- CVS Health (Columbus, OH)
- … solutions that promote high-quality healthcare for members. We are seeking a dedicated Utilization Management (UM) Nurse to join our remote team. **Position ... Summary** The Appeals Nurse Consultant plays a key role...multistate/compact licensure privileges. **Preferred Qualifications** + 1+ year(s) of Appeals experience in Utilization Management .… more
- McLaren Health Care (Grand Blanc, MI)
- …maintenance of continuing education requirements _Preferred:_ + Experience in utilization management /case management /clinical documentation. + Certification ... commercial insurance. 8. Educates health team colleagues about complex clinical appeals , utilization review, including role, responsibilities tools, and… more
- Evolent (Montpelier, VT)
- …and accomplishments. **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to ... and as an RN - **Required** + Minimum of 5 years in Utilization Management , health care Appeals , compliance and/or grievances/complaints in a quality… more
- Cognizant (Phoenix, AZ)
- …background - Registered Nurse (RN) . 2-3 years combined clinical and/or utilization management experience with managed health care plan . 3 years' experience ... Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced...care revenue cycle or clinic operations . Experience in utilization management to include Clinical Appeals… more
- Centene Corporation (New York, NY)
- …Knowledge of NCQA, Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. **License/Certification:** + LPN - ... 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, national organization offering competitive… more
- McLaren Health Care (Mount Clemens, MI)
- …education sessions to maintain competency and knowledge of regulations in denials, utilization management , care management , clinical documentation, and ... . Provides support to both internal and external customers for denial/ appeals activities and audits. Assists with monitoring and auditing activities, reviews… more
- Catholic Health (Buffalo, NY)
- …(the payers) and internal stakeholders including, but not limited to, Utilization Review, Case Management , Clinical Documentation Integrity, Health Information ... (CPMA), Certified Case Manager (CCM) or any other certification approved by management + Certification in a Nationally Recognized Utilization Review Criteria… more
- Northwell Health (Melville, NY)
- …needed. Preferred Skills 3-5 years experience in Utilization Review, Case Management , and Clinical Appeals . 3-5 years of acute inpatient clinical experience. ... Review standard and regulations. Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria; conducts… more
- Nuvance Health (Danbury, CT)
- …in Milliman and InterQual Guidelines required * Minimum of 2-3 years experience as Utilization Management Nurse in an acute care setting required, minimum ... members of the interdisciplinary care team * Current working knowledge of utilization management , performance improvement and managed care reimbursement. Working… more
- State of Connecticut, Department of Administrative Services (East Hartford, CT)
- Utilization Review Nurse Coordinator (40 Hour) Office/On-site Recruitment # 250924-5613FP-001 Location East Hartford, CT Date Opened 9/30/2025 12:00:00 AM Salary ... - is accepting applications for a full-time Utilization Review Nurse Coordinator (https://www.jobapscloud.com/CT/specs/classspecdisplay.asp?ClassNumber=5613FP&R1=&R3=)… more
- Minnesota Visiting Nurse Agency (Minneapolis, MN)
- *_SUMMARY:_* We are currently seeking a*Staff Nurse *to join our Utilization Management department in a*/*FLOAT*/*/assignment to support Inpatient, Psych and ... *Assessment:* * Collects, reviews, and documents clinical data relevant to utilization management , including patient status, treatment plans, and healthcare… more
- Brighton Health Plan Solutions, LLC (NC)
- …BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests ... to ensure timely review of services and care. * Provides referrals to Case management , Disease Management , Appeals & Grievances, and Quality Departments as… more
- Idaho Division of Human Resources (Nampa, ID)
- …is responsible for planning, developing, implementing, and administering an effective Utilization Management Program. This program ensures compliance with all ... Utilization Review and Nurse Educator -...+ Collaborate with leadership to evaluate and enhance the Utilization Management Program, ensuring quality care and… more
- Beth Israel Lahey Health (Boston, MA)
- …and Responsibilities:** 1, Performs a variety of concurrent and retrospective utilization management -related reviews and functions to ensure that appropriate ... payer certification, and denied cases. 6. Monitors effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics,… more
- University of Utah Health (Salt Lake City, UT)
- …communication skills. + Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria. + The ability to ... and as a team member. **Qualifications** **Qualifications** **Required** + One year Utilization Review or Case Management experience. **Licenses Required** +… more
- Beth Israel Lahey Health (Plymouth, MA)
- …years recent, broad clinical experience in the hospital setting + Experience with utilization management within the last 3 years required + An understanding ... + Collaborates with the multidisciplinary team to assess and improve the denial management , documentation, and appeals process. + Collaborates with UR Manager… more
- Beth Israel Lahey Health (Plymouth, MA)
- …years recent, broad clinical experience in the hospital setting + Experience with utilization management within the last 3 years required + An understanding ... + Collaborates with the multidisciplinary team to assess and improve the denial management , documentation, and appeals process. + Collaborates with UR Manager… more
- Alameda Health System (Oakland, CA)
- Director, Utilization Management + Oakland, CA + Highland General Hospital + SYS Utilization Management + Full Time - Day + Nursing + Req #:40826-30155 + ... plans **Role Overview:** Alameda Health System is hiring! The Director of Utilization Management holds a critical role encompassing operational oversight,… more
- Mount Sinai Health System (New York, NY)
- …Excel and Word + Strong Communication skills Non-Bargaining Unit, BEZ - Utilization Management - WST, Mount Sinai West **Responsibilities** **A. ... **Job Description** **Insurance Specialist Mount Sinai West Utilization Mgmt FT Days EOW** To maintain front.../ Off-site Insurance reviews + Implements first step of appeals process to assist Appeals Nurse… more
- Minnesota Visiting Nurse Agency (Minneapolis, MN)
- …Minimum 3 years of experience in clinical care, utilization review, case management , or clinical denials/ appeals -OR- * An approved equivalent combination of ... *_SUMMARY:_* We are currently seeking a Utilization Management Analyst to join our...teams. The UM Analyst helps ensure regulatory compliance, timely appeals , and reduction of avoidable denials through proactive collaboration… more