- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …within regulatory timeframes.The TeamAs an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will serve as a liaison and ... healthcare? Bring your true colors to blue. The RoleThe Clinical Appeals Nurse Reviewer... Reviewer is responsible for applying sound clinical judgement to review provider and member… more
- Children's Hospital Boston (Boston, MA)
- …Posting Description:Department Summary: The UM Case Managers at Boston Children's review documentation within 1 business day of patient admission to assess ... for the appropriate level of care for admissions and with post-discharge appeals of payer denials. They identify and implement initiatives to manage utilization… more
- Brockton Hospital (Brockton, MA)
- …external review agencies, to coordinate activities involved in medical record review , denials, appeals and reconsideration hearings. Works closely with the ... include the development and supervision of staff (RNs, LPN's,SWs and non- clinical support), evaluation and maintenance of case management skills and outcomes,… more
- Humana (Providence, RI)
- …a key enterprise leader, with responsibility for evolving Humana's Utilization Management of medical review by physician or nurse , with a focus on our 5+ million ... + Lead an operational team of Medical Directors to review authorizations and ensure clinical decision-making skills...the impactable drivers of prior authorization and look at appeals rate with denials and overturns. Deliver the upmost… more