- 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
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- Ready to help us transform healthcare? Bring your true colors to blue. The RoleThe RN Utilization Management Reviewer is responsible for facilitating ... benefit to provide the best quality care. The TeamThe RN Utilization Management Reviewer...+ Licensure in additional states a plus. + For registered nurses only: a bachelor's degree in (BSN) preferred.… more
- Humana (Boston, MA)
- **Become a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the ... communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work...skills to make an impact** **Required Qualifications** + Licensed Registered Nurse ( RN ) in the… more
- CenterWell (Boston, MA)
- … RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to ... put health first** Conviva Care Solutions is seeking a RN who will collaborate with other health care givers...DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous… more
- Brockton Hospital (Brockton, MA)
- …responsibilities. EDUCATION: + RN with Master's Degree + Current License as Registered Nurse in the Commonwealth of Massachusetts EXPOSURE CATEGORY: It is ... management experience Proven experience in coordinating discharge planning and utilization review experience required. Prior management experience… 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 ... reviews. **Required Qualifications** + 5+ years' experience as a Registered Nurse with at least 1 year...lower levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC… more
- Beth Israel Lahey Health (Burlington, MA)
- …the medical necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue integrity, these specialized ... Analyst works with physicians, the payers and inpatient case management team to validate the medical necessity of the...necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue… more
- Beth Israel Lahey Health (Cambridge, MA)
- …SKILLS, AND ABILITIES REQUIRED** 1. RN with experience in risk management , quality assessment, or utilization management . 2. Strong spreadsheet, ... on the key performance indicators and quality measures, the RN specialist also aims to foster a culture of...reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review … more
- Evolent (Boston, MA)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks ... quality and cost effective care delivery. **What You'll Be Doing:** + Performs utilization review of outpatient procedures and ancillary services. + Fulfills on… more
- Commonwealth Care Alliance (Boston, MA)
- …Work collaboratively with internal departments-including Clinical Operations, Contracting, Network Management , Utilization Management , and Business ... Knowledge, Skills, Abilities & Language (nice to have):** + Familiarity with care management and utilization management systems and workflows for populations… more
- Beth Israel Lahey Health (Needham, MA)
- …practice model. **Job Description:** **Essential Responsibilities:** 1. Performs utilization management , care coordination, and discharge planning ... third weekend & rotating holiday required) Job Summary: The RN Case Manager (CM) facilitates the coordination of care.... 4. Knowledge of discharge planning practices, understanding of utilization review practices including third party payer… more
- Highmark Health (Boston, MA)
- …triaging members to appropriate resources for additional support. + Implement care management review processes that are consistent with established industry, ... **Required** + 7 years in any combination of clinical, case/ utilization management and/or disease/condition management ...in addressing targeted populations **LICENSES or CERTIFICATIONS** **Required** + RN license in PA or WV or DE or… more
- Commonwealth Care Alliance (Boston, MA)
- …member experience. * Address provider inquiries related to care coordination, utilization management , and program participation, collaborating with internal ... does not have direct reports. Essential Duties & Responsibilities: Provider Relationship Management * Serve as the primary relationship manager and point of contact… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …health care settings (Inpatient, outpatient, or differing levels of care). + Utilization Management experience, preferred. + Active licensure in Massachusetts is ... Bring your true colors to blue. The Role The RN Case Manager is responsible for facilitating care for...standards to create, follow and appropriately document comprehensive care management plans. + Review medication list and… more
- Highmark Health (Boston, MA)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... and the proper action to complete the retrospective claim review with the goal of proper and timely payment...experience in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder… more
- Humana (Boston, MA)
- …in state of employment + 3 years clinical RN experience + 2 years of Utilization Review , Case Management , or Quality Management experience + Strong ... of action. The Quality Audit Professional 2 supports the Healthcare Quality Management Team in administering and implementing the Clinical Quality Management … more
- Brockton Hospital (Brockton, MA)
- …of five years clinical experience in an acute care facility required. Prior experience in case management , utilization review or discharge planning required. ... of our patients. Provides medical-surgical pediatric and obstetrical case management services to Brockton Hospital patients. Responsible for assuring continuity… more
- Edward M. Kennedy Community Health Center, Inc. (Framingham, MA)
- …require evening, weekend and/or holiday shifts on a rotating basis. Required Qualifications: + Registered Nurse License in MA + Bachelor's degree in Nursing from ... are currently hiring a Clinical Care Manager - OBAT RN based in Framingham. As part of a team-based...Care Manager (CCM) provides, coordinates, and organizes evidence-based care management to Medical Assistant Treatment Program (MAT) patients. As… 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...with disabilities to perform the essential functions. + Current Registered Nurse multi-state compact license in the… 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 ... in lab pre-analytical techniques preferred Licensure: + Current Massachusetts license as a Registered Nurse required OR + Current Massachusetts license as a… more