- Molina Healthcare (Milwaukee, WI)
- JOB DESCRIPTION **Job Summary** The Medical Claim Review Nurse provides support for medical claim review activities. Responsible for ensuring ... hospital setting, including at least 1 year of utilization review , medical claims review...or equivalent combination of relevant education and experience. * Registered Nurse ( RN ). License must… more
- Molina Healthcare (Green Bay, WI)
- …work on set schedule) Looking for a RN with experience with appeals, claims review , and medical coding. **Job Summary** Utilizing clinical knowledge and ... Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in … more
- Cognizant (Madison, WI)
- …role expectations. **What you need to have to be considered** . Educational background - Registered Nurse ( RN ) . 2-3 years combined clinical and utilization ... Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact...the medical necessity determinations to the Health Plan/ Medical Director based on the review of… more
- CVS Health (Madison, WI)
- …Perform medical necessity reviews. **Required Qualifications** + 5+ years' experience as a Registered Nurse with at least 1 year of experience in a hospital ... virtual** **training.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS...setting. + A Registered Nurse that holds an active, unrestricted… more
- Elevance Health (Waukesha, WI)
- …and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to payment. Researches new healthcare-related questions ... **Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon...Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Clinical Fraud Investigator II** is responsible… more
- Molina Healthcare (Milwaukee, WI)
- …Microsoft Excel (edit/save spreadsheets, sort/filter) **Required License, Certification, Association** Licensed registered nurse ( RN ), Licensed practical ... internal policies, and contract requirements. This position completes a medical review to facilitate a referral to...corresponding medical records to determine accuracy of claims payments. + Review of applicable policies,… more
- Sedgwick (Madison, WI)
- …providers to support the claim request and documents decision rationale. + Completes medical review of all claims by reviewing medical documentation ... clinical evaluations on claims that require additional review based on medical condition, client requirement,... management of claims including comprehension of medical terminology and substantiating claim decisions. **ADDITIONAL… more
- Humana (Madison, WI)
- …guidance where needed. Follows established guidelines/procedures. **KEY ACCOUNTABILITIES** + Review medical documentation, obtain additional information that may ... TRICARE, all HGB policies and procedures as well as medical necessity review criteria and privacy requirements... RN license + 3 years of clinical RN Experience + Appeals nursing experience + Claims… more
- Sedgwick (Madison, WI)
- …Place to Work(R) Fortune Best Workplaces in Financial Services & Insurance Nurse Allocator- RN Medicare Compliance **Prior Medicare-set-aside (MSA) experience ... **PRIMARY PURPOSE OF THE ROLE:** To perform provider outreach, specialized document review , and analysis and interpretation of interventions for the preparation of… more
- Evolent (Madison, WI)
- …+ Performs other duties as assigned. **The Experience You'll Need (Required):** + Registered Nurse or Licensed Practical/Vocational Nurse with a current, ... for performing precertification and prior approvals. Tasks are performed within the RN /LVN/LPN scope of practice, under Medical Director direction, using… more
- Ascension Health (Glendale, WI)
- …safety information. Collect, evaluate, and maintain data concerning injuries, complaints, claims , and/or other patient safety-related data. + Educate and train the ... with legal counsel to coordinate the investigation, processing, and defense of claims against the organization. + Enhance the organization's and the larger… more
- Elevance Health (Waukesha, WI)
- **Telephonic Nurse Case Manager II** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Elevance Health (Waukesha, WI)
- **Telephonic Nurse Case Manager Senior** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training ... in different states; therefore, Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager Senior** is responsible for care management within the… more
- Elevance Health (Waukesha, WI)
- **Telephonic Nurse Case Manager II** **Location** : This role enables associates to work virtually full-time, with the exception of required in-person training ... different states; therefore Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager II** is responsible for performing care management within… more