- Molina Healthcare (OH)
- …appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct...denied cases in which a formal appeals request has been made or upon request by… more
- Evolent (Columbus, OH)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Evolent Appeals Nurse 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… more
- Evolent (Columbus, OH)
- …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
- Molina Healthcare (Cincinnati, OH)
- …responsibilities will include specialized medical necessity reviews and/or appeals and supporting market performance. Performance activities include physician ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- Elevance Health (Columbus, OH)
- …will make an impact:** + Perform physician-level case review, following initial nurse review, of Medical Oncology regimens and supportive care. + Perform ... physician-level case review, following initial nurse review, of chemotherapy regimens. + Determine medical necessity...a subject matter expert. + Perform first level provider appeals as designated by the client for adverse determinations.… more
- Sharecare (Columbus, OH)
- …enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited to medical, ... 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status +...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Trinity Health (Columbus, OH)
- …RHIA, RHIT, CCS, CPC/COC or other coding credentials and/or Licensed Vocational Nurse / Licensed Practical Nurse licensure is required. CHC (Healthcare Compliance ... accordingly. Epic experience desired. 9. Experience and knowledge of working on appeals for insurance denials and identifying root cause. 10. Knowledge of Hospital… more
- Medical Mutual of Ohio (OH)
- …or fully remote; Ohio residents preferred. Prior Authorization experience or appeals preferred._** **Responsibilities** . Delivers and facilitates a variety of ... the state of Ohio in one of the following: Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Independent Social Worker (LISW) or Licensed Social… more
- Elevance Health (Independence, OH)
- …including assessments, service planning, care coordination, transition planning, member appeals , state hearings, and member and caregiver education and training. ... an equivalent background. Preferred Skills, Capabilities and Experiences: + Licensed Registered Nurse (RN) or Licensed Independent Social Worker (LISW) for the state… more