- Healthfirst (GA)
- **Duties/Responsibilities:** + Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review, ... and reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems + Allocate,… more
- CVS Health (Atlanta, GA)
- …Must have active current and unrestricted RN licensure in state of residence. + Utilization Management is a 24/7 operation and work schedules will include ... in med surg or specialty area. + Managed Care experience preferred, especially Utilization Management . + Preference for those residing in EST zones.… more
- CVS Health (Atlanta, GA)
- …Monday through Friday 8:30-5pm EST. No weekends or holidays. + 1+ years of utilization review/ utilization management required. + 3+ years of behavioral ... clinical skills to coordinate, document and communicate all aspects of the utilization /benefit management program. Applies critical thinking and is knowledgeable… 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
- Elevance Health (Columbus, GA)
- ** Utilization Management Representative I** **Virtual:** This role enables associates to work virtually full-time, with the exception of required in-person ... integration, and ensures essential face-to-face onboarding and skill development. The ** Utilization Management Representative I** will be responsible for… more
- Baylor Scott & White Health (Atlanta, GA)
- **LOCATION:** Remote **SPECIALTY/DEPARTMENT:** Care Management : Case Management Utilization Management Appeals or grievances **SHIFT/SCHEDULE:** ... on position type and/or level **Job Summary** A Registered Nurse in Nursing Professional Development Generalist role...IN ONE OR MORE OF THE FOLLOWING SPECIALITIES:** **Case Management ** ** Utilization Management ** **Appeals or… more
- Emory Healthcare/Emory University (Atlanta, GA)
- …all case management activities at the local hospital, including utilization management , transitions of care, discharge planning, payer authorization, medical ... programs + And more **Description** We are seeking a capable **Director, Care Management ** who has acquired broad experience in caring for patients and has developed… more
- Molina Healthcare (Savannah, GA)
- … and effective resource management . + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure ... IT and data analysts to produce tools to report, monitor and improve Utilization Management . + Actively participates in regulatory, professional and community… more
- Evolent (Atlanta, GA)
- …Doing:** As a Clinical Reviewer, Nurse , you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference ... are supported by Field Medical Directors (MDs) in the utilization management determination process. + Reviews charts...**Qualifications:** + Current, unrestricted state licensure as a Registered Nurse + Associate or Bachelors in Nursing … more
- Humana (Atlanta, GA)
- …course of action. **Key Functions:** + Serves as a liaison between Humana utilization management (UM) operations, Humana's Risk and Compliance lines of defense, ... regarding prior authorization reviews, prepayment retrospective reviews, and any additional utilization management functions. + Develop and implement … 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 ... using a keyboard. **Preferred Qualifications** - 1+ years' Case Management experience or discharge planning, nurse navigator...lower levels of care. - 1+ years' experience in Utilization Review. - CCM and/or other URAC recognized accreditation… 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 ... in **Specialty Pharmacy or Oncology.** **Preferred Qualifications** + 1+ years' Case Management experience or discharge planning, nurse navigator or nurse… more
- Select Medical (Atlanta, GA)
- … within the plan of care. + Demonstrates compliance with facility-wide Utilization Management policies and procedures. + Coordinates UR compliance with ... current licensure in a clinical discipline either as a Nurse or a Respiratory Therapist OR Social Work SW/MSW...what is right. The Case Manager is responsible for utilization reviews and resource management , discharge planning,… more
- Humana (Atlanta, GA)
- …interpretation skills, with prior experience participating in teams focusing on quality management , utilization management , case management , discharge ... Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a… more
- Highmark Health (Atlanta, GA)
- …Inc. **Job Description :** **JOB SUMMARY** This job implements effective utilization management strategies including: review of appropriateness of health ... depending on where clinical care is being provided. **Preferred** + Certification in utilization management or a related field **SKILLS** + Working knowledge of… more
- Trinity Health (Athens, GA)
- …level of care throughout hospitalization in compliance with CMS and organizational utilization management requirements. RN CM helps to ensure medical necessity ... verbal report. Refers cases to home health, hospice, skilled nursing care facilities, DME companies, and other OP services...in a hospital setting; preferred 1 year in case management , utilization management , or discharge… more
- Molina Healthcare (Augusta, GA)
- …Experience** Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual ... / MCG guidelines. **Preferred License, Certification, Association** Active, unrestricted Utilization Management Certification (CPHM). MULTI STATE / COMPACT… more
- Elevance Health (Atlanta, GA)
- …management plan and modifies as necessary. + Assists with development of utilization /care management policies and procedures. + Participates in or leads ... services in multiple states. + AS or BS in nursing preferred. Certification as a Case Manager is preferred....management experience and minimum of 1 year in Nurse Care Mgr II role or equivalent experience; or… 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
- ChenMed (East Point, GA)
- …informed decisions re: goals of care, palliative care and hospice. + Utilization /Financial Management -managing resource utilization and reimbursement for ... in the ambulatory health care center setting, or occasionally in acute care, nursing homes, skilled nursing facilities (SNF) and home settings depending on… more