• SUNSHINE ENTERPRISE USA LLC (Orange, CA)
    …Grievance & Appeals Nurse Specialist Department (s): Grievance and Appeals Resolution Services (GARS) Reports to: Manager Clinic Operations, Grievance & ... Preferably in the following related areas of responsibility: Grievances and Appeals , Utilization Management and/or Quality Management. An equivalent combination… more
    Upward (07/24/25)
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  • WakeMed (Raleigh, NC)
    Overview The Behavioral Health Case Manager for Utilization Review is responsible for assisting patients and families in recognizing and managing mental health, ... and thereby optimize third party payment for services. Assists physicians in preparing appeals when payment has been denied by insurance companies. Assists in the… more
    Upward (07/15/25)
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  • CHPW (Seattle, WA)
    …Create an equitable work environment. About the Role The Level I Utilization Management Clinician performs utilization review for medical or behavioral ... health requests using utilization review criteria, technologies, and tools. Identifies, coordinates, and implements high quality, cost-effective alternatives when… more
    Upward (07/23/25)
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  • NYULMC (New York, NY)
    …outcomes of communication with payor and authorization status. Notifies departmental manager of all unresolved utilization problems/issues. Acts as ... to join our team as a Registered Nurse, Care Manager , Day Shift. In this role, the successful candidate...across the acute care continuum. Evaluates appropriate clinical resource utilization , and assesses patients for transitioning to the next… more
    Upward (07/10/25)
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  • Rice County, MN (Faribault, MN)
    …Hourly Location : Faribault, MN Job Type: Full-Time Job Number: 2025-038 Department : Social Services Opening Date: 07/03/2025 Closing Date: Continuous Job Summary ** ... to appropriate agencies. Develops County childcare plan, ensures implementation and utilization of the plan, and monitors outcomes. Fosters effective local and… more
    Upward (07/07/25)
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  • CHS Utilization and Appeals

    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 ... from payors for additional clinical documentation. Acts as liaison between the Utilization and Appeals Management Department and the physician of record, as… more
    Catholic Health Services (07/24/25)
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  • Manager , Customer Solution Center…

    LA Care Health Plan (Los Angeles, CA)
    Manager , Customer Solution Center Appeals and Grievances Job Category: Management/Executive Department : CSC Appeals & Grievances Location: Los Angeles, ... net required to achieve that purpose. Job Summary The Manager , Customer Solution Center Appeals and Grievances...in a manner consistent with regulatory requirements from the Department of Managed Health Care, Department of… more
    LA Care Health Plan (07/08/25)
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  • Appeals Manager

    BronxCare Health System (Bronx, NY)
    Overview The Appeals Manager is responsible to assist in the analysis and preparation of response to denial notification letters that arrive in letter and ... to best respond to all hospital denials notification and documentation efforts. The Appeals Manager will provide timely tracking and trending of all denials… more
    BronxCare Health System (06/21/25)
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  • Grievance/ Appeals Analyst I

    Elevance Health (Cerritos, CA)
    … Analyst I** is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post ... **Title: Grievance/ Appeals Analyst I** **Virtual:** This role enables associates...requirements. + As such, the analyst will strictly follow department guidelines and tools to conduct their reviews. +… more
    Elevance Health (07/18/25)
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  • Clinical Appeals Nurse (RN)

    Molina Healthcare (Houston, TX)
    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...has been made or upon request by another Molina department to reduce the likelihood of a formal appeal… more
    Molina Healthcare (07/20/25)
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  • Insurance Appeals Coordinator

    Munson Healthcare (Traverse City, MI)
    …customer service/interpersonal skills 6. Monitors and sorts incoming communication to the Utilization Management and Appeals department , including faxes, ... verbal communication skills. ORGANIZATIONAL RELATIONSHIP . Report to the Manager of Utilization Management and works closely... Utilization Management and works closely with the Utilization Management and Appeals team . Interacts… more
    Munson Healthcare (07/20/25)
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  • Manager Utilization Management

    Beth Israel Lahey Health (Burlington, MA)
    …Officer as part of an integrated Revenue Cycle model. + Ensures the Utilization Review department maintains documented, up-to-date policies and procedures and ... a job, you're making a difference in people's lives.** Manages the Utilization Management (UM) team, maintaining effective and efficient processes for determining… more
    Beth Israel Lahey Health (06/06/25)
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  • Manager , Utilization Review

    Children's Mercy Kansas City (Kansas City, MO)
    …review functions utilizing InterQual and/or MCG screening guidelines, and clinical denials/ appeals oversight. Participates in department and hospital performance ... to integrated inpatient teams; assists Director in the management of department ; including personnel and fiscal management and development of, and training… more
    Children's Mercy Kansas City (06/17/25)
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  • Insurance Specialist-Mount Sinai West-…

    Mount Sinai Health System (New York, NY)
    …Nurse denial phone calls for UM Nurse to follow + Prioritizes work as per department protocol (IPRO Discharge Appeals / Insurance requests) + Support Appeals ... **Job Description** **Insurance Specialist Mount Sinai West Utilization Mgmt FT Days EOW** To maintain front...To maintain front end operations of the Case Management Department by monitoring all incoming correspondence and ensuring it… more
    Mount Sinai Health System (07/23/25)
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  • Utilization Management Manager

    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
    CareFirst (07/12/25)
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  • Per Diem RN Case Manager

    Children's Hospital Boston (Boston, MA)
    …Posting Title:Per Diem RN Case Manager , Utilization Management/ReviewDepartment:Patient Services-Patient Care OperationsAutoReqId:80451BRStatus:Part-TimeStandard ... experience required, pediatric experience preferred. + Experience as a Case Manager (Discharge Planning and or Utilization Management) preferred. Licensure/… more
    Children's Hospital Boston (06/16/25)
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  • Utilization Review Intake RN Behavioral…

    AdventHealth (Glendale Heights, IL)
    …and financial indicators including LOS, cost per case, avoidable days, resource utilization , readmission rates, concurrent denials, and appeals . *Uses data to ... 60139 **The role you'll contribute:** The role of the Utilization Management (UM) Registered Nurse (RN) is to use...UM RN is responsible to document findings based on department and regulatory standards. When screening criteria does not… more
    AdventHealth (06/13/25)
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  • Pharmacist, Utilization Management (UM)

    Molina Healthcare (Bellevue, NE)
    …(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
    Molina Healthcare (07/19/25)
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  • Manager - Utilization Review

    Ochsner Health (Lafayette, LA)
    …the daily operations of all assigned divisions within the case management department in collaboration with the case management and social services leadership. ... systems (CMS) regulations, compliance and quality metrics. Experience managing denials and appeals of all payer cases in a timely and organized manner. Preferred… more
    Ochsner Health (05/31/25)
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  • Case Manager I - Sharp Memorial Hospital…

    Sharp HealthCare (San Diego, CA)
    …documents as appropriate in the electronic medical record and provides information to the department head as indicated. + Utilization review and utilization ... **Facility:** Sharp Memorial Hospital **City** San Diego ** Department ** **Job Status** Regular **Shift** Day **FTE** 1...1 **Shift Start Time** **Shift End Time** Certified Case Manager (CCM) - Commission for Case Manager more
    Sharp HealthCare (07/13/25)
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