- Evolent (Raleigh, NC)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of ... a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and… more
- Cognizant (Raleigh, NC)
- …to Friday - Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced level work related to clinical ... . Maintain working knowledge of applicable health insurers' internal claims, appeals , and retro-authorization as well as timely filing deadlines and processes.… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in ... timely and accurate decisions + Ensure strict adherence to Appeals and Utilization Management (UM) processes and regulatory and...employment + Minimum of 5 years' experience in Clinical Appeals and Grievances within a managed care or payor… more
- Brighton Health Plan Solutions, LLC (NC)
- …provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with ... of services and care. * Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed. * Develop and review… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …all Clinical Services (CS) functions (prior authorization, concurrent review, appeals , case management, disease management, population health) per defined Client ... all WC State Reporting and audits. Essential Qualifications + Currently licensed Registered Nurse (RN), Nurse Practitioner (NP), or Physician Assistant (PA) with… more