- 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...nd unrestricted Massachusetts license required Minimum of five years clinical experience in utilization management ,… more
- OptiMindHealth (Cambridge, MA)
- …improve access to holistic and cost-effective mental health care while supporting our clinical and administrative staff in all aspects of their work. Our team ... all aspects of referral relationships including access, communication and medical management are working positively for these medical providers and healthcare… more
- Boston Medical Center (Boston, MA)
- … Certification (CCM) preferred or obtained within 24 months Knowledge of utilization review , discharge planning, managed care, and community resources Equal ... fast-paced environment and is passionate about patient-centered care? Join our Care Management team and help patients navigate the healthcare system with efficiency,… more
- The Home for Little Wanderers (Waltham, MA)
- …documentation and billing in a timely manner. Ensure that documentation meets utilization review and quality assurance standards. Attend in-service training and ... partner violence and health relationship psychoeducation to LGBTQ+ clients. Provide case management services; act as a liaison with collateral agencies and programs;… more
- South Shore Health (Weymouth, MA)
- …and organizational resources, patient care processes, and data analysis. Knowledge of utilization management as it relates to third party payers Knowledge ... of America) Under the general supervision of the Case Management Manager acts as a patient advocate/Case Manager to...assuring the highest quality of care is maintained. Applies review criteria to determine medical necessity for admission and… more
- Boston Medical Center (Boston, MA)
- …qualified medical direction and supervision, is also educated to be responsible for the clinical needs of the patient on ECMO which can include: (1) maintenance of ... therapy as ordered, as evidenced by hospital documentation, self-audit, and supervisory review . Such therapy includes but is not limited to oxygen administration,… more
- 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 (Boston, MA)
- …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
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …us transform healthcare? Bring your true colors to blue. The Role The RN Utilization Management Reviewer is responsible for facilitating care for members ... provide the best quality care. The Team The RN Utilization Management Reviewer is part...and retrospective reviews with emphasis on utilization management , discharge planning, care coordination, clinical outcomes,… 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
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …business expert for member and provider submitted appeals. Working collaboratively with Physician review unit, Utilization Management , Case Management , ... Nurse Reviewer is responsible for applying sound clinical judgement to review provider and member...Member appeals and Grievance, Provider Service, Claims, Network Management , and Medical Policy teams. This role is eligible… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …the Home Infusion Therapy, Specialty Pharmacy Network and Medical Utilization Management for pharmaceuticals programs + Partner with clinical and non- ... the Retail Pharmacy, Medicare Advantage Part D, Home Infusion Therapy, and Medical Utilization Management benefits. This position is eligible for the Flex… more
- Evolent (Boston, MA)
- …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 (Boston, MA)
- …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
- Beth Israel Lahey Health (Burlington, MA)
- …the multidisciplinary team to ensure a timely process. Registered Nurses (RNs) with utilization review experience, case management experience, and med/surg ... in people's lives.** Joint role of Case Manager and Utilization Review Nurse **Job Description:** The Inpatient...of medical/surgical nursing care experience. -Two years of Case Management or Utilization Management experience… more
- Humana (Boston, MA)
- …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 (Boston, MA)
- …Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a medical ... 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
