- SUNSHINE ENTERPRISE USA LLC (Orange, CA)
- …hour Duration: Up to 6 months. Job Summary The Grievance and Appeals Nurse Specialist participates in managing medical appeals and state hearing reviews ... Job Description Grievance & Appeals Nurse Specialist At Sunshine Enterprise...those listed above is also qualifying. Preferred Qualifications Active Registered Nurse ( RN ) license to… more
- NYULMC (New York, NY)
- …Position Summary: We have an exciting opportunity to join our team as a Registered Nurse , Care Manager, Day Shift. In this role, the successful candidate ... to the health care team. Coordinates the collection of medical record documentation for review by the...Minimum Qualifications: To qualify you must have a Professional Registered Nurse in New York State with… more
- Tenet Health (West Palm Beach, FL)
- …reporting of data for other departments. Qualifications EDUCATION Graduate of Registered Nurse Program EXPERIENCE 2 years acute care RN experience LICENSE ... Job Description Summary Responsible for utilization review and discharge planning of all acute clinical...vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you… more
- NavitsPartners (Hyannis, MA)
- Job Title: Registered Nurse - Case Management (Travel) Location: Hyannis, MA Job Type: Contract Pay: $70 - $80.03/hour | $3,201/week (Travel Rate) Schedule: 40 ... Weekend | Rotating Holidays Job Overview We are seeking a highly skilled and motivated Registered Nurse - Case Manager (Travel) to join a dynamic care team in… more
- UofL Health (Louisville, KY)
- …communities we serve through compassionate, innovative, patient-centered care. The Utilization Review RN performs activities which support the Utilization ... Health experience (required for positions at Peace Hospital) Licensure: *Active Kentucky Registered Nurse License or compact license with privileges to work… more
- Clarke County Hospital (Osceola, IA)
- …surgical services departments, staff development, front line staff orientation and nurse residency program that includes staff clinical competencies, standards of ... records, reports, statistics, and budgetary information for administrative and regulatory review Develops and maintains job descriptions and scope of practice for… more
- NavitsPartners (Worcester, MA)
- …for discharge planning needs Perform assessments and reassessments using InterQual(R) standards Review medical necessity of admissions and escalate concerns per ... Job Title: Travel RN - Case Management Specialist Location: Hyannis, MA...protocol Handle payer communication, appeals , and notifications such as HINN Coordinate services for… more
- Vivo HealthStaff (Burbank, CA)
- …policies and influence process improvements. Qualifications: 1. Graduate from an accredited Registered Nursing Program; RN preferred. 2. Minimum of five years ... to all regulatory, accreditation, and health plan standards for associated medical groups. Key Responsibilities: 1. Supervise licensed and non-licensed denial unit… more
- Jaz Staffing Agency (Houston, TX)
- …of Social Work program. Licenses/Certifications: Current and valid license to practice as a Registered Nurse in the state of Texas or Current and valid license ... About the job Case Manager for The Texas Medical Center The purpose of the Case Manager...identify potential issues and forwards information to Clinical Quality Review Department. Ensures that all elements critical to the… more
- Kaiser Permanente (Denver, CO)
- …requests including analysis of Out of Area and/or Urgent Care situations Partners with medical review to review and determine appropriateness of high dollar, ... If unable to make final determine/ outcome facilitate additional review by KP RN . Review ...Review cases to determine if benefit exception applies. Appeals and escalated issues for members and providers: Receive… more
- CHPW (Seattle, WA)
- … director regarding identified variances within the case against criteria utilized for medical review . Regularly communicates with the UM Manager, Medical ... Role The Level I Utilization Management Clinician performs utilization review for medical or behavioral health requests...relevant experience. Have a current, unrestricted license as an RN or LPN. Have at least two years clinical… more
- University of Iowa Hospitals & Clinics (Iowa City, IA)
- …billed. This role will conduct concurrent reviews as directed in the hospital's Utilization Review Plan and review of medical records to ensure criteria ... evidenced-based clinical review screening criteria as a guide to support medical necessity determinations and refers cases with failed criteria to the Physician… more
- Bryan Health (Lincoln, NE)
- …12. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved ... for the early identification of potential patients through interdisciplinary team members and medical record review . 3. *Collaborates with the rehab physician to… more
- St. Luke's University Health Network (Allentown, PA)
- …ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, claims data and coding of all ... Works inside with adequate lighting, comfortable temperature and ventilation. EDUCATION: Registered Nurse required, BSN preferred. Current license required. .… more
- Actalent (Boston, MA)
- Clinical Review Clinician Job Description As a Clinical Review Clinician specializing in appeals , you will be responsible for preparing case reviews for ... Medical Directors by thoroughly researching appeals , reviewing...the basis for each appeal. You will ensure timely review , processing, and response to appeals in… more
- Centene Corporation (Sacramento, CA)
- …PST Hours.** + **Position Purpose:** Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine ... for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …most appropriate decision within regulatory timeframes.The TeamAs an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will serve ... Key Responsibilities: + Review provider and member appeals utilizing sound clinical judgement, medical policy,...with medical necessity determinations. Key Qualifications: + Registered Nurse with an active unrestricted professional… more
- Centene Corporation (Olympia, WA)
- …State and NCQA requirements. + Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of ... **Position Purpose:** Act as the liaison for all statewide appeals , fair hearings, review organizations, and other...NCQA standards. + Maintain files and logs for all appeals + Coordinate with Medical Director(s) to… more
- Centene Corporation (Salem, OR)
- …requirements. **(PST preferred).** + Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of ... **Position Purpose:** Act as the liaison for all statewide appeals , fair hearings, review organizations, and other...NCQA standards. + Maintain files and logs for all appeals + Coordinate with Medical Director(s) to… more
- Emory Healthcare/Emory University (Atlanta, GA)
- …more **Description** We're seeking under the direction of the **Utilization Management Appeals Professional, Registered Nurse ** is responsible for managing ... **MINIMUM QUALIFICATIONS** : + License - Must have a valid, active unencumbered Registered Nurse license or temporary permit approved by the Georgia Licensing… more
