- Unknown (Reno, NV)
- …evaluation of all program aspects, including budgets, faculty and staff, clinical site liaisons, curriculum development, and program compliance with regulatory ... meetings and ensuring the quality of instruction through program review and strategic planning. Applicants must have a Master's...nursing programs, and direct patient care as a registered nurse . The role requires a current RN license, experience… more
- AmeriHealth Caritas (Philadelphia, PA)
- **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with ... appeals , ensuring compliance with all regulatory milestones + Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation,… more
- Adecco US, Inc. (Minneapolis, MN)
- …and criteria to clinical reviews . Utilization Management, pre-authorization, concurrent review , or appeals experience **Why work for Adecco?** . Weekly Pay ... eight-hour days **Pay:** $40.50 to $42.50 an hour **Responsibilities of the RN Appeals Reviewer :** . Responsible for conducting thorough reviews of member and… more
- LA Care Health Plan (Los Angeles, CA)
- Registered Nurse (RN) Manager, Appeals and Grievances General Operations ( Clinical ) Job Category: Clinical Department: CSC Appeals & Grievances ... Clinical ) is responsible for the daily oversight of clinical appeals and grievances functions within the...for accuracy, clarity, and cultural appropriateness and sensitivity. + Review and monitor procedures for identifying quality of care… more
- Centene Corporation (Trenton, NJ)
- …of all appeals requests + Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry ... within the Eastern Standard Time Zone.** **Position Purpose:** Performs clinical reviews needed to resolve and process appeals...analyzing the basis for the appeal + Ensures timely review , processing, and response to appeal in accordance with… more
- Centene Corporation (Jefferson City, MO)
- …of all appeals requests + Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry ... benefits including a fresh perspective on workplace flexibility. **Position Purpose:** Performs clinical reviews needed to resolve and process appeals by… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor directs and coordinates the accurate implementation of the clinical appeal process for ... and serves as a resource for associates within the Clinical Appeals and Analysis unit. We are...appeals and reconsiderations, including Regulatory complaints and External review requests. Accountable for quality review and… more
- Elevance Health (Cleveland, OH)
- ** Nurse Appeals -Licensed Nurse **...Review requests. .Acts as a resource for both clinical and non- clinical teams, by managing and ... necessary and is dependent on court hearing schedules. The Nurse Appeals is responsible for investigating and...including ensuring accurate entry, investigation, and analysis of state appeals ; summarizing medical information for review by… more
- St. Luke's University Health Network (Allentown, PA)
- …serve, regardless of a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- Elevance Health (Tampa, FL)
- ** Nurse Appeals ** **Hybrid 1:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing ... an accommodation is granted as required by law._ The ** Nurse Appeals ** is responsible for investigating and...medical information for medical director, consultants and other external review . + Prepares recommendations to either uphold or deny… more
- Elevance Health (Columbus, OH)
- ** Nurse Appeals RN** **Location** : Ohio-Cincinnati, Columbus, Mason, or Seven Fields _(Must be within commutable distance to the listed locations.)_ ... an accommodation is granted as required by law._ The ** Nurse Appeals ** is responsible for investigating and...medical information for medical director, consultants and other external review . + Prepares recommendations to either uphold or deny… more
- CVS Health (Lansing, MI)
- …clinical judgment and regulatory knowledge. **Key Responsibilities** + Responsible for the review and resolution of clinical appeals . + Reviews ... day. **Position Summary** CVS Aetna is seeking a dedicated ** Appeals Nurse Consultant** to join our remote...3+ years clinical experience. **Preferred Qualifications** + Appeals , Managed Care, or Utilization Review experience.… more
- BronxCare Health System (Bronx, NY)
- …arrive in letter and electronic format. Collaborating with the Department Denial and Appeals Coordinators, Physician Advisors, and the clinical staff, the Appeal ... Overview The Appeals Manager is responsible to assist in the...for timely response by the department physician advisors and clinical staff. Qualifications - NYS Registered Nurse … more
- Nuvance Health (Danbury, CT)
- …Days, Evenings, Nights available* *Summary:* The purpose of the Denial Prevention Nurse is to ensure that all patient admissions are appropriately status within ... critical part in preventing payment denials by providing timely and accurate clinical information to all payers, while ensuring compliance with CMS requirements,… more
- CommonSpirit Health (Centennial, CO)
- …a Registered Nurse . 3 years with progressive experience in utilization review , preferred. Prior experience writing clinical denial appeal letters required. ... to help you flourish and leaders who care about your success. The RN Clinical Denials Appeals Specialist functions as a revenue management liaison for all… more
- LA Care Health Plan (Los Angeles, CA)
- …in Nursing for Registered Nurses Experience Required: At least 8 years of clinical appeals and grievances experience in a managed care, utilization management ... Lead Customer Solution Center Appeals and Grievances RN Job Category: Clinical... unit. This position is responsible for the quality review of complex and/or escalated clinical A&G… more
- Northwell Health (Melville, NY)
- …+ Ensures compliance with current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect ... decisions and billing status and ensures compliance with the Utilization Review standard and regulations. + Performs concurrent and retrospective utilization… more
- Dignity Health (Rancho Cordova, CA)
- …regulatory appeals , and maintaining a detailed activity log for leadership review . The nurse will actively participate in audits, identifying and ... and maintaining patient confidentiality (HIPAA) are also essential. Ultimately, the Appeals and Grievances Nurse monitors denial trends, recommends corrective… more
- UNC Health Care (Kinston, NC)
- …for all audit and appeals work activities. Assists with documentation review to support the clinical documentation specialists and Patient Financial ... + Minimum 3-5 years of applied clinical experience as a Registered Nurse required. + 2 years utilization review , care management, or compliance experience… more
- Elevance Health (OH)
- …considered for employment, unless an accommodation is granted as required by law. The **Lead Clinical Review Nurse ** is responsible for serving as a team ... directors in interpreting appropriateness of accurate claims payment. May also manage appeals . **How you'll make a difference:** + Conducts retrospective reviews and… more
