- Humana (Providence, RI)
- …a part of our caring community and help us put health first** The Weekend Utilization Management Nurse 2 utilizes clinical nursing skills to support the ... documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are… more
- Humana (Providence, RI)
- **Become a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the ... documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are… more
- Cognizant (Providence, RI)
- …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 and… more
- Lincoln Financial (Providence, RI)
- …and/or proficiency with Disability Management (STD/LTD) knowledge, Workers Compensation, Utilization Review and/or nurse case management preferred skills ... Role at a Glance** We are excited to bring on a highly motivated Nurse Disability Consultant to our clinical organization. This position will be responsible for… more
- Fallon Health (Worcester, MA)
- … Nurse in a clinical setting required. + 2 years' experience as a Utilization Management /Prior Authorization nurse in a managed care payer preferred. + ... Facebook, Twitter and LinkedIn. **Brief summary of purpose:** The PA Nurse uses a multidisciplinary approach to review service requests (prior-authorizations),… more
- University Medicine (Providence, RI)
- SUMMARY: Reporting to the Manager of Case Management , the nurse case manager is responsible for providing comprehensive screenings, assessment, care coordination ... services, disease education with the intent of encouraging self- management for patients with chronic conditions. The Nurse...to the right level of care and decrease unnecessary utilization . The nurse case manager is an… more
- CVS Health (Woonsocket, RI)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... Abuse or Maternity/ Obstetrics experience. **Preferred Qualifications** + 1+ years' Case Management experience or discharge planning, nurse navigator or nurse… more
- State of Massachusetts (Westborough, MA)
- …clinical support to OLTSS staff who manage those programs. Additionally, the nurse will provide input on cross-cutting clinical initiatives affecting LTSS programs. ... clinical support to OLTSS program teams in the day-to-day management of their programs, in the form of reviewing...indicators, or other projects as assigned. Working with fellow Nurse Reviewers, OLTSS program staff, and the OLTSS Senior… more
- Fallon Health (Worcester, MA)
- …including state/federal regulatory agency and three to five years clinical experience in utilization review, appeals, or case management within a healthcare or ... and member expectations. Under the direction of the Director, the Appeal Nurse represents, manages and oversees second level appeal cases (Office of Medicaid,… more
- Atrius Health (Easton, MA)
- …Growing together.* *SUMMARY * Under the direction of the Department Chief, Nurse Leader or designee, this registered professional nurse provides practice ... across the lifespan. This position is responsible for effective care delivery and management of patient care within a specialty, utilizing the nursing process and… more
- Highmark Health (Providence, RI)
- …Nursing **EXPERIENCE** **Required** + 7 years in any combination of clinical, case/ utilization management and/or disease/condition management experience, or ... within the first 6 months of employment. **Preferred** + Certification in utilization management or a related field + Certification in Case Management … more
- Evolent (Providence, RI)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and ... **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to company policies and… more
- BAYADA Home Health Care (Canton, MA)
- …Living communities **_._** Are you a solutions-oriented, team-focused **Registered Nurse or Therapist (Physical Therapist, Physical Therapist Assistant, Occupational ... create alignment to common goals across multiple levels of management ? Would you like to be viewed as a...members to deliver on our differentiated offerings. Through the utilization of outcome driven data analytics, this role will… more
- Highmark Health (Providence, RI)
- …timeframes and notification requirements are met. + Communicate effectively with Utilization Management Staff, providers, other internal and external customers ... Documents, processes and routes requests for services to the nurse reviewer and other departments based on documentation procedures,...and management . + Route Cases Based on Established Guidelines. +… more
- Charter Care Health Partners (North Providence, RI)
- …of a specific patient population. Performs functions related to Patient Advocacy; Utilization Review; Resource Management ; Continuum of Care Management ... and Clinical Documentation Management . Collects data via utilization with Care Port to enhance the quality and...preferred) with current license to practice as a Registered Nurse in the State of Rhode Island or in… more
- Charter Care Health Partners (North Providence, RI)
- …of a specific patient population. Performs functions related to Patient Advocacy; Utilization Review; Resource Management ; Continuum of Care Management ... and Clinical Documentation Management . Collects data via utilization with Care Port to enhance the quality and...preferred) with current license to practice as a Registered Nurse in the State of Rhode Island or in… more
- Sharecare (Providence, RI)
- …/ new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical, ... + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Fallon Health (Worcester, MA)
- …field preferred **License** : Active, unrestricted license as a Registered Nurse in Massachusetts **Certification:** Certification in Case Management strongly ... supervision, and support for direct report nursing and disease management staff fostering integration within care teams and member...not limited to Transition of Care and Emergency Room utilization * Generates and or utilizes reports to ensure… more
- Molina Healthcare (Norfolk, MA)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. **Required Qualifications** * At ... looking for a candidate with a MA RN licensure. Candidates with case management and home health are highly preferred. Bilingual candidates are encouraged to apply… more
- Edward M. Kennedy Community Health Center, Inc. (Milford, MA)
- …The Clinical Care Manager (CCM) provides, coordinates, and organizes evidence-based care management to chronic disease patients, especially to those who are most at ... patients, ensuring optimal care including acute illness and chronic disease management , lifestyle and behavior education, and preventive care across multiple health… more