- BroadPath Healthcare Solutions (Tucson, AZ)
- …staff on managed care and Medicaid policies and procedures D. Conducts staff and medical director audits on appeal activities + Assists with appeal file ... **Overview** BroadPath is seeking a highly motivated and results-driven ** UM RN Appeals Coordinator.** This role collaborates with clinical review staff, medical … more
- Commonwealth Care Alliance (Boston, MA)
- …dental and other vendors to assure integration, oversight, and efficiency of UM processes and functions. - Ensures compliance with all contract requirements, state ... the CMO and VPMA to develop and advance the UM program and leads and organizes the ongoing evaluation...- Minimum five (5) years of clinical experience in medical or behavioral health care delivery Required Knowledge, Skills… more
- HealthCare Support (Houston, TX)
- …approved medical guidelines. Refers cases that do not meet criteria to Medical Director for review. 2. Assists in discharge planning especially Home Health ... services and if not meeting criteria, refer to the Medical Director . 3. Participates in Community Nursing...required information into the managed care platform, adhering to UM policies and procedures. 5. Assists in the coordination… more
- BroadPath Healthcare Solutions (Tucson, AZ)
- …and present authorization requests with supporting documentation for review with the Medical Director . + Assume responsibility for ensuring timely reviews of ... Working knowledge of medical standards of practice or experience with using UM medical criteria (ie Milliman and InterQual) required. + Strong Computer… more
- Commonwealth Care Alliance (Boston, MA)
- … staff, including nurse reviewers and support personnel. - Act as liaison with medical director , provider relations, case management and quality teams to support ... Management (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care… more
- Humana (Lincoln, NE)
- **Become a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The ... Medical Director work assignments involve moderately complex to complex issues...work is assisted by diverse resources which may include national clinical guidelines, CMS policies and determinations, clinical reference… more
- CVS Health (Hartford, CT)
- …candidates can live anywhere in the contiguous United States. **Position Summary** The Lead Director of UM Innovation Delivery is a critical leader and has ... and objectives. + Drive transformation initiatives to modernize healthcare UM operations by aligning cross-functional teams (business, IT, architecture, operations)… more
- Elevance Health (Chicago, IL)
- **Clinical Operations Associate Medical Director ** **Carelon Medical Benefit Management** **Genetic Testing Utilization Management/Review** **Virtual:** This ... domains, including radiology, cardiology and oncology._ The **Clinical Operations Associate Medical Director ** is responsible for supporting the medical… more
- University of Maryland, Baltimore (Baltimore, MD)
- The University of Maryland School of Medicine is seeking a Chair and Medical Director of Critical Care for the UM Capital Region Health Medical Center ... Associates, PA They will work closely and in collaboration with the Trauma Medical Director , Chief of Cardiac Surgery, Surgery, Medicine, Neurocritical Care. The… more
- Elevance Health (Las Vegas, NV)
- …nursing judgment to determine whether treatment is medically necessary and provides consultation to Medical Director on cases that are unclear or do not satisfy ... care, eg, if services are not in line with diagnosis. + Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems… more
- CVS Health (Springfield, IL)
- …support to Account Management in support of Key Clients as assigned. The Medical Director transacts Utilization Management UM activities (prior authorization ... Fortune 6 company, has an outstanding opportunity for a Medical Director - Medical Affairs...review activities and other quality oversight processes for internal Director UM decisions. If specifically assigned to… more
- Sharp HealthCare (San Diego, CA)
- …the position, and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp ... + 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons...+ Achieves and maintains benchmarked utilization and cost management ( UM ) goals and clinical quality improvement (QI) objectives, in… more
- CVS Health (Springfield, IL)
- …Michigan, Kansas and Oklahoma. Support for other regions may occasionally be required. The UM Medical Director will ensure timely and consistent responses to ... a regional role that primarily supports the Aetna Better Health Plan of Illinois. This UM (Utilization Management) Medical Director will be a "Work from… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …you see is right for you, we encourage you to apply! Job Description: The Medical Director participates in the broad array of activities of the Medical ... reviews and may require peer-to-peer discussions with providers regarding UM case review determinations. + Provides clinical expertise on...and medical criteria. + Assists with training medical director colleagues and nursing staff ,… more
- CVS Health (Trenton, NJ)
- …primarily supporting the Aetna Northeast Medicaid plan and the UM team. The UM Medical Director will ensure timely and consistent responses to members ... region but may support other plans when needed. This UM (Utilization Management) Medical Director ...any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression,… more
- Humana (Indianapolis, IN)
- …and build collaborative care models in their practices + Coordinates with the Medical Director to integrate the administration and management of behavioral and ... in this role collaborates closely with Clinical Services and the Chief Medical Officer(CMO) to integrate the day-to-day administration and strategic management of… more
- Elevance Health (Miami, FL)
- ** Medical Director - Florida Medicare Plans** Location: This role enables associates to work virtually full-time, with the exception of required in-person ... in Florida near our Miami or Tampa locations.** The ** Medical Director ** will support the following Florida...criteria (eg, MCG, InterQual, CMS guidelines). + Collaborate with UM nurses and case managers to review inpatient admissions,… more
- University of Maryland, Baltimore (Baltimore, MD)
- …physician-scientist with expertise in clinical trial design and execution to serve as Director of Clinical Trial Innovation.* The UM -IHC is a large-scale ... life and longevity of the citizens of Maryland. The UM -IHC, located in North Bethesda, MD, is a collaborative...of Maryland College Park, and the University of Maryland Medical System, funded with initial grants from the State… more
- Molina Healthcare (NY)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... state, and local laws and regulatory requirements affecting the medical and clinical staff. + Marketplace UM ...experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- UCLA Health (Los Angeles, CA)
- …UCLA Health Medicare Advantage Plan is looking for a dedicated and forward-thinking Associate Medical Director to help shape the future of our plan. In this ... key leadership role, you'll work closely with the UHMAP Medical Director and play a vital part...do: + Lead the development, implementation, and training of medical policies. + Provide clinical determinations for UM… more
