- Commonwealth Care Alliance (Boston, MA)
- …timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role ... Utilization Management , the Nurse Utilization Management (UM) Reviewer is...**Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior authorization in a variety… more
- US Tech Solutions (Canton, MA)
- …all aspects of clinical decision making and support needed to perform utilization management , medical necessity determinations and benefit determinations using ... criteria through participation in the IMPAC. + Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM… more
- CVS Health (Providence, RI)
- …care **Preferred Qualifications** + NICU experience highly preferred + Managed care/ utilization review experience + Ability to multitask, prioritize and ... clinical skills to coordinate, document and communicate all aspects of the utilization /benefit management program. Applies critical thinking and knowledge in… more
- Commonwealth Care Alliance (Boston, MA)
- … Management is responsible for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible ... reports to the Director of Utilization Management * Oversees clinical decision review for...reviews). * Hire, train and mentor UM staff, including nurse reviewers and support personnel. * Act as liaison… more
- Evolent (Providence, RI)
- …Join Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Pain Management Clinical Reviewer , Nurse , you will be a key member of the ... utilization management team. We can offer you...providing better health outcomes. **Collaboration Opportunities:** As a Clinical Reviewer , Nurse , you will routinely interact with… 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
- Amergis (Canton, MA)
- …to facility wide personnel. + Demonstrated understanding of external agency interface with Utilization Review , Case Management , Patient Safety and Quality ... / Week Amergis Healthcare is seeking an experienced Registered Nurse and self-motivated individual to provide data collection and...collection and related activities for Quality Improvement (QI) and Utilization Review as well as completion of… more
- Sharecare (Providence, RI)
- …total healthcare management and ensure cost effective, appropriate resource utilization and quality outcomes. The Clinical Registered Nurse is also ... the participants and their Primary Care Provider according to the disease management program intervention guidelines. A Clinical Registered Nurse is supervised… more
- Fallon Health (Worcester, MA)
- …oriented, person-centered care, disease progression, disease prevention, wellness and management of chronic and episodic illness consistent with the participant's ... to Summit ElderCare program participants focusing on disease prevention, wellness and management of chronic and episodic illness. Addresses advance directives in a… more
- Fresenius Medical Center (Lincoln, RI)
- …and acts as the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member eligibility. Facilitate timely ... workup of patients for access management , dialysis services, patient education, hospitalizations, and kidney transplantation as appropriate, and ensures coordination… more
- Commonwealth Care Alliance (Boston, MA)
- …is strongly preferred. + Experience in Medicaid/Medicare grievances and appeals and/or Utilization Review is strongly preferred. **Required Knowledge, Skills & ... and summarizes medical information for medical director, consultants, and other external review . + Prepares recommendations to either uphold or deny appeal and… more
- Brockton Hospital (Brockton, MA)
- … management experience Proven experience in coordinating discharge planning and utilization review experience required. Prior management experience ... delays through problem resolution and follow-up. Monitors on-site case managers and utilization review staff to ensure compliance with Signature Healthcare… more
- Beth Israel Lahey Health (Boston, MA)
- …daily schedule to expedite surgical cases or personnel. Works in collaboration with the Nurse in Charge and Anesthesia, but is ultimately responsible to the OR ... Nurse Manager. **Job Description:** PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:...during which hours, the substitution of cases and the utilization of specific rooms for specific cases. + Assures… more
- Molina Healthcare (Worcester, MA)
- …integrated) performing one or more of the following activities: care review / utilization management (prior authorizations, inpatient/outpatient medical ... including 3 or more years in one or more of the following areas: utilization management , case management , care transition and/or disease management… more
- Charter Care Health Partners (North Providence, RI)
- …progress of a specific patient population. Performs functions related to Patient Advocacy; Utilization Review ; Resource Management ; Continuum of Care ... preferred) with current license to practice as a Registered Nurse in the State of Rhode Island or in...experience with case management , patient navigation, case management , utilization review or discharge… more
- Children's Hospital Boston (Boston, MA)
- …concurrent review process for acute psychiatric care + Possessing experience in Utilization Management / Utilization Review + Demonstrating the ability ... + Experience as a Case Manager (Discharge Planning and or Utilization Management ) preferred. Licensure/ Certifications: + Current Massachusetts license… more
- CVS Health (Providence, RI)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... or Specialty Pharmacy. **Preferred Qualifications** + 1+ years' Case Management experience or discharge planning, nurse navigator...lower levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC… more
- Fallon Health (Worcester, MA)
- …tier of service at subacute facilities * Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services * Recognizes, ... Ad Hoc request when required * Concurrent and retrospective review utilizing a multitude of systems and electronic records...working with a frail or elder population. Recent case management or utilization management experience… more
- Highmark Health (Providence, RI)
- …Highmark Inc. **Job Description :** **JOB SUMMARY** This job implements effective utilization management strategies including: review of appropriateness of ... and offers interventions and/or alternatives. **ESSENTIAL RESPONSIBILITIES** + Implement care management review processes that are consistent with established… more
- Children's Hospital Boston (Boston, MA)
- …reporting on blood utilization and wastage trends, evaluating blood management and stewardship initiatives through statistical review , and participating in ... transfusion safety through education, audits, quality improvement, transfusion event review , and active surveillance of the blood ordering through transfusion… more