- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, ... changing environment- flexibility in assignment. * Proficient in Utilization Review process including benefit interpretation, contract language, medical and… more
- Cognizant (Raleigh, NC)
- …. Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with ... background - Registered Nurse (RN) . 2-3 years combined clinical and/or utilization management experience with managed health care plan . 3 years' experience in… more
- CenterWell (Raleigh, NC)
- …will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review ... RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to work… more
- Humana (Raleigh, NC)
- …communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently ... caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing...in an acute care setting + Previous experience in utilization management/ utilization review for a… more
- Granville Medical Center (Oxford, NC)
- Registered Nurse - ICU Location: Granville Health System, Oxford, NC About Granville Health System: For over a century, Granville Health System has been at the ... Health System has extended its services throughout Granville County, ensuring convenient medical care access for its residents. The Granville Health System main… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- About The Role Brighton Health Plan Solutions (BHPS) provides Utilization Review / Medical and Case Management services for Workers' Compensation. The Workers' ... Compensation Nurse Case Reviewer collaborates with medical care...for timely return to work. + Provides case management, utilization review , continued stay reviews, and based… more
- Granville Health System (Oxford, NC)
- Registered Nurse # ICU Location: Granville Health System, Oxford, NC # About Granville Health System: For over a century, Granville Health System has been at the ... Health System has extended its services throughout Granville County, ensuring convenient medical care access for its residents. The Granville Health System main… more
- Highmark Health (Raleigh, NC)
- …**Job Description :** **JOB SUMMARY** This job implements effective complimentary utilization and case management strategies for an assigned member panel. Provides ... to appropriate resources for additional support. + Implement care management review processes that are consistent with established industry, corporate, state, and… more
- Evolent (Raleigh, NC)
- …mission. Stay for the culture. **What You'll Be Doing:** The Nurse Practitioner/Physician Assistant (ARNP/NP/PA) Cardiology is responsible for support and assistance ... for all cardiology administrative and clinical utilization management and quality improvement functions under the auspices...under the auspices of the office of the Chief Medical Officer. **ESSENTIAL DUTIES AND RESPONSIBILITIES** : include the… more
- Novo Nordisk (Raleigh, NC)
- About the Department The Clinical, Medical and Regulatory (CMR) department at Novo Nordisk is one of the most diverse and collaborative groups within the ... and developing and implementing regulatory strategies with the FDA to providing medical education and collecting data to support efficacy and new product… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …and performance monitoring, oversees all Workers' Compensation (WC) Case Management and Utilization Review (UR) Programs. + Collaborates with the Chief ... for the Casualty and Clinical Services departments which in turn includes Utilization Management, Case Management and Population Health divisions. The position can… more
- Datavant (Raleigh, NC)
- …Specialist is to effectively defend utilization of available health services, review of admissions for medical necessity and necessity of continued stay ... expertise successfully. Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in...to author appeal letter Identification of referrals to the medical director for review + Select appropriate… more
- Highmark Health (Raleigh, NC)
- …and retrospective claims review basis. Review process includes a review of medical documentation, itemized bills, and claims data to assure appropriate ... and the proper action to complete the retrospective claim review with the goal of proper and timely payment...in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder or… more
- UNC Health Care (Chapel Hill, NC)
- …cost-effective discharge planning. + Serve as a key resource in case management, utilization review , and discharge planning. + Stay compliant with all regulatory ... assess the risk level of patients based on various factors such as medical conditions, social determinants of health, and behavioral health needs. b. Develop… more
- Deloitte (Raleigh, NC)
- …nurse , physician, physician assistant, case manager, clinical documentation specialist, utilization review , informatics RN, Quality, DRG Validation and health ... for improvement, and tracks progress. Job Duties and Responsibilities: + Analyze medical records for inpatient and outpatient service areas for accuracy of coding… more
- Oracle (Raleigh, NC)
- …(ECD) alignments, Critical Care workflow implementation, Multi-Disciplinary Rounding, and various nurse chart review and documentation optimizations. The ideal ... experienced Nursing analyst to collaborate directly with clients at a prominent academic medical center in the Midwest. This remote role will act as the primary… more
- UNC Health Care (Chapel Hill, NC)
- …through the integrating and functions of point of entry case management, utilization review , and effective patient flow activities. Responsibilities: 1. Capacity ... tasks as appropriate. 4. Clinical Appropriateness Assessment- Using established medical necessity criteria products and departmental guidelines perform assessments… more