- Molina Healthcare (Fort Worth, TX)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... clinical/ medical reviews of retrospective medical claim reviews, medical claims and...Claims Auditing, Medical Necessity Review and Coding experience +… more
- Elevance Health (Grand Prairie, TX)
- …and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to payment. Researches new healthcare-related questions ... **Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU**...Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Clinical Fraud Investigator II** is responsible… more
- Elevance Health (Grand Prairie, TX)
- **Telephonic Nurse Case Manager II** **Location: Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Molina Healthcare (Fort Worth, TX)
- … claims with corresponding medical records to determine accuracy of claims payments. + Review of applicable policies, CPT guidelines, and provider ... policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or… more
- Molina Healthcare (Fort Worth, TX)
- …retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as ... Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial… more
- Elevance Health (Grand Prairie, TX)
- …Finder and follows up with provider on referrals given. + Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care. + ... make an impact:** + Managing incoming calls or incoming post services claims work. + Determines contract and benefit eligibility; provides authorization for… more