- 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
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …TeamAs an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will serve as a liaison and business expert for member and ... your true colors to blue. The RoleThe Clinical Appeals Nurse Reviewer is responsible for applying sound...provider submitted appeals. Working collaboratively with Physician review unit, Utilization Management ,… more
- Beth Israel Lahey Health (Plymouth, MA)
- …years recent, broad clinical experience in the hospital setting + Experience with utilization management within the last 3 years required + An understanding ... using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal clinical denials related to the care provided to… more
- Beth Israel Lahey Health (Burlington, MA)
- …you're making a difference in people's lives.** Joint role of Case Manager and Utilization Review Nurse **Job Description:** The Inpatient Registered ... the multidisciplinary team to ensure a timely process. Registered Nurses (RNs) with utilization review experience, case management experience, and med/surg… more
- Beth Israel Lahey Health (Plymouth, MA)
- …years recent, broad clinical experience in the hospital setting + Experience with utilization management within the last 3 years required + An understanding ... using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal clinical denials related to the care provided to… 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
- Elevance Health (Woburn, MA)
- …Finder and follows up with provider on referrals given. + Refers cases requiring clinical review to a nurse reviewer ; and handles referrals for specialty ... ** Utilization Management Representative II** **Virtual:** This...+ Processes incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and… more
- Beth Israel Lahey Health (Burlington, MA)
- …taking a job, you're making a difference in people's lives.** Manages the Utilization Management (UM) team, maintaining effective and efficient processes for ... collaboration with the Physician Advisors, Collaborates and helps facilitate the Utilization Review Committee. Continuously monitors processes for opportunities… more
- Sharecare (Boston, MA)
- …appropriate resource utilization and desired clinical outcomes. The Disease Management Nurse is also responsible during their interactions with participants ... learn more, visit www.sharecare.com . **Job Summary:** The Disease Management Nurse has the responsibility for supporting...and to take the pre and post tests to review competency during orientation. Yearly competency tests are required… more
- Humana (Boston, MA)
- …and Physical Therapy utilization review + Previous experience in utilization management , case management , discharge planning and/or home health or ... community and help us put health first** The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care... depending on case findings. + Educates providers on utilization and medical management processes. + Enters… more
- Baystate Health (Springfield, MA)
- …Health Center** The **ACO Nurse Care Manager i** s responsible for the management of care for a defined group of patients including complex care management , ... Nurse Care Manager, Community...management application is required and is vital. Care management program metrics including, emergency room utilization ,… more
- Lawrence General Hospital (Lawrence, MA)
- …appropriate referrals and facilitates appropriate discharge plans. + Works in conjunction with Utilization Review Nurse , Social Worker and Clinical Care ... As the Complex Care Nurse Manager provides evidence-based assessments, tools, information, and...acute care setting with discharge planning, continuing care, care management , and utilization review . +… more
- Baystate Health (Springfield, MA)
- …in partnership with nursing/provider leadership, Performance Improvement Coordinator, and Risk Management . Additionally, review adverse events and be a member ... **Summary:** The Perinatal Safety Nurse is a member of Obstetric Nursing Leadership...and medical leadership and other departments such as Risk Management and Healthcare Quality. This individual will report to… more
- Humana (Boston, MA)
- …criteria or comparable (such as Interqual, etc.) **Preferred Qualifications** + Utilization Review /Quality Management experience + BA/BSN degree ... of our caring community and help us put health first** The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following… more
- Tufts Medicine (Lowell, MA)
- …productivity and utilization of all resources. The ED Clinical Resource Nurse utilizes the nursing process, leadership skills and current evidence based clinical ... grow with us? Tufts Medicine Lowell General Hospital is seeking an **ED Clinical Resource Nurse .** The ED Clinical Resource Nurse is a Registered Nurse with… more
- …and advising subordinates as necessary. Resolving routine personnel problems. Authorize and review utilization of home health nursing, social work, occupational, ... healthcare quality and safety, is looking for a** **Clinical Nurse Manager** **to join our** **Home Health** **team!** **Why...speech therapy for medical necessity and appropriateness of care. Review plans of care to ensure functional outcomes and… more
- Beth Israel Lahey Health (Wakefield, MA)
- …system considered in lieu of degree. + Active, unrestricted Massachusetts Registered Nurse License required. Certification in Case Management (CCM) preferred. NH ... making a difference in people's lives.** The Care Manager, RN provides care management services to the BILHPN primary care physicians focusing on at risk, high… more