- CVS Health (Woonsocket, RI)
- …And we do it all with heart, each and every day. **Position Summary:** The ** Utilization Management Clinical Nurse Consultant - Prior Authorization** ... internal and external constituents in the coordination and administration of the utilization /benefit management function. + Gathers clinical information and… more
- Cognizant (Providence, RI)
- …. Educational background - Registered Nurse (RN) . 2-3 years combined clinical and/or utilization management experience with managed health care plan ... 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 … more
- Humana (Providence, RI)
- …of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... determination of the appropriate courses of action. The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent… more
- CVS Health (Woonsocket, RI)
- … (UM) Nurse Consultant. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all ... and state regulated turn-around times. This includes reviewing written clinical records. **Key Responsibilities of the UM Nurse...practice experience as an RN required. + 2+ Years Utilization Management experience. + Must be willing… more
- CVS Health (Woonsocket, RI)
- …internal and external constituents in the coordination and administration of the utilization /benefit management function. + Gathers clinical information and ... skills to coordinate, document, and communicate all aspects of the utilization /benefit management program. + Applies critical thinking and knowledge in… more
- CVS Health (Woonsocket, RI)
- … skills to coordinate, document and communicate all aspects of the utilization /benefit management program. Applies critical thinking and is knowledgeable in ... and external constituents in the coordination and administration of the utilization /benefit management function. **Required Qualifications** + 3+ years post… more
- Evolent (Providence, RI)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are ... independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. Acts as a member advocate by… more
- Sharecare (Providence, RI)
- …helps to drive cost effective and appropriate resource utilization and desired clinical outcomes. The Disease Management Nurse is also responsible during ... for everyone. To learn more, visit www.sharecare.com . **Job Summary:** The Disease Management Nurse has the responsibility for supporting the goals and… more
- US Tech Solutions (RI)
- …HAVE MANAGED CARE exp and Medicare/Medicaid knowledge. + MUST HAVE UM experience, inpatient utilization management review. + MUST HAVE 1 YEAR OF UTILIZATION ... **Job Description:** + Responsible for the review and evaluation of clinical information and documentation. + Reviews documentation and interprets data obtained from… more
- University Medicine (Providence, RI)
- SUMMARY: Reporting to the Manager of Case Management , the nurse case manager is responsible for providing comprehensive screenings, assessment, care coordination ... services, disease education with the intent of encouraging self- management for patients with chronic conditions. The Nurse...to the right level of care and decrease unnecessary utilization . The nurse case manager is an… more
- CVS Health (Woonsocket, RI)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... self-insured clients. + Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures… more
- Highmark Health (Providence, RI)
- …Degree in Nursing **EXPERIENCE** **Required** + 7 years in any combination of clinical , case/ utilization management and/or disease/condition management ... panel of members that range in health status/severity and clinical needs; and assesses health management needs...first 6 months of employment. **Preferred** + Certification in utilization management or a related field +… more
- Evolent (Providence, RI)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and ... accomplishments. **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to company… more
- Charter Care Health Partners (North Providence, RI)
- …Continuum of Care Management (Discharge planning) and Clinical Documentation Management . Collects data via utilization with Care Port to enhance the ... residency if that state is a member of the Nurse Licensure Compact. Five (5) years of clinical...clinical experience that includes recent experience with case management , patient navigation, case management , utilization… more
- Charter Care Health Partners (North Providence, RI)
- …Continuum of Care Management (Discharge planning) and Clinical Documentation Management . Collects data via utilization with Care Port to enhance the ... residency if that state is a member of the Nurse Licensure Compact. Five (5) years of clinical...clinical experience that includes recent experience with case management , patient navigation, case management , utilization… more
- Highmark Health (Providence, RI)
- …timeframes and notification requirements are met. + Communicate effectively with Utilization Management Staff, providers, other internal and external customers ... requirements. Documents, processes and routes requests for services to the nurse reviewer and other departments based on documentation procedures, including review… more
- Sharecare (Providence, RI)
- …3rd parties for care management and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case ... / new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical,… more
- Genesis Healthcare (Middletown, RI)
- …Regional Management and AlignMed Partners to oversee the implementation, utilization , and outcomes measurement of AlignMed Partners Clinical Programs. The ... in Middletown, RI. This is a Dual Role Attending Physician/Medical Director. It is clinical in nature. Must be BC/BE Internal Medicine or Family Medicine with LTC… more
- Genesis Healthcare (Middletown, RI)
- …with assigned Centers and AlignMed Partners managers to oversee the implementation, utilization , and outcomes measurement of AlignMed Partners Clinical Programs ... in Middletown, RI. This is a Dual Role Attending Physician/Medical Director. It is clinical in nature. Must be BC/BE Internal Medicine or Family Medicine with LTC… more