- US Tech Solutions (Canton, MA)
- …of clinical decision making and support needed to perform utilization management , medical necessity determinations and benefit determinations using ... remote, but Massachusetts RN license required.** **Job Summary The Clinical Reviewer is a licensed professional -a...unrestricted Massachusetts license required + Minimum of five years clinical experience in utilization management ,… more
- Commonwealth Care Alliance (Boston, MA)
- … Utilization Management reports to the Director of Utilization Management * Oversees clinical decision review for services requiring prior ... for overseeing and managing the daily operation of the Utilization Management Review Nurse and... Nurse and Specialist staff responsible for conducting centralized clinical review and authorization creation for centrally… more
- Evolent (Providence, RI)
- …from providers per guidelines. + Utilizing clinical guidelines approved by the Utilization Management Committee (UMC), the URN has the authority to authorize ... cost-effective care. **Collaboration Opportunities** : As a Radiation Technologist in the Utilization Management department, you will work closely with other… more
- Commonwealth Care Alliance (Boston, MA)
- … and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA ... Manager Utilization Management , the Nurse Utilization Management (UM) Reviewer is...direct reports. **Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior… more
- Actalent (Boston, MA)
- …with all company policies and standards. Essential Skills + Proficiency in clinical review , case management , utilization review , and utilization ... Clinical Review Clinician Job Description As... Clinical Review Clinician Job Description As a Clinical...Medicare, and Medicaid regulations is preferred. + Familiarity with utilization management processes is preferred. + State… more
- Commonwealth Care Alliance (Boston, MA)
- …local regulatory guidelines. + Serve as the lead for CCA's Utilization Review functions working closely with other medical management team members. + Support ... review findings, actions, and outcomes in accordance with Utilization + Management policies; meets health plan...a clinical resource and coach for the utilization management team + Is available and… more
- Evolent (Providence, RI)
- …the mission. Stay for the culture. **What You'll Be Doing:** **Cardiovascular Utilization Management Reviewer (Interventional Cardiologist)** Are you ready ... make a meaningful impact on patient care in a non- clinical setting? Join our Utilization Management...within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure… more
- Evolent (Providence, RI)
- …clinical expertise in developing cardiovascular programs that include improvements to clinical effectiveness of utilization management (UM) and risk-based ... critical role in **Performance Suite risk arrangements with payers and strategic utilization management initiatives.** This is an opportunity for a… more
- Humana (Providence, RI)
- …Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a medical ... their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Humana (Providence, RI)
- …Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a medical ... their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Humana (Providence, RI)
- …Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a medical ... their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Children's Hospital Boston (Boston, MA)
- …Posting Title:Per Diem RN Case Manager, Utilization Management /ReviewDepartment:Patient Services-Patient Care OperationsAutoReqId:80451BRStatus:Part-TimeStandard ... + Experience as a Case Manager (Discharge Planning and or Utilization Management ) preferred. Licensure/ Certifications: + Current Massachusetts license… more
- CenterWell (Providence, RI)
- … Clinical Pharmacist develops, maintains, and/or operationalizes strategies related to utilization management edits and/or clinical coverage policies for ... caring community and help us put health first** The Clinical Drug Evaluation and Policy Strategies Senior Clinical...policy development and recommends drug coverage and potential drug utilization tools to mitigate Humana's cost and trend while… more
- Insight Global (Boston, MA)
- Job Description Insight Global is sourcing for a Utilization Management Director to join a not-for-profit community based healthcare organization within the ... federal, state, and local regulatory guidelines. -Support the development of utilization management policy initiatives. -Support the development and… more
- Evolent (Providence, RI)
- …match reviewer for Spine Surgery cases. you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference ... Provides clinical rationale for standard and expedited appeals. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the MD… more
- Wolters Kluwer (Providence, RI)
- …customer relationships to retain and grow existing commercial customer base. + Review account utilization management reporting and provide recommendations. ... as expanding existing business relationships in the rapidly evolving specialty of clinical neurology. You will play a pivotal role in cultivating consultative… more
- Fresenius Medical Center (Lincoln, RI)
- …or federal surveys. + Participates in the completion of the FMS Administrative Clinical Review . **PHYSICAL DEMANDS AND WORKING CONDITIONS:** + The physical ... requirements. Ensure provision of quality patient care while maintaining cost-effective clinical operations in accordance with all legal, compliance, and regulatory… more
- WellSense (Boston, MA)
- …closely with leaders and staff from other teams and departments, including BH Care Management , BH Utilization Management , medical Care Management , and ... Clinical Support (Supervisor) is responsible for the daily operations and performance management of the Behavioral Health Clinical Support Team. This role… more
- Tufts Medicine (Boston, MA)
- …either through residency training or prior job experience. 4. Experience in drug utilization review and analysis. **Duties and Responsibilities:** The duties and ... **Job Overview** Clinical pharmacists (CP) work closely with other health...for accurate charging. 11. Participates in multidisciplinary team meetings, review discharge medication lists from skilled nursing facilities and… more
- Highmark Health (Providence, RI)
- … operations and care management functions + Understanding of Care Management & Utilization Management business processes **LICENSES or CERTIFICATIONS** ... **JOB SUMMARY** This job will have director level accountability for the Clinical Services product engineering team and associated Product portfolio. The incumbent… more