- Commonwealth Care Alliance (Boston, MA)
- …Reporting to the Manager Utilization Management, the Nurse Utilization Management ( UM ) Reviewer is responsible for day-to-day timely clinical and service ... authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in...with Standard Operating Procedures + Ensures accurate documentation of clinical decisions and works with UM Manager… more
- CenterWell (Boston, MA)
- …our caring community and help us put health first** The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical ... **Required Qualifications** + Must be a licensed Registered Compact Nurse license (RN) with no disciplinary action and ability...Lung or Critical Care Nursing experience required + Prior clinical experience preferably in an acute care, skilled or… more
- Evolent (Boston, MA)
- …with clinical decision-making criteria sets (ie Milliman, InterQual) + UM Experience + Strong interpersonal, oral and written communication skills. + Possess ... 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
- Humana (Boston, MA)
- …a part of our caring community and help us put health first** The Telephonic Nurse Case Manager will be a member of the In-Home Case Management Team, providing a ... beneficiary's capacity for self- care, to cost-effectively achieve desired clinical outcomes and to enhance quality of medical care....and to enhance quality of medical care. The **Telephonic Nurse Case Manager** will collect and document data to… more
- Highmark Health (Boston, MA)
- …experience, or provider operations and/or health insurance experience + 1 year in a clinical setting **Preferred** + 5 years in UM /CM/QA/Managed Care + 1 year ... 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… more
- Datavant (Boston, MA)
- …recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully. Ideal candidate should be a Licensed ... Practical Nurse or Registered Nurse well versed in...denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines. **You will:** +… more
