- Molina Healthcare (Cincinnati, OH)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... **Job Duties** + Performs clinical/ medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which… more
- Medical Mutual of Ohio (OH)
- …perform pre-employment substance abuse and nicotine testing._ **Title:** _Clinical Appeal & Claim Review Nurse II_ **Location:** _Ohio_ **Requisition ID:** ... of care. **Responsibilities** + Independently evaluates basic to complex medical claims and/or appeal cases and associated...+ 3 years experience as a Registered Nurse in acute care, critical care, emergency medical… more
- CVS Health (Delaware, OH)
- …Franklin, Delaware, Madison, Pickaway or Union Counties, Ohio + Must have active and unrestricted Registered Nurse ( RN ) Licensure in the state of Ohio + 2+ ... all case management activities with members to evaluate the medical needs of the member to facilitate the member's...in Nursing **License** + Must have active and unrestricted Registered Nurse ( RN ) Licensure in… more
- CVS Health (Oregon, OH)
- …needs based on key questions and conversation. **Required Qualifications** - Active and unrestricted Registered Nurse ( RN ) or Licensed in Social Work (LISW) ... We are seeking self-motivated, energetic, detail oriented, highly organized, tech-savvy Registered Nurses to join our Case Management team. This opportunity offers… more
- CVS Health (Oregon, OH)
- …and health needs based on key questions and conversation. **Required Qualifications** - Active Registered Nurse ( RN ) License - 3 years of clinical experience ... day. **Position Summary** _- Must reside in_ **_Ohio_** The Nurse Case Manager is responsible for telephonically and/or face...all case management activities with members to evaluate the medical needs of the member to facilitate the member's… more
- Public Consulting Group (Columbus, OH)
- …sector. To learn more, visit www.publicconsultinggroup.com . PCG is currently seeking a qualified Registered Nurse to perform as a Case Manager. The Case Manager ... Proven working experience in case management, including as a nurse , medical , mental health care manager or...plans. + Current license, certification or registration as a Registered Nurse or Social Worker **Working Conditions**… more
- Molina Healthcare (OH)
- …to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. ... nursing experience with broad clinical knowledge. + Five years experience conducting medical review and coding/billing audits involving professional and facility… more
- Molina Healthcare (OH)
- …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse ( RN ) performs clinical/ medical reviews of… more
- Guardian Life (Columbus, OH)
- …providing comprehensive medical reviews and analysis of long-term disability claims . The RN Clinical Consultant identifies restrictions, limitations and ... duration impacting functional capacity based on medical data, to assist the Claim Managers...The RN Clinical Consultant reviews long-term disability claims to determine the impact of claimants' medical… more
- Elevance Health (Independence, OH)
- …network management input and dollar volume of provider. + Analyzes data to select claims to be reviewed, conducts reviews using medical charts, medical ... notes, and provider contracts. + Verifies dollar amount on claim is correct in claims system and...education and experience, which would provide an equivalent background. RN , LPN or medical coding certification strongly… more
- Elevance Health (Mason, OH)
- …and efficiency recommendations. **Minimum Requirements:** + Requires current, active, unrestricted Registered Nurse license in applicable state(s). + Requires a ... experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing… more
- Trinity Health (Columbus, OH)
- …(JD) degree preferred. + **Licensure / Certification:** State of Ohio Licensed Registered Nurse required; Certified Professional in Healthcare Risk Management ... of You! **What we offer:** + Competitive compensation and benefits packages ( medical , dental, and vision) + Retirement savings account with employer match starting… more
- Sedgwick (Columbus, OH)
- …accredited college or university preferred. Current Certified Rehabilitation Counselor (CRC) or Registered Nurse ( RN ) license required. Current license, ... clinical evaluations on claims that require additional review based on medical condition, client requirement,... management of claims , including comprehension of medical terminology and substantiating claim decisions. **ADDITIONAL… more
- Lincoln Financial (Columbus, OH)
- …as indicated **What we're looking for** * 4 Year/Bachelor's Degree in Nursing * Registered Nurse License - Current, unrestricted license in the state where the ... organization. This position will be responsible for reviewing, analyzing, and interpreting medical information available for disability claims . In this role you… more
- Medical Mutual of Ohio (OH)
- Founded in 1934, Medical Mutual is the oldest and one of the...the state of Ohio in one of the following: Registered Nurse ( RN ), Licensed Practical ... progressive experience in health plan case management or utilization review which includes training and curriculum development. **Professional Certification(s):** +… more
- Cleveland Clinic (Beachwood, OH)
- …Graduate from an accredited school of Professional Nursing + Current state licensure as a Registered Nurse ( RN ) + Three years of clinical nursing experience ... respected healthcare organizations in the world. As Disability Plan Nurse , you will primarily review short-term disability...appropriate utilization of benefit plans. + Prepare background and medical data for use in committee review … more
- Otsuka America Pharmaceutical Inc. (Columbus, OH)
- …to travel up to 25%.** **Educational Qualifications** Required: + Bachelor's Degree or Registered Nurse ( RN ). Minimum of 10 years industry experience ... and guidance, ICH/GCP, and Otsuka SOPs.** **Contribute to the development and review of all critical clinical study documents, including clinical protocols, informed… more
- Lincoln Financial (Columbus, OH)
- …duties as required. **What we're looking for** * Minimum of 5 years of disability claims experience * Current Registered Nurse license or Licensure in ... you will be responsible for leading and managing a team of nurse disability consultants and behavioral health consultants. This includes partnering closely with… more
- Elevance Health (Columbus, OH)
- …enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims . + Responsible for independently ... Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Investigator Senior** is responsible for the independent… more
- Lincoln Financial (Columbus, OH)
- …at a Glance** We are excited to bring on a Clinical Director to our claim 's organization. This role will be remote, or hybrid based on the proximity to Charlotte ... stakeholders that require collaboration with resources from clinical and claims . * Directs operational workforce & volume analysis, including analysis… more