- Commonwealth Care Alliance (Boston, MA)
- …timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role ... Utilization Management , the Nurse Utilization Management (UM) Reviewer is...**Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior authorization in a variety… more
- US Tech Solutions (Canton, MA)
- …all aspects of clinical decision making and support needed to perform utilization management , medical necessity determinations and benefit determinations using ... criteria through participation in the IMPAC. + Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM… more
- Commonwealth Care Alliance (Boston, MA)
- … Management is responsible for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible ... reports to the Director of Utilization Management * Oversees clinical decision review for...reviews). * Hire, train and mentor UM staff, including nurse reviewers and support personnel. * Act as liaison… more
- Children's Hospital Boston (Boston, MA)
- …Posting Title:Per Diem RN Case Manager, Utilization Management /ReviewDepartment:Patient Services-Patient Care OperationsAutoReqId:80451BRStatus:Part-TimeStandard ... + Experience as a Case Manager (Discharge Planning and or Utilization Management ) preferred. Licensure/ Certifications: + Current Massachusetts license… more
- Amergis (Canton, MA)
- …to facility wide personnel. + Demonstrated understanding of external agency interface with Utilization Review , Case Management , Patient Safety and Quality ... / Week Amergis Healthcare is seeking an experienced Registered Nurse and self-motivated individual to provide data collection and...collection and related activities for Quality Improvement (QI) and Utilization Review as well as completion of… more
- CVS Health (Boston, MA)
- …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… more
- CVS Health (Boston, MA)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... Pharmacy or Oncology.** **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… more
- Humana (Boston, MA)
- …Qualifications** + Bachelor's or Master's degree in Nursing + Prior/current experience in Utilization Management / Utilization Review with MCG + Direct ... community and help us put health first** The **Telephonic Nurse Case Manager** will be a member of the...Case Manager** will be a member of the Case Management Team, providing a comprehensive, holistic approach for case… more
- Sharecare (Boston, MA)
- …total healthcare management and ensure cost effective, appropriate resource utilization and quality outcomes. The Clinical Registered Nurse is also ... the participants and their Primary Care Provider according to the disease management program intervention guidelines. A Clinical Registered Nurse is supervised… more
- Fallon Health (Worcester, MA)
- …oriented, person-centered care, disease progression, disease prevention, wellness and management of chronic and episodic illness consistent with the participant's ... to Summit ElderCare program participants focusing on disease prevention, wellness and management of chronic and episodic illness. Addresses advance directives in a… more
- Fresenius Medical Center (Lincoln, RI)
- …and acts as the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member eligibility. Facilitate timely ... workup of patients for access management , dialysis services, patient education, hospitalizations, and kidney transplantation as appropriate, and ensures coordination… more
- Commonwealth Care Alliance (Boston, MA)
- …is strongly preferred. + Experience in Medicaid/Medicare grievances and appeals and/or Utilization Review is strongly preferred. **Required Knowledge, Skills & ... and summarizes medical information for medical director, consultants, and other external review . + Prepares recommendations to either uphold or deny appeal and… more
- Beth Israel Lahey Health (Boston, MA)
- …daily schedule to expedite surgical cases or personnel. Works in collaboration with the Nurse in Charge and Anesthesia, but is ultimately responsible to the OR ... Nurse Manager. **Job Description:** PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:...during which hours, the substitution of cases and the utilization of specific rooms for specific cases. + Assures… more
- Molina Healthcare (Worcester, MA)
- …integrated) performing one or more of the following activities: care review / utilization management (prior authorizations, inpatient/outpatient medical ... including 3 or more years in one or more of the following areas: utilization management , case management , care transition and/or disease management… more
- Children's Hospital Boston (Boston, MA)
- …concurrent review process for acute psychiatric care + Possessing experience in Utilization Management / Utilization Review + Demonstrating the ability ... + Experience as a Case Manager (Discharge Planning and or Utilization Management ) preferred. Licensure/ Certifications: + Current Massachusetts license… more
- Fallon Health (Worcester, MA)
- …tier of service at subacute facilities * Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services * Recognizes, ... Ad Hoc request when required * Concurrent and retrospective review utilizing a multitude of systems and electronic records...working with a frail or elder population. Recent case management or utilization management experience… more
- Children's Hospital Boston (Boston, MA)
- …reporting on blood utilization and wastage trends, evaluating blood management and stewardship initiatives through statistical review , and participating in ... transfusion safety through education, audits, quality improvement, transfusion event review , and active surveillance of the blood ordering through transfusion… more
- Fresenius Medical Center (Waltham, MA)
- …USV related billing concerns. + Communicating with the relevant personnel and management regarding all major issues impacting billing operations and collections. + ... Participates in team meetings with Intake, Denial Management , Billing, Cash and Follow up teams to assure...mandated by Medicare. + Assures the correct setup and utilization of billing software (Advantx/Medical Manager) and maintains system… more
- Edward M. Kennedy Community Health Center, Inc. (Framingham, MA)
- …Clinical Care Manager (CCM) provides, coordinates, and organizes evidence-based care management to Medical Assistant Treatment Program (MAT) patients. As an employer ... patients receive optimal care including acute illness and chronic disease management , education about lifestyle and behavior modification, and preventive care across… more