- Molina Healthcare (Orlando, FL)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... **Job Duties** + Performs clinical/ medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which… more
- MyFlorida (Orlando, FL)
- …that all verbal orders, including telephone orders from attending physicians, are reviewed by a registered nurse . + If no RN is available, receive all ... reflective of resident's status, and providing supervision and guidance to the Registered ( RN ), Licensed Practical Nurse (LPN), Certified Nursing… more
- USAA (Tampa, FL)
- …to include 6 years of experience working as a Registered Nurse ( RN ), Nurse Practitioner (NP), or Medical Doctor (MD) with accountability for highly ... us special and impactful. **The Opportunity** USAA Life Company's Claim Team is seeking a talented ** Medical ...+ Expert Advice: Ability to review complicated medical records and medical claims ,… more
- Public Consulting Group (Tallahassee, FL)
- …sector. To learn more, visit www.publicconsultinggroup.com . PCG is currently seeking a qualified Registered Nurse to perform as a Case Manager. The Case Manager ... Proven working experience in case management, including as a nurse , medical , mental health care manager or...plans. + Current license, certification or registration as a Registered Nurse or Social Worker **Working Conditions**… more
- Molina Healthcare (FL)
- …to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. ... nursing experience with broad clinical knowledge. + Five years experience conducting medical review and coding/billing audits involving professional and facility… more
- AdventHealth (Altamonte Springs, FL)
- …: Remote **The role you will contribute:** The role of the Utilization Management (UM) Registered Nurse ( RN ) is to use clinical expertise by analyzing ... resolutions of conflicts between status and authorization. Evaluates clinical review (s) and physician documentation for at-risk claims ;.... Current and valid license to practice as a Registered Nurse (ADN or BSN) required. .… more
- Molina Healthcare (Orlando, FL)
- …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse ( RN ) performs clinical/ medical reviews of… more
- Guardian Life (Tallahassee, FL)
- …providing comprehensive medical reviews and analysis of long-term disability claims . The RN Clinical Consultant identifies restrictions, limitations and ... duration impacting functional capacity based on medical data, to assist the Claim Managers...The RN Clinical Consultant reviews long-term disability claims to determine the impact of claimants' medical… more
- MetLife (Tampa, FL)
- …quarterly meetings with the Vocational resource and Account team member. * Participate in claim review meetings as requested by the customer. * Utilize tools ... for meetings Key Responsibilities: * Independently assess, analyze and render appropriate claim decisions pursuant to certificates on all claims . * Compare… more
- Elevance Health (Miami, FL)
- …network management input and dollar volume of provider. + Analyzes data to select claims to be reviewed, conducts reviews using medical charts, medical ... notes, and provider contracts. + Verifies dollar amount on claim is correct in claims system and...education and experience, which would provide an equivalent background. RN , LPN or medical coding certification strongly… more
- Elevance Health (Tampa, FL)
- …and efficiency recommendations. **Minimum Requirements:** + Requires current, active, unrestricted Registered Nurse license in applicable state(s). + Requires a ... experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing… more
- Sedgwick (Tallahassee, FL)
- …accredited college or university preferred. Current Certified Rehabilitation Counselor (CRC) or Registered Nurse ( RN ) license required. Current license, ... clinical evaluations on claims that require additional review based on medical condition, client requirement,... management of claims , including comprehension of medical terminology and substantiating claim decisions. **ADDITIONAL… more
- Lincoln Financial (Tallahassee, FL)
- …as indicated **What we're looking for** * 4 Year/Bachelor's Degree in Nursing * Registered Nurse License - Current, unrestricted license in the state where the ... organization. This position will be responsible for reviewing, analyzing, and interpreting medical information available for disability claims . In this role you… more
- Otsuka America Pharmaceutical Inc. (Tallahassee, FL)
- …to travel up to 25%.** **Educational Qualifications** Required: + Bachelor's Degree or Registered Nurse ( RN ). Minimum of 10 years industry experience ... and guidance, ICH/GCP, and Otsuka SOPs.** **Contribute to the development and review of all critical clinical study documents, including clinical protocols, informed… more
- Lincoln Financial (Tallahassee, FL)
- …duties as required. **What we're looking for** * Minimum of 5 years of disability claims experience * Current Registered Nurse license or Licensure in ... you will be responsible for leading and managing a team of nurse disability consultants and behavioral health consultants. This includes partnering closely with… more
- Ascension Health (Jacksonville, FL)
- …applicable processes and procedures. **Requirements** Licensure / Certification / Registration: + Registered Nurse credentialed from the Florida Board of Nursing ... claims , quality indicators and other risk-related data. + Coordinate the medical staff's professional performance evaluation and peer review programs in a… more
- NHS Management, LLC (Tallahassee, FL)
- …with company match + Paid Holidays and Paid Vacation Requirements + Must be a Registered Nurse in good standing + Previous experience in a supervisory capacity ... way. We are in search of a qualified Regional Nurse Consultant: The Regional Nurse Consultant will...to include reviews of significant events/unusual occurrences and a review of the medical record. We offer… more
- Elevance Health (Tampa, FL)
- …enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims . + Responsible for independently ... Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Investigator Senior** is responsible for the independent… more
- MyFlorida (Tampa, FL)
- …examination by a licensed physician, physician assistant, or licensed advanced practice registered nurse , based on specifications established by the commission. ... but are not limited to fraud against the Medicaid Program, false claims against the Medicaid program, investigating possible criminal violations of any applicable… more
- Lincoln Financial (Tallahassee, FL)
- …at a Glance** We are excited to bring on a Clinical Director to our claim 's organization. This role will be remote, or hybrid based on the proximity to Charlotte ... stakeholders that require collaboration with resources from clinical and claims . * Directs operational workforce & volume analysis, including analysis… more