- Molina Healthcare (Akron, OH)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... schedule) Looking for a RN with experience with appeals, claims review , and medical coding....clinical/ medical reviews of retrospective medical claim reviews, medical claims and… more
- Lincoln Financial (Columbus, OH)
- …for conducting initial and ongoing interviews with claimants, obtaining, and reviewing medical records and making timely and ethical claim determinations. You'll ... through phone and e-mail to gather information regarding the Short Term Disability claim . + Collaborating with fellow case managers, nurse case managers and… more
- Elevance Health (Mason, OH)
- …Capabilities and Experiences:** + **Operating room and/or auditing experience highly preferred.** + ** Medical claims review with prior health care fraud ... you will make an impact:** + Investigates potential fraud and over-utilization by performing medical reviews via prepayment claims review and post payment… more
- CVS Health (OH)
- …within time zone of residence.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, ... Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.… more
- Cognizant (Columbus, OH)
- …. Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with ... 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… more
- CVS Health (OH)
- …and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness. RN ... - Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit...and multiple diagnoses that impact functionality. - Reviews prior claims to address potential impact on current case management… more
- Elevance Health (Mason, OH)
- …and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to payment. Researches new healthcare-related questions ... **Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU**...Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Clinical Fraud Investigator II** is responsible… more
- CVS Health (OH)
- …+ 3+ years clinical nursing experience, with 1-3 years managed care experience in Utilization Review , Medical Claims Review , or other specific program ... weekends depending on business needs** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in… more
- Elevance Health (Mason, OH)
- **Telephonic RN Nurse Case Manager I** **Sign On Bonus: $3000** **Location: This role enables associates to work virtually full-time, with the exception of required ... in different states; therefore Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager I** is responsible for performing care management within… more
- Elevance Health (Cincinnati, OH)
- **Telephonic Nurse Case Manager II** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Sedgwick (Columbus, OH)
- …review process including making a recommendation of specialty for the Independent Medical Review process. + Developing and delivering training materials and ... Best Workplaces in Financial Services & Insurance Sr. VP Medical Director **PRIMARY PURPOSE** **:** To evaluate medical...the following: + Conducting reviews on cases where the nurse is seeking treatment plan clarification, claim … more
- Sedgwick (Dublin, OH)
- …CA 91304 **PRIMARY PURPOSE** : Provides disability case management and routine claim determinations based on medical documentation and the applicable disability ... system. + Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims . + Evaluates and arranges appropriate… more
- Medical Mutual of Ohio (OH)
- Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million ... planning coordination and facilitation. Works with IT and Clinical Nurse staff to aid in the loading of HEDIS...in the loading of HEDIS data and collection of medical records. Works closely with HEDIS vendor support to… more
- Molina Healthcare (Cleveland, OH)
- …retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as ... Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial… more
- Elevance Health (Mason, OH)
- …experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing ... the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims...you will make an impact:** + Analyzes and audits claims by integrating medical chart coding principles,… more
- Veterans Affairs, Veterans Health Administration (Cleveland, OH)
- …determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible to apply. ... of Veterans in various settings, including the Emergency Department, non-Mental Health medical floors, and the Community Living Center (CLC). This population of… more
- CVS Health (OH)
- …plans. Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most ... a caseload. The Care Management Associate supports comprehensive coordination of medical services including Care Team intake, screening and supporting the… more