurse Case Manager II** is responsible for care management within the scope of licensure for members with complex and chronic care needs by ... ** Nurse Case Manager II** **Location:** This role enables...providers, claims or service issues. Assists with development of utilization /care management policies and procedures. **Minimum Requirements:**… more
- Elevance Health (Atlanta, GA)
- …criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management within the scope of licensure for members with complex and chronic care ... **Telephonic Nurse Case Manager II** **Location: This role enables...claims or service issues. + Assists with development of utilization /care management policies and procedures. **Minimum Requirements:**… more
- Elevance Health (Atlanta, GA)
- …with providers, claims or service issues. + Assists with development of utilization /care management policies and procedures. **Minimum Requirements:** + Requires ... **Telephonic Nurse Case Manager I** **Location: This role enables... Case Manager I** is responsible for telephonic care management within the scope of licensure for members with… more
- Elevance Health (Atlanta, GA)
- …on company needs. The ** Nurse Case Manager II** is responsible for care management within the scope of licensure for members with complex and chronic care needs ... with providers, claims or service issues. + Assists with development of utilization /care management policies and procedures. **Minimum Requirements:** + Requires… more
- Highmark Health (Atlanta, GA)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... itemized bills, and claims data to assure appropriate level of payment and resource utilization . It is also used to identify issues which can be used for education… more