- Cognizant (Raleigh, NC)
- …and retro-authorization as well as timely filing deadlines and processes. . Review clinical denials including but not limited to referral, preauthorization, ... determinations to the Health Plan/Medical Director based on the review of clinical documentation in accordance with...have to be considered** . Educational background - Registered Nurse (RN) . 2-3 years combined clinical … more
- Evolent (Raleigh, NC)
- …clients as scheduled. + Determines medical necessity and appropriateness of services using clinical review criteria. + Accurately documents all review ... for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …(UM) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting ... UM/Appeals regulatory guidelines including URAC, NCQA, and ERISA + Proficiency in Clinical Appeals, Utilization Review , and Grievance processes including benefit… more
- Fresenius Medical Center (Garner, NC)
- …or federal surveys. + Participates in the completion of the FMS Administrative Clinical Review . **PHYSICAL DEMANDS AND WORKING CONDITIONS:** + The physical ... requirements. Ensure provision of quality patient care while maintaining cost-effective clinical operations in accordance with all legal, compliance, and regulatory… more
- Fresenius Medical Center (Knightdale, NC)
- **About this role:** As a Clinical Manager with Fresenius Medical Care, you will ensure that quality patient care is delivered while maintaining clinical ... or chronic kidney disease. **Training and advancement:** You will enter our Clinical Leadership Program that creates and supports a culture of continuous learning… more
- UNC Health Care (Raleigh, NC)
- … nursing care consistent with professional standards. Reporting and accountable to the Nurse Manager/Director, the Clinical Nurse is responsible for ... date: September 2025 - March 2026, the New Graduate Nurse Program will offer varied start dates based on...and confidence in the professional role. In addition to clinical orientation on the unit, the Residency program provides… more
- PruittHealth (Durham, NC)
- ** CLINICAL COMPETENCY COORDINATOR / NURSE EDUCATOR.** **Join the PruittHealth family, where the health and safety of our workforce is our top priority!** We're ... provided to patients is determined by assessing competency of clinical staff on an ongoing basis, evaluating care provided...conditions and acuity. 7. Meets regularly with DHS to review learning needs, coordinate training and to implement plans… more
- Sharecare (Raleigh, NC)
- … helps to drive cost effective and appropriate resource utilization and desired clinical outcomes. The Disease Management Nurse is also responsible during their ... more, visit www.sharecare.com . **Job Summary:** The Disease Management Nurse has the responsibility for supporting the goals and...and to take the pre and post tests to review competency during orientation. Yearly competency tests are required… more
- Dispatch Health (Raleigh, NC)
- **How You'll Make an Impact** DispatchHealthis looking for a Lead Nurse Practitioner/Physician Assistant (Advanced Practice Provider or APP) to join our growing ... clinical team in **Raleigh Durham, NC** . **_There is...APP coaching and service recovery, as necessary. + Chart Review with aim to promote evidence based medical practice… more
- Sunrise Senior Living (Raleigh, NC)
- …is to be a part of.** **Job ID** 2025-234685 **JOB OVERVIEW** The Wellness Nurse is responsible for monitoring the health and well-being of our residents and ... administration, communication with resident support services and families, and maintaining clinical quality assurance while leading and demonstrating the Mission for… more
- Cardinal Health (Raleigh, NC)
- …both scheduled outbound calls and inbound call queue. + Meets regularly with Clinical Supervisor and/or Senior Nurse , Individualized Care to discuss feedback ... who need them-faster.** **_What Individualized Care contributes to Cardinal Health_** Clinical Operations is responsible for providing clinical specialties… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …disability services for timely return to work. + Provides case management, utilization review , continued stay reviews, and based on clinical judgment and state ... About The Role Brighton Health Plan Solutions (BHPS) provides Utilization Review /Medical and Case Management services for Workers' Compensation. The Workers'… more
- CVS Health (Raleigh, NC)
- …clients. + Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures and regulatory ... needs to ensure appropriate administration of benefits. + Applies clinical judgment to the incorporation of strategies designed to...**Required Qualifications** + 5+ years' experience as a Registered Nurse with at least 1 year of experience in… more
- CVS Health (Raleigh, NC)
- …criteria to evaluate outpatient and inpatient services requiring precertification and concurrent review . + Conduct clinical reviews via phone and electronic ... healthcare for members. We are seeking a dedicated Utilization Management (UM) Nurse Consultant to join our remote team. **Key Responsibilities** + Apply critical… more
- BAYADA Home Health Care (Raleigh, NC)
- …is seeking a Registered Nurse (RN) to fill the position of **RN Clinical Manager** for our Raleigh, NC Medicare Certified Senior Living home health office. This ... clients living in Senior Living Communities. **As an RN Nurse Manager your day may look like this!** +...and support business growth. + Management and mentoring of Clinical Associates and field staff + Facilitate new hire… more
- Elevance Health (Durham, NC)
- ** Nurse Appeals RN-Quality of Care** **Hybrid 1:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while ... Work Hours:** Monday-Friday, 8:00AM -5:00 PM Eastern Standard Time The ** Nurse Appeals** is responsible for investigating and processing and medical necessity… more
- Elevance Health (Raleigh, NC)
- ** Nurse Appeals - Litigation & Legal Support** **Location:** North Carolina, candidates must be residents of North Carolina to be considered. **In Office ... necessary and is dependent on court hearing schedules. The ** Nurse Appeals - Litigation & Legal Support** is responsible...leadership by managing State Fair Hearing and External Medical Review requests. + Acts as a resource for both… more
- Elevance Health (Durham, NC)
- **Telephonic Nurse Case Manager II** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...health related field and minimum of 5 years of clinical experience; or any combination of education and experience,… more
- Surgery Care Affiliates (Raleigh, NC)
- …do it. Each decision we make is rooted in seven core values: + Clinical quality + Integrity + Service excellence + Teamwork + Accountability + Continuous improvement ... will. Responsibilities We are actively hiring for an Registered Nurse (RN) PreOp PACU. + Promote the mission, vision,...with other disciplines as needed. + Participate in quality review and performance improvement projects. + Participate in the… more
- Insight Global (Sanford, NC)
- Job Description A client of Insight Global is looking for a strong Nurse practitioner to assist in coordination of clinical operations, including medical ... database(s), as per standard protocols ORGANIZATIONAL RELATIONSHIPS * Will work with other clinical team members in the Kalamazoo Wellness clinic as well as interact… more