- Evolent (Raleigh, NC)
- …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… 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 (Garner, NC)
- **About this role:** As a Clinical Manager with Fresenius Medical Care, you will ensure that quality patient care is delivered while maintaining clinical ... kidney disease. **Training and advancement:** You will enter our Clinical Leadership Program that creates and supports a culture...a tremendous asset that sets us apart. At Fresenius Medical Care, you will truly make a difference in… 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 ... or change at any time, with or without notice. Primary Responsibilities + Independently review and analyze pre and post service medical necessity, benefit, and… more
- Elevance Health (Durham, NC)
- ** Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU** **Location:** This role requires associates to be in-office 1 - 2 ... Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The ** Clinical Fraud Investigator II** is responsible… more
- Humana (Raleigh, NC)
- …Manager, Fraud and Waste Investigator: Nurse Audit/ Review performs clinical audit/validation processes to ensure that medical record documentation and ... approach, resources, schedules and goals. The Manager, Fraud and Waste Investigator: Nurse Audit/ Review validates and interprets medical documentation to… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …Medical and Case Management services for Workers' Compensation. The Workers' Compensation Nurse Case Reviewer collaborates with medical care providers, ... and the evaluation of coverage under the Plan. The Nurse Case Manager reports to the Casualty Department Manager.... review , continued stay reviews, and based on clinical judgment and state WCB Medical Treatment… more
- North Carolina Central University (Durham, NC)
- …and disease prevention. May supervise, teach, and evaluate students and other medical staff. Provides clinical knowledge to health-related queries from faculty ... director. Patient care is provided in an outpatient clinical setting. Nurse Practitioner may practice general...modalities. + To make accurate decisions based upon the review of patient symptoms and medical records.… 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
- Dispatch Health (Cary, NC)
- …recovery, as necessary. + Chart Review with aim to promote evidence based medical practice and adherence to DispatchHealth clinical pathways + Work as part ... Lead Nurse Practitioner or Physician Assistant FNP PA-C **How...readiness to practice during the interview process, arrange MATs ( medical assessment tool) as needed, and complete Clinical… more
- Humana (Raleigh, NC)
- …in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The Nurse reviews the medical documentation, researching claims, ... and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to...Medical Directors on submitted G&A cases. The G&A Nurse will participate in initiatives which result in improved… 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 ... reviewing medical records and documentation. **KEY RESPONSIBILITIES:** 1. Coordinates clinical competency assessment and training needs of clinical staff,… more
- Sunrise Senior Living (Raleigh, NC)
- …is to be a part of.** **Job ID** 2025-235355 **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
- CVS Health (Raleigh, NC)
- …benefit overall claim management. + Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to ... in the US with virtual training.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993,… more
- CenterWell (Raleigh, NC)
- …complaints. + Makes clinical level of care determination based on discussion, medical records, and any other pertinent clinical data. Matches these needs to ... regarding Home Health, Hospice, and Palliative Care Services. + Assist with clinical eligibility review for alternate services + Participates in special… more
- Elevance Health (Durham, NC)
- …and Quality of Care cases. + Extrapolates and summarizes medical information for medical director. + Prepares nurse summaries for Quality of Care cases and ... ** Nurse Appeals RN-Quality of Care** **Hybrid 1:** This...forwards to Medical Director for review and determination. +...grievances/quality of care issues and is a resource for clinical and non- clinical team members in expediting… more
- Datavant (Raleigh, NC)
- …years of CDI experience + 3+ years of clinical experience in an academic medical center + Registered Nurse license, Bachelor's degree in Nursing + CCDS or ... realize our bold vision for healthcare. **What We're Looking For:** As a Clinical Documentation Quality Improvement (CDQI) Specialist, you will play a pivotal role… more
- Griswold Home Care, Inc (Durham, NC)
- Are you looking to apply your leadership skills and clinical expertise in a dynamic and rewarding work environment? Join the Griswold team in championing ... RN Administrator, you'll play a vital role in overseeing non- medical client cases and performing ongoing care education for...the care plan to reflect any change, a documented review of the updated care plan with the caregivers,… more
- Insight Global (Sanford, NC)
- …for a strong Nurse practitioner to assist in coordination of clinical operations, including medical surveillance, OSHA recordkeeping, facility operations and ... They should be comfortable with documenting patient data in electronic medical database(s), as per standard protocols ORGANIZATIONAL RELATIONSHIPS * Will work… more
- Highmark Health (Raleigh, NC)
- …over a specified panel of members that range in health status/severity and clinical needs; and assesses health management needs of the assigned member panel and ... utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent conducts… more