- CareFirst (Baltimore, MD)
- …of the Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs and Quality of Care Complaint Unit. May lead ... that week. **ESSENTIAL FUNCTIONS:** + Directs the Medical Review and Appeals units and manages multiple strategic clinical projects that span organizational… more
- UNC Health Care (Rocky Mount, NC)
- …the health and well-being of the unique communities we serve. **Summary:** The Recovery Audit Nurse will work closely with other Business Office staff members to ... with primary focus on managed-care and commercial payers (will work closely with Case Management / Utilization Review staff), and 3) reviews and appeals … more
- The Cigna Group (Bloomfield, CT)
- …**Job Requirements include, but not limited to:** + Must have experience in Medicare Appeals , Utilization Case Management or Compliance in Medicare Part C + ... **Cigna Healthcare Medicare Appeals Reviewer:** We will depend on you to...appeal have been addressed properly and accurately; e) prepare case files for submission to Independent Review Entity, which… more
- Hackensack Meridian Health (Hackensack, NJ)
- …efficient reviews and appeals . + May be required to Facilitates payer audit requests, ie Equiclaim, RAC, etc. for medical necessity denials. + Participate in all ... serve as a leader of positive change. The **Appeal Nurse Specialist** will be responsible for the timely review...be responsible for the timely review and submission of appeals for denied managed care inpatient and/or outpatient claims… more
- Houston Methodist (Nassau Bay, TX)
- …(UM) programs including Medical Claims Review, Precertification and Reconsiderations and Appeals . Collaborates with the Director of Case Management/Social Svcs ... At Houston Methodist, the Manager Case Mgmt Social Svcs position is responsible for...to identify trends and opportunities for process improvement. Develops audit reports to identify quality issues and areas for… more
- LifePoint Health (Rutherfordton, NC)
- …up with any denials through the appeals process; including RAC chart audit reviews. Emergency Department (ED) Case Management1. Serves as a gatekeeper of ... appropriately from admission through discharge. Coordinates care and services within the case managed population. Educates Physicians and staff in Case … more
- State of Colorado (Denver, CO)
- …throughout the State which includes but is not limited to parole supervision through case management to ensure community safety. We invite you to explore the DYS ... as the first line resource for staff when evaluating case complexity. Determines the need for referrals to other...invoices, Electronic Health Record documentation. Ensures that DYS medical audit standards are met in the medical clinic and… more
- Centene Corporation (Madison, WI)
- …and maintain the audit process and tools related to: authorizations, appeals , quality events, and case management in CCMS; interrater reliability related ... into the credentialing subsystem + Develop and maintain the audit schedule + Audit staff as outlined...Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), Registered Nurse (RN), or Licensed Psychologist (Ph.D. or Psy.D.) Pay… more
- Centene Corporation (Trenton, NJ)
- …and maintain the audit process and tools related to: authorizations, appeals , quality events, and case management in CCMS; interrater reliability related ... to InterQual; and data entry into the credentialing subsystem + Develop and maintain the audit schedule + Audit staff as outlined in the system auditing policies… more
- Highland General Hospital (Oakland, CA)
- …and internal compliance studies. + Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals . ... all other duties as assigned. + Performs daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and… more
- Highland General Hospital (Oakland, CA)
- …Medicare and internal compliance studies. -Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals ... all other duties as assigned. -Performs daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and… more