- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor directs and coordinates the accurate implementation of the clinical appeal process for ... and serves as a resource for associates within the Clinical Appeals and Analysis unit. We are...appeals and reconsiderations, including Regulatory complaints and External review requests. Accountable for quality review and… more
- Centene Corporation (Salem, OR)
- …that all appeal letters generated comply with both State and NCQA requirements. + Review clinical information for all appeals utilizing nationally recognized ... a current RN or LPN** **Oregon state license **Utilization review , case management, and appeals experience in...report verbal and written information regarding member and provider clinical appeals , including information follow up +… more
- Molina Healthcare (Salt Lake City, UT)
- **JOB DESCRIPTION** **Job Summary** The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals ... regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and… more
- AmeriHealth Caritas (Philadelphia, PA)
- **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with ... appeals , ensuring compliance with all regulatory milestones + Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation,… more
- St. Luke's University Health Network (Allentown, PA)
- …serve, regardless of a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- CommonSpirit Health (Centennial, CO)
- …to help you flourish and leaders who care about your success. The RN Clinical Denials Appeals Specialist functions as a revenue management liaison for all ... as a Registered Nurse. 3 years with progressive experience in utilization review , preferred. Prior experience writing clinical denial appeal letters required.… more
- Texas Health Resources (Arlington, TX)
- Clinical Reviews, Denial and Appeals RN...Work hours: Monday - Friday from 8:00am - 4:30pm Clinical Review and Denials Department highlights: + ... time frames and files appeal per contracted agreement. + Tracks, monitors, manage clinical denials and appeals and appeal outcomes for reporting as requested.… more
- LA Care Health Plan (Los Angeles, CA)
- …(A&G) & General Operations ( Clinical ) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals & Grievances ... for accuracy, clarity, and cultural appropriateness and sensitivity. + Review and monitor procedures for identifying quality of care...appeals & grievance process. Create a best in clinical appeals process that is efficient and… more
- LA Care Health Plan (Los Angeles, CA)
- …in Nursing for Registered Nurses Experience Required: At least 8 years of clinical appeals and grievances experience in a managed care, utilization management ... Lead Customer Solution Center Appeals and Grievances RN Job Category: Clinical... unit. This position is responsible for the quality review of complex and/or escalated clinical A&G… more
- McLaren Health Care (Grand Blanc, MI)
- …of the patient care team. Educates health team colleagues about complex clinical appeals /denials, utilization review , including role, responsibilities tools, ... of accepting position. + Three years of recent denial management, case management, clinical documentation, or utilization review experience + Five years of … more
- Nuvance Health (Danbury, CT)
- …critical part in preventing payment denials by providing timely and accurate clinical information to all payers, while ensuring compliance with CMS requirements, ... behaviors to internal leadership for assistance in resolution. *Responsibilities* * Review all inpatient admission and observation cases using InterQual, or Milliman… more
- Stanford Health Care (Palo Alto, CA)
- …role in the Revenue Cycle Denials Management Department by managing and resolving clinical appeals related to government audits and denials. This position ... likelihood of a successful appeal. + Proofreading and Editing: Review and edit appeals for clarity and...regulations, payor policies, and industry best practices related to clinical appeals and denials management. Evaluate internal… more
- Genesis Healthcare (Los Angeles, CA)
- …to reduce AR/DSO and outstanding clinical accounts as needed and generates clinical appeals when necessary. 15. Assists with and completes special projects ... serve. Responsibilities The Manager, Case Management is responsible for the clinical , administrative, and financial oversight of the territory's center-based care… more
- Houston Methodist (Sugar Land, TX)
- …responsible for performing utilization review activities, and monitoring the clinical denial management and appeals process, as applicable, in collaboration ... management or equivalent revenue cycle clinical role + Experience includes writing clinical appeals for medical necessity compliance or level of care for… more
- Adecco US, Inc. (Minneapolis, MN)
- …and criteria to clinical reviews . Utilization Management, pre-authorization, concurrent review , or appeals experience **Why work for Adecco?** . Weekly Pay ... eight-hour days **Pay:** $40.50 to $42.50 an hour **Responsibilities of the RN Appeals Reviewer :** . Responsible for conducting thorough reviews of member and… more
- CaroMont Health (Gastonia, NC)
- …Management, Quality and/or Case Management preferred. Minimum of three years experience in clinical area with clinical review experience. Requires excellent ... are accurately determined. Refers to physician advisor and /or second level reviewer when necessary. Documents initial review , communications, and referrals in… more
- UCLA Health (Los Angeles, CA)
- …concurrent reviews, appeals , grievances, peer-to-peer). + Support day-to-day UM and Clinical Appeals operations. + Partner with clinical and operational ... and play a vital part in developing and guiding clinical policy that's grounded in the latest scientific research...team on safe, effective medication use; participate in drug review rounds and P&T Committee. + Contribute to interdisciplinary… more
- Veterans Affairs, Veterans Health Administration (Middleton, WI)
- …Fault, and Worker's Compensation cases to validate related care for reimbursement. Conducts clinical appeals as required by the third-party payers to overturn ... to promote improvements in patient care through systematic evaluation and analytical review of clinical information. Responsibilities Responsibilities of the RUR… more
- Guidehouse (Birmingham, AL)
- …Insurance Companies to resolve claim denials and account balances. + Performing Non- Clinical Appeals . + Assisting Supervisor/Manager as needed with various ... portals, fax, email or mail. This position will also review , and upload documents received by all payers to...+ 0-2 years medical billing experience working with UB04, appeals & denials. **What Would Be Nice to Have**… more
- Blue Cross Blue Shield of Massachusetts (Boston, MA)
- …the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer also provides clinical leadership in other areas of BCBSMA. The ... your true colors to blue. The Role The Physician Reviewer is responsible for evaluating clinical service...clinical practice in order to participate in panel appeals + Experience in Utilization Management in a managed-care… more