- Optum (San Juan, PR)
- …and internal standards. Ensure timely resolution to meet required deadlines Collect, review , and validate supporting documentation for appeals . Conduct thorough ... Optum is a global organization that delivers care , aided by technology to help millions of...needed to make an appropriate determination Determine if appeal review is clinical or administrative Research and… more
- SUNSHINE ENTERPRISE USA LLC (Orange, CA)
- …Farsi, Chinese, Korean, Spanish, Vietnamese). Knowledge of: Medicare and Medi-Cal health care program regulations. Clinical review processes including how ... to analyze and research clinical issues. Managed care and health care industries. Appeals and grievance processes. At Sunshine Enterprise USA LLC, we… more
- MedStar Health (Baltimore, MD)
- Candidates with previous Utilization Review or Denials/ Appeals experience preferred General Summary of Position Responsible for coordinating and monitoring the ... denial management and appeals process. Combines clinical , business and regulatory...to avoid denials and improve efficiency in delivery of care through review and examination of denials.… more
- BlueCross BlueShield of Tennessee (Chattanooga, TN)
- …review , special review requests, and UM pre-certifications and appeals , utilizing medical appropriateness criteria, clinical judgement, and contractual ... Clinical Review Manager - The BlueAdvantage... Clinical Review Manager - The BlueAdvantage Inpatient Utilization Management...A strong nursing background working a variety of adult care settings is preferred. There are a few shift… more
- UnitedHealth Group (Minneapolis, MN)
- …medical director teams focusing on inpatient care management, clinical coverage review , member appeals clinical review , medical claim review ... Optum is a global organization that delivers care , aided by technology to help millions of... and provider appeals clinical review Success in this technology-heavy role requires exceptional leadership… more
- Pyramid Consulting, Inc. (Fort Myers, FL)
- …and resolving complaints and appeals . Key Requirements and Technology Experience: Key skills; Care management Long term care Home visits 2+ years of Care ... Immediate need for a talented Long term care coordinator. This is a 03+ months contract...with long-term potential and is located in Florida(Hybrid). Please review the job description below and contact me ASAP… more
- Children's Mercy KC (Kansas City, MO)
- …address and resolve issues. The High-Risk Nurse Lead is an expert at the roles of Clinical Review Nurse Care Manager and Care Coordination Case Manager ... administrative processes and data related to medical necessity denials, clinical appeals , long length of stay rounds,...final appeal outcome to identify and resolve insurance/payer issues; clinical care delivery concerns; Care … more
- Curant Health (Smyrna, GA)
- …judgment to plan and accomplish goals. Provides clinical assistance in review /preparation of prior authorization and/or appeals as needed. Maintain harmony ... opportunity to do just this by joining our growing Clinical Services team! We are not only committed to...patients we serve, but yours as well. Curant means CARE , and that is just what we do. Our… more
- Squirrel Hill Health Center (Pittsburgh, PA)
- …Center (SHHC), is a Federally Qualified Health Center (FQHC), seeking a dedicated Clinical Support Coordinator to join our team. The ideal candidate will ensure that ... providers, and insurance companies to streamline the authorization process. The Clinical Support Coordinator will assist SHHC Providers in managing and maintaining… more
- UnitedHealth Group (Metairie, LA)
- …the Inpatient Care Management team and Clinical Coverage Review team (prior authorization), Appeals and Grievances, Optum Behavioral Solutions, Optum ... state regulator-driven pay-for-quality initiatives. The CMO oversees market peer review processes, including Quality of Care and...Health Equity designation Innovation - The CMO leads the clinical interface with care providers and UHN… more
- Children's Mercy KC (Kansas City, MO)
- …physicians, nursing, payers, patients, and coworkers. Utilizes knowledge of hospital processes, clinical patient care , state and federal regulations and payer ... appeals , physician decision trends related to level of care and status, and denials data to coach to...in Health Administration and 5-7 years experience in Management, Care Management, Utilization Review , and Performance Improvement… more
- Corewell Health (Royal Oak, MI)
- …criteria, when appropriate. Works collaboratively with departmental, revenue cycle, and clinical appeals staff, physicians, and payers to obtain authorization ... and discharge planning of all hospitalized patients. 1. Identifies patients that need care management services (ie utilization review ; care coordination;… more
- Baptist Memorial Health Care Corporation (Memphis, TN)
- …required actions to resolve the account balance promptly by submitting appeals , correcting account information, coordinating requests for medical records, requesting ... based by state specified requirements. Ability to recognize and communicate to clinical staff or designee when insurance companies require additional review … more
- Inland Empire Health Plan (Rancho Cucamonga, CA)
- …and high-risk members' utilization of services in all settings (outpatient, inpatient, concurrent review , and transitions of care ). 3. Take a leading role in ... strategy, network performance improvement, quality improvement, medical economics, and value-based care contracts. 7. Provide oversight of the clinical … more
- Veterans Health Administration (Fredericksburg, VA)
- …the following KSA's: Advanced knowledge of medical terminology and a wide range of clinical flow processes relating to access to care across multiple clinics, ... Summary This position is located in Primary Care in Fredericksburg. The Lead Medical Support Assistant...employees and refers others, such as formal grievances and appeals , to the supervisor or appropriate management official. Work… more
- AndHealth (Indianapolis, IN)
- …pharmacists and ensure they have the appropriate training and resources necessary for clinical care . Work collaboratively with all AndHealth and Community Health ... psoriatic arthritis, pulmonary arterial hypertension rheumatoid arthritis, and transplant. Regularly review and be familiar with clinical guidelines and… more
- Blue Shield of California (Oakland, CA)
- …or their designee. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in ... These functions include performance of pre-service and retrospective utilization review , Appeals and Grievances, and provider claims...of FEP membership to provide access to high-quality health care to these members Serve as a clinical… more
- Telligen (Boston, MA)
- …services given are appropriate and necessary. Serves as the medical expert with peer review and appeals processes. Works closely with assigned teams to meet ... other physicians and clinical support staff on clinical policy, process, and improvement of health care...functions. Serves as a technical expert on the peer review and appeals processes. Represents Telligen policies… more
- BlueCross BlueShield of Tennessee (Chattanooga, TN)
- …in providing multidisciplinary staff supervision with a minimum of five years of clinical experience in a variety of managed care treatment settings. Work ... Join Our Team as a Medical Review Director- Behavioral Health! Are you a dedicated...ensuring the highest standards of medical necessity determinations and clinical metrics analysis. You may be a great match… more
- Experity (Sioux Falls, SD)
- …software solutions that remove complexities and simplify operations for 5700+ urgent care clinics across the country. We create, maintain, and support products to ... experience: from patients finding clinics and making appointments, to checking in, to clinical documentation, and to the final bill paid by the patient. Our team… more
