- AmeriHealth Caritas (Washington, DC)
- …Under the direction of a supervisor, the Clinical Care Reviewer - Utilization Management evaluates medical necessity for inpatient and outpatient services, ... overtime, and weekends based on business needs **Responsibilities** + Conduct utilization management reviews by assessing medical necessity, appropriateness of… more
- Ascension Health (Baltimore, MD)
- …the offer._ **Responsibilities** Provide health care services regarding admissions, case management , discharge planning and utilization review . ... **Details** + **Department:** Utilization Management + **Schedule:** Hybrid work...healthcare team members. + May prepare statistical analysis and utilization review reports as necessary. + Oversee… more
- CVS Health (Annapolis, MD)
- …care **Preferred Qualifications** + NICU experience highly preferred + Managed care/ utilization review experience + Ability to multitask, prioritize and ... clinical skills to coordinate, document and communicate all aspects of the utilization /benefit management program. Applies critical thinking and knowledge in… more
- Sharecare (Washington, DC)
- …appropriate resource utilization and desired clinical outcomes. The Disease Management Nurse is also responsible during their interactions with participants ... learn more, visit www.sharecare.com . **Job Summary:** The Disease Management Nurse has the responsibility for supporting...and to take the pre and post tests to review competency during orientation. Yearly competency tests are required… more
- Evolent (Washington, DC)
- … Management Clinical Reviewer, Nurse , you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference ... Clinical Reviewers are supported by Field Medical Directors (MDs) in the utilization management determination process. + Reviews charts and analyzes clinical… more
- Veterans Affairs, Veterans Health Administration (Baltimore, MD)
- …determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible to apply. ... Responsibilities Duties: Critical Care Registered Nurse (RN) is responsible for providing competent, evidence-based care to assigned patients and oversight of… more
- Ivyhill Technologies LLC (Bethesda, MD)
- …nursing program. Must have three (3) years of clinical nursing experience. Referral Management (RM) and Utilization Management (UM) experience is preferred. ... referral management services for beneficiaries in the Defense Health Network. Registered Nurse will have overall responsibility for timely review of Right of… more
- Johns Hopkins University (Baltimore, MD)
- The Department of Emergency Medicine is seeking a **_Sr. Nurse Practitioner_** to work collaboratively within a multidisciplinary health care team. Responsible for ... support in response to emergency situations. + Prepare chart documentation for review and counter signature by the physician. + Determine differential diagnosis. +… more
- Johns Hopkins University (Baltimore, MD)
- The Department of Emergency Medicine is seeking a **_Sr. Nurse Practitioner_** to work collaboratively within a multidisciplinary health care team. Responsible for ... support in response to emergency situations. + Prepare chart documentation for review and counter signature by the physician. + Determine differential diagnosis. +… more
- BAYADA Home Health Care (Falls Church, VA)
- …operations. This individual will be responsible for overseeing the day-to-day management of the agency, ensuring high-quality patient care, regulatory compliance, ... metrics including admission rates, re-hospitalizations, visit productivity, and clinician utilization . + Collaborate with referral sources, physicians, hospitals, and… more
- Fresenius Medical Center (Hyattsville, MD)
- …and acts as the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member eligibility. Facilitate timely ... workup of patients for access management , dialysis services, patient education, hospitalizations, and kidney transplantation as appropriate, and ensures coordination… more
- Fresenius Medical Center (Baltimore, MD)
- …auditing activities. + Accountable for completion of the Annual Standing Order Review and Internal Classification of Disease (ICD) coding. + Manages clinic ... financials including efficient utilization of supplies or equipment and regular profits and...of supplies or equipment and regular profits and loss review . + Responsible for all required network reporting and… more
- Molina Healthcare (Woodbridge, VA)
- …and Behavioral health services. Strongly prefer candidates with a background on utilization management or appeals. Excellent computer multi-tasking skills and ... Medical, or ER unit. **Preferred License, Certification, Association** Active, unrestricted Utilization Management Certification (CPHM). To all current Molina… more
- Ivyhill Technologies LLC (Bethesda, MD)
- …an Associate's Degree and a minimum of 2 years of experience in Utilization Management , Referral Management , Authorization/Denials, or Medical Claims ... Team Ivyhill is currently seeking to hire Referral Management (Non- Nurse ) Reviewers to support its...review duties, seeking guidance from the product line nurse (s), and other members of the healthcare team and… more
- CareFirst (Baltimore, MD)
- …Active State Licensure and/or Compact State Licensure. **Experience:** 5 years experience in Utilization Management or Case Management at CareFirst BlueCross ... **Resp & Qualifications** **PURPOSE:** The Care Management Supervisor supervises, directs and coordinates the activities...(MCG) to act as a resource to conduct concurrent review for medical necessity and appropriate level of care… more
- Ivyhill Technologies LLC (Bethesda, MD)
- …nursing program. Must have three (3) years of clinical nursing experience. Referral Management (RM) and Utilization Management (UM) experience is preferred. ... Ivyhill is currently seeking to hire Referral Management (RN) Training Manager to support its contract...all incoming RM staff to be able to accurately review referrals utilizing the Specialty Referral Guideline (SRG) compliance… more
- GetWellNetwork, Inc. (Washington, DC)
- …Manager will take the Get Well program to the next level by driving nurse engagement, focusing on increased utilization , and leading projects of functionality to ... Well's Client Service Manager is responsible for effective product utilization and successful outcomes for the Get Well system...of the Get Well system by conducting quarterly account review meetings pertaining to account roadmap; conduct nurse… more
- Trinity Health (Silver Spring, MD)
- …experience in the development and management of quality, risk, and utilization review processes. + Strong leadership, communication, and analytical skills. + ... a high level of patient satisfaction and effective resource utilization . + Collaborate with certified nurse midwives,...deliver comprehensive care. + Participate in quality, risk, and utilization review processes. + Supervise and teach… more
- CVS Health (Washington, DC)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... or Specialty Pharmacy. **Preferred Qualifications** + 1+ years' Case Management experience or discharge planning, nurse navigator...lower levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC… more
- Highmark Health (Washington, DC)
- …Highmark Inc. **Job Description :** **JOB SUMMARY** This job implements effective utilization management strategies including: review of appropriateness of ... and offers interventions and/or alternatives. **ESSENTIAL RESPONSIBILITIES** + Implement care management review processes that are consistent with established… more