- Humana (Raleigh, NC)
- **Become a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the ... documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests ... working remotely. Primary Responsibilities * Performs behavioral health clinical utilization reviews using evidenced based guidelines, policies and nationally… more
- CenterWell (Raleigh, NC)
- …RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability ... Therapy, DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare… more
- Humana (Raleigh, NC)
- **Become a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the ... documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are… more
- Cognizant (Raleigh, NC)
- …background - Registered Nurse (RN) . 2-3 years combined clinical and/or utilization management experience with managed health care plan . 3 years' experience ... Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced...care revenue cycle or clinic operations . Experience in utilization management to include Clinical Appeals and… more
- Veterans Affairs, Veterans Health Administration (Durham, NC)
- …Care System is looking to fill one (1) full time Registered Nurse Manager vacancy for the Emergency Department service line. Responsibilities Job Description/Scope ... Psychiatry Emergency Care staff, and Medical Support Assistants. The work of the Nurse Manager is supported by an excellent administrative staff, including a Quality… 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' ... and the evaluation of coverage under the Plan. The Nurse Case Manager reports to the Casualty Department Manager....services for timely return to work. + Provides case management , utilization review, continued stay reviews, and… more
- UNC Health Care (Chapel Hill, NC)
- …serve. The individual selected for this position will function as a Neonatal Nurse Practitioner (NNP) delivering critical care medical management in the Newborn ... **Description** Have you considered a Neonatal Nurse Practitioner career with UNC Health? This opportunity...standards. The practitioner has responsibility for complete daily medical management of a caseload of critically ill newborn infants… more
- Highmark Health (Raleigh, NC)
- …Nursing **EXPERIENCE** **Required** + 7 years in any combination of clinical, case/ utilization management and/or disease/condition management experience, or ... within the first 6 months of employment. **Preferred** + Certification in utilization management or a related field + Certification in Case Management … more
- Elevance Health (Durham, NC)
- …required.** The **Telephonic Nurse Case Manager II** is responsible for care management within the scope of licensure for members with complex and chronic care ... **Telephonic Nurse Case Manager II** **Location:** This role enables...claims or service issues. + Assists with development of utilization /care management policies and procedures. **Minimum Requirements:**… more
- Evolent (Raleigh, NC)
- …responsible for support and assistance for all cardiology administrative and clinical utilization management and quality improvement functions under the auspices ... is 11:30-8:00 eastern** **OTHER SKILLS and ABILITIES:** Strong clinical, management , communication, and organizational skills. Demonstrated leadership skills Analytic… more
- UNC Health Care (Chapel Hill, NC)
- …**Professional Experience Requirements:** * Five (5) years of experience in care management , utilization management , discharge planning, care coordination, ... operations for designated Clinical Care Management Department team(s). Provides management direction to Case Managers, Utilization Managers, Clinical Social… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …for the Casualty and Clinical Services departments which in turn includes Utilization Management , Case Management and Population Health divisions. ... + Strong skills in management of a clinical team. + Previous Utilization Management experience required. + Previous experience in Case Management … more
- UNC Health Care (Chapel Hill, NC)
- …7. Payer Communication: a. Collaborate with payers, insurance companies, and utilization management teams to optimize reimbursement and facilitate timely ... planning. + Serve as a key resource in case management , utilization review, and discharge planning. +...7 years of employment date. **Licensure/Certification Requirements:** * Registered Nurse with a valid license to practice in North… more
- Datavant (Raleigh, NC)
- …function as delegated by management Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in DRG downgrade denials and appeal ... of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for...expertise successfully. Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in… more
- Sharecare (Raleigh, NC)
- …/ new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical, ... + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Granville Medical Center (Oxford, NC)
- Registered Nurse - Emergency Department Location: Granville Health System, Oxford, NC About Granville Health System: For over a century, Granville Health System has ... professional and personal fulfillment. Position Overview: A professional Registered Nurse (RN), caregiver who assumes responsibility and accountability for multiple… more
- Highmark Health (Raleigh, NC)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... itemized bills, and claims data to assure appropriate level of payment and resource utilization . It is also used to identify issues which can be used for education… more
- UNC Health Care (Morrisville, NC)
- …7. Payer Communication: a. Collaborate with payers, insurance companies, and utilization management teams to optimize reimbursement and facilitate timely ... needs and service agreements. **Applicants with 2 years of triage, care management , and/or care transitions experience are strongly preferred.** Become part of an… more
- Deloitte (Raleigh, NC)
- …to collaborate with clinicians, physicians, NP/PAs, ancillary departments, Quality, Case Management , Finance, Revenue Cycle, and Coders + Other skills include the ... both formal and informal education of physicians, CDI team, health information management and other clinical staff + Develop in-service education tools as necessary… more