- Molina Healthcare (Austin, TX)
- …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 (Austin, TX)
- …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 (Austin, TX)
- …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 (Austin, TX)
- …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
- CVS Health (Austin, TX)
- …accordance with contract. + -Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) ... incoming correspondence and internal referrals. + Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management. + Performs… more
- Molina Healthcare (Austin, TX)
- …medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse ... and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends… more
- Sharecare (Austin, TX)
- …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
- Prime Therapeutics (Austin, TX)
- …leads cross functional committees that review FWA member lock in appeals . **Responsibilities** + Leverage clinical judgement to evaluate members for potential ... years of work experience in case management or professional practice + Current Registered Nurse (RN) license in good standing with the Board of Nursing as required… more
- Ascension Health (Austin, TX)
- …related to coding, medical records/documentation, precertification, reimbursement and claim denials/ appeals . + Assess and coordinate discharge planning needs with ... and regulations. **Requirements** Licensure / Certification / Registration: + Licensed Registered Nurse credentialed from the Texas Board of Nursing or current home… more