- CenterWell (Sacramento, CA)
- …our caring community and help us put health first** The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical ... **Required Qualifications** + Must be a licensed Registered Compact Nurse license (RN) with no disciplinary action and ability...Lung or Critical Care Nursing experience required + Prior clinical experience preferably in an acute care, skilled or… more
- Humana (Sacramento, CA)
- …community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills to support the coordination, ... from medical records sent from Behavioral Health Facilities to obtain sufficient clinical information. The Utilization Management Behavioral Health Nurse 2 work… more
- Humana (Sacramento, CA)
- …a part of our caring community and help us put health first** The Telephonic Nurse Case Manager will be a member of the In-Home Case Management Team, providing a ... beneficiary's capacity for self- care, to cost-effectively achieve desired clinical outcomes and to enhance quality of medical care....and to enhance quality of medical care. The **Telephonic Nurse Case Manager** will collect and document data to… more
- Highmark Health (Sacramento, CA)
- …experience, or provider operations and/or health insurance experience + 1 year in a clinical setting **Preferred** + 5 years in UM /CM/QA/Managed Care + 1 year ... over a specified panel of members that range in health status/severity and clinical needs; and assesses health management needs of the assigned member panel and… more
- Dignity Health (Sacramento, CA)
- …stays and documents the interactions. + Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the ... Requirements** **Minimum:** + Two (2) years of acute hospital clinical experience - OR - a Masters degree in...Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification **Knowledge to be successful in the role:**… more
- Centene Corporation (Sacramento, CA)
- …the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, ... Purpose:** Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises… more
- Datavant (Sacramento, CA)
- …recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully. Ideal candidate should be a Licensed ... Practical Nurse or Registered Nurse well versed in...denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines. **You will:** +… more
- Molina Healthcare (Sacramento, CA)
- California residents preferred.** **EMERGENCY ROOM ADMISSIONS REVIEW NURSE ** **_3-12 NIGHT SHIFT 7:30PM - 08:30AM PACIFIC HOURS NON EXEMPT, 3 days a week will ... hours as posted._** **JOB DESCRIPTION** **Job Summary** Provides support for clinical member services review assessment processes. Responsible for verifying that… more
- Molina Healthcare (Sacramento, CA)
- …Pacific Business Hours.** JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that ... services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes… more
- Molina Healthcare (Sacramento, CA)
- …Pacific business hours.** JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that ... services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes… more
- Molina Healthcare (Sacramento, CA)
- …at the most effective setting. *Evaluates effectiveness of utilization management ( UM ) practices - actively monitoring for over and under-utilization. * Educates ... and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical … more