- Medical Mutual of Ohio (OH)
- …workplace and perform pre-employment substance abuse and nicotine testing._ **Title:** _Clinical Appeal & Claim Review Nurse II_ **Location:** _Ohio_ ... + Independently evaluates basic to complex medical claims and/or appeal cases and associated records by applying clinical , regulatory, and… more
- UPMC (Pittsburgh, PA)
- …established processes. + Collaborate with physician leadership as warranted in preparation of appeal / clinical review responses. + BSN or Bachelors degree ... your career? UPMC is hiring a full-time Revenue Cycle Clinical Review Nurse. This position works Monday...the local care management departments by initiating the retrospective appeal process for acute inpatient clinical denials… more
- Corewell Health (Grand Rapids, MI)
- …+ Resolve appeal requests prior to committee or fair hearing review , when appropriate, including collaboration internally with all levels within the organization ... knowledge of policies and procedures, including medical policies which may impact the appeal and review process Preferred + Intermediate or advanced level using… more
- Fallon Health (Worcester, MA)
- …the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, ... FH members and FH with their complaints regarding denied claims , referrals, membership, and benefit issues as well as...Coordinator is responsible for the presentation of the member appeal to the FH Medical Director, Center for Medicare/Medicaid… more
- Molina Healthcare (WI)
- …+ Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience ... + Performs clinical /medical reviews of retrospective medical claim reviews, medical claims and previously denied...reports quality of care issues. + Assists with Complex Claim review including DRG Validation, Itemized Bill… more
- CVS Health (Hartford, CT)
- …of this Medical Director role include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered ... of Aetna clinical and coding policy and experience with appeals, claim review , reimbursement issues, and coding is preferable, but a willingness to learn is… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …the most appropriate decision within regulatory timeframes.The TeamAs an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will ... The RoleThe Clinical Appeals Nurse Reviewer is responsible for applying sound clinical judgement to review provider and member appeals for denied services… more
- SSM Health (MO)
- …areas. The scope of responsibility is all post-billed denials (inclusive of clinical denials). Engages with key leadership including regional leaders to identify and ... correct root cause of denied claims through process improvements, set goals, measure process effectiveness...contributor to achieve goals. Lead projects to improve denial claim performance, compliance and efficiency within the denials process… more
- Baptist Memorial (Memphis, TN)
- …performing activities related to denied claims such as obtaining authorizations, claims review , patient billing, appeal writing, auditing, and/or denial ... appeal , collaborate with coding/billing for formulation of appeal with corrected claims and denial resolution...Physician Advisor communication may be necessary to provide further clinical review from the physician perspective as… more
- Baptist Memorial (Memphis, TN)
- …performing activities related to denied claims such as obtaining authorizations, claims review , patient billing, appeal writing, auditing, and/or denial ... appeal , collaborate with coding/billing for formulation of appeal with corrected claims and denial resolution...Physician Advisor communication may be necessary to provide further clinical review from the physician perspective as… more
- R1 RCM (Detroit, MI)
- …what you will experience working as a Clinical Coding Appeals Nurse:** + Review and interpret medical records to appeal denied and underpaid claims . ... Clinical Coding Appeals Nurse** , you will help review and interpret medical records to draft appeals of...medical records to draft appeals of denied and underpaid claims . Every day you will review medical… more
- Beth Israel Lahey Health (Plymouth, MA)
- …contract changes as they pertain to level of care determination and the appeal /denial process. + Oversees utilization review workflow processes to ensure timely ... for identified deficiencies. + Facilitates peer-to-peer communication in support of submitted claims . + Participates on the Utilization Review Committee +… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …medical information was provided to the third-party payer. + If necessary, helps clinical team understand denial and coordinates appeal process. + Creates cost ... clinical and/or related experience required. Case Management, Utilization Review and/or Prior Authorization experience is preferred. + **Certification/Licensure/Registration:**… more
- City and County of San Francisco (San Francisco, CA)
- …2574 positions + All City departments with open permanent positions can review your application Under general supervision, conducts professional-level work in ... clinical psychology; carries out psychodiagnostic examinations and psychotherapy of...on the application form the language(s) in which they claim proficiency. Important Note: Please make sure it is… more
- Houston Methodist (Houston, TX)
- …with physicians, revenue cycle personnel, and payers to successfully clear front end claim edits, appeal clinical denials, and address customer service ... + Integrates the payer medical policies, case specific medical documentation, and claims information into a concise appeal letter, including appropriate medical… more
- Great River Health (West Burlington, IA)
- …an ongoing basis regarding clinical documentation.What you will do + Clinical documentation review of documentation-Accurate and timely record review ... information. + Excellent organization skills-Manage multiple priorities-Regular and reliable attendance. + Appeal denied claims and follow up on the appeal… more
- University of Rochester (Rochester, NY)
- …in claim resolution process for Strong Memorial Hospital (SMH) clinical staff and outside agencies regarding contractual obligations. Assures on-going positive ... **Responsibilities:** GENERAL PURPOSE With considerable latitude for independent judgment, the Claim Resolution Rep IV is responsible for the follow up and… more
- San Antonio Behavioral Health (San Antonio, TX)
- The Director of Utilization Review (UR) in a behavioral health setting oversees the UR process, ensuring appropriate and cost-effective care while adhering to ... the UR team, developing, and implementing policies, and collaborating with clinical staff to ensure optimal patient outcomes. Overseas utilization management and… more
- Cedars-Sinai (Beverly Hills, CA)
- …are not limited to payor update reviews, claim data analysis, assist with appeal process, review and incorporate payor clinical criteria into medication ... Arizona, Nevada, Oregon, Colorado, Texas, Minnesota, Georgia and Florida. The Clinical Prior Authorization Pharmacist Specialist at Cedars-Sinai Medical Center will… more
- Houston Methodist (The Woodlands, TX)
- …revenue cycle regarding any claim issues or concerns that may require clinical review during the pre-bill, audit, or appeal process. **GROWTH/INNOVATION ... cases to the Physician Advisor (or services) for appropriate second level review , peer-peer discussions, and payer denial- appeal needs. Consults with… more