- Appcast (Randallstown, MD)
- …Advisor and administrative personnel for unresolved issues. Identifies opportunities for expedited appeals and collaborates with the Care Manager and Physician ... Utilization Review Nurse RN Randallstown, MD NORTHWEST HOSPITAL...potential and actual denials and coordinates with nurse Care Manager and/or Social Worker for any follow up necessary.… more
- Catholic Health Services (Melville, NY)
- …why Catholic Health was named Long Island's Top Workplace! Job Details The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews ... for additional clinical documentation. + Acts as liaison between the Utilization and Appeals Management Department and the physician of record, as required. +… more
- Catholic Health Services (Melville, NY)
- …for services and coordinates utilization / appeals management review. + Assist Utilization and Appeals Manager in setting up communications with payors ... advisors and facility departments. + Develops/validates daily work lists for Utilization and Appeals Manager . + Assist with all insurance and regulatory… more
- Nuvance Health (Danbury, CT)
- *Description* *Summary:* The Manager , Denials Prevention & Appeals Operations is responsible for the direct oversight of daily operations of clinical denial ... position will work closely with the Denials Prevention & Appeals Administration Manager to guide the development...the Physician Advisors or attending physicians to support concurrent appeals . * Monitor and analyze utilization data… more
- Actalent (Sacramento, CA)
- …and Reviews. + Experience with prior authorization, pre-service and post-service review, appeals , utilization management, utilization review, and case ... Job Title: Appeals and Grievances Registered Nurse Job Description We...appropriate care. This position reports directly to the Nurse Manager and plays a key role in providing fair… more
- Elevance Health (Norfolk, VA)
- **Title: Grievance/ Appeals Analyst I** **Virtual:** This role enables associates to work virtually full-time, with the exception of required in-person training ... for employment, unless an accommodation is granted as required by law._ The **Grievance/ Appeals Analyst I** is an entry level position in the Enterprise Grievance &… more
- Molina Healthcare (Yonkers, NY)
- …Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/ Appeals . + Provides training, leadership and mentoring for less ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct...Officer on denial decisions. + Resolves escalated complaints regarding Utilization Management and Long-Term Services & Supports issues. +… more
- Catholic Health (Buffalo, NY)
- …role of management and oversight of team Summary: The Clinical Denials and Appeals , Clinical Supervisor is responsible for the people, carrying out and documenting ... the appeals process for denied claims denied due to reasons...payers) and internal stakeholders including, but not limited to, Utilization Review, Case Management, Clinical Documentation Integrity, Health Information… more
- Elevance Health (Richmond, VA)
- …must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... **Medical Director-Dermatology Appeals ** **Location:** This role enables associates to work...and quality. + Work independently with oversight from immediate manager . + May be responsible for an entire clinical… more
- Elevance Health (New York, NY)
- …must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... **Behavioral Health Medical Director-Psychiatrist Appeals ** **Location:** This role enables associates to work...Director Associates. + Works independently with oversight from immediate manager . + May be responsible for an entire clinical… more
- Elevance Health (Chicago, IL)
- ** Appeals Nurse Reviewer I** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training sessions, ... set of clinical domains, including radiology, cardiology and oncology. The ** Appeals Nurse Reviewer I** is responsible for conducting preauthorization, out of… more
- Beth Israel Lahey Health (Plymouth, MA)
- …a job, you're making a difference in people's lives.** Full Time **Job Description:** ** Utilization Review & Denials management manager - Full Time** **Who We ... and Serve Your Community!** **In your role as a Utilization Review & Denials Management Manager , you...strategy in response to reimbursement denials. + Responsible for appeals and follow up on clinical denials escalated through… more
- CVS Health (UT)
- …that promote high-quality healthcare for members. **Position Summary** The Associate Manager is responsible for oversight of Utilization Management staff. ... + 5+ years of acute experience as a Registered Nurse + 3+ years of Utilization Management experience + 3+ year(s) of Appeals experience in Utilization … more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** Manages the utilization of referral services. Enhances quality of care by assuring compliance with policies, including safety, ... **ESSENTIAL FUNCTIONS:** + Trains staff on standards of practice of Utilization Management and reimbursement methodologies and treatment coding. + Manages policies… more
- Children's Mercy Kansas City (Kansas City, MO)
- …and training oversight of programs and services. Responsible for effective utilization review and proper resource management of patients, including patient statusing ... functions utilizing InterQual and/or MCG screening guidelines, and clinical denials/ appeals oversight. Participates in department and hospital performance improvement… more
- Mount Sinai Health System (New York, NY)
- …as per department protocol (IPRO Discharge Appeals / Insurance requests) + Support Appeals Nurse / Manager by confirming status of denials + Tracking status ... **Job Description** **Insurance Specialist Mount Sinai West Utilization Mgmt FT Days EOW** To maintain front...+ Requests or provides Medical Records as required for appeals , On / Off-site Insurance reviews + Implements… 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=) (Regulatory) position,… more
- University of Utah Health (Salt Lake City, UT)
- …advancement, and overall patient outcomes. **Responsibilities** + Applies approved utilization criteria to monitor appropriateness of admissions with associated ... or third-party payer. + Alerts and discusses with physician/provider and case manager /discharge planner when patient no longer meets medical necessity criteria for… more
- Molina Healthcare (Orlando, FL)
- …(such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services ... The Pharmacist, UM will be responsible for reviewing coverage determinations and appeals in a timely, compliant, and accurate manner. The Pharmacist, UM will… more
- AmeriHealth Caritas (Philadelphia, PA)
- … Management, provides organizational leadership in the operational areas of appeals , utilization review, quality improvement, and related policy and ... practice initiatives in collaboration with the Corporate Medical Directors, Utilization Management and the Vice President, Medical Affairs. ; **Work Arrangement:** +… more
