- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …providers, as appropriate. At the request of the Senior Medical Director of the Physician Review Unit (PRU), the reviewer also provides clinical leadership ... Bring your true colors to blue. The Role The Physician Reviewer is responsible for evaluating pre...anticipatory case management for members whose cases come for review , identifying opportunities for improved care coordination and placing… more
- Blue Cross Blue Shield of Massachusetts (Boston, MA)
- …adjudicate these requests. At the request of the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer also provides clinical ... Bring your true colors to blue. The Role The Physician Reviewer is responsible for evaluating clinical..., in partnership with case managers + Participate in Physician Psychologist Review Units' appeal process of… more
- Healthfirst (NY)
- **Duties/Responsibilities:** + The Medical Peer Reviewer will assess/ review requests for authorization, and claims payment, based on medical records and internal ... and make informed clinical judgments and recommendations. + The Medical Peer Reviewer will render determinations in the format and within timeframes to follow… more
- ChenMed (Miami, FL)
- …The Physician Reviewer is the primary physician reviewer for Utilization Management/Clinical Appropriateness review cases in our organization. Other ... duties include advising other physician reviewers and attending daily calls with health plan...preferred + At least one (1) year of utilization review experience preferred **PAY RANGE:** $198,797 - $283,995 Salary… more
- Insight Global (New York, NY)
- …a fully remote Physician Reviewers for a leading health insurance company. The Physician Reviewer will review requests for care before, during, and after ... understand them, and they use the right templates to keep everything consistent. Physician Reviewers also talk directly with doctors when needed to explain decisions… more
- Chenega Corporation (Rockville, MD)
- …a **Chenega Professional Services Strategic Business Unit** company, is looking for a Physician - Contract Medical Reviewer (CMR) to support the Department of ... or License to practice in the US as a physician 's assistant or nurse practitioner. + Licensure: Must possess...MD location. + Professional Background: Relevant experience in claims review , healthcare administration, or related fields. + A minimum… more
- AmeriHealth Caritas (Washington, DC)
- …for approval or denial decisions + Identify and escalate complex cases requiring physician review or additional intervention + Ensure compliance with Medicaid ... cases are escalated to the Medical Director for further review . The reviewer independently applies medical and behavioral health guidelines to authorize… more
- Dana-Farber Cancer Institute (Brookline, MA)
- Reporting to the Director of Billing Compliance, the Senior Billing Compliance Reviewer will be responsible for the identification and performance of Billing ... Compliance inpatient and ambulatory activities. The Senior Reviewer will assist in the development and execution of the annual Billing Compliance work plan. They… more
- Hartford HealthCare (Hartford, CT)
- …Island. We consist of a team of professionals ranging from Medical Assistants to Physician Assistants and everything in between. Our physician led medical group ... The primary responsibility of the Metabolic and Bariatric Surgical/Medical Clinical Reviewer (MBSCR) is to ensure the accurate and timely collection, documentation,… more
- Elevance Health (Las Vegas, NV)
- **Nurse Reviewer I** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing ... set of clinical domains, including radiology, cardiology and oncology. The **Nurse Reviewer I** is responsible for conducting preauthorization, out of network and… more
- Elevance Health (Grand Prairie, TX)
- …client health plan network. + Mentors and coaches new employees in the nurse review process. + Notifies ordering physician or rendering service provider office ... **Nurse Reviewer II** **Location:** This role enables associates to...meets medical necessity criteria or requires additional medical necessity review . + Conducts initial medical necessity review … more
- Carle Health (Peoria, IL)
- …Arts (LPHA) authorizing Integrated Assessment and Treatment Plans. Will complete thorough review of each document, provide clinical guidance to team members, and ... ensure compliance with IATP standards. LPHA reviewer provides behavioral health assessment, intervention, and consultation to individuals and/or groups identified as… more
- Dana-Farber Cancer Institute (Brookline, MA)
- Reporting to the Director of Billing Compliance, the Billing Compliance Reviewer will be responsible for review and analysis of coding and compliance activities ... are met, and the program aligns with industry standards. The Billing Compliance Reviewer is responsible for meeting with providers 1:1 post-audit and educating them… more
- Guthrie (Cortland, NY)
- …than one year of experience) Summary The LPN Utilization Management (UM) Reviewer , in collaboration with Care Coordination, Guthrie Clinic offices, other ... physician offices, and the Robert Packer Hospital Business Office,...care services. The responsibilities include: + Facilitating communication between physician offices, payers, Care Coordination and other hospital departments… more
- Zelis (FL)
- …interests that shape who you are. Position Overview The Inpatient DRG Reviewer will be primarily responsible for conducting post-service, pre-payment and post pay ... Clinic and client specific coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest...provider in the form of medical records such as physician notes, lab tests, images (x-rays etc.), and with… more
- SSM Health (OK)
- …Performs concurrent analytical reviews of clinical and coding data to improving physician documentation for all conditions and treatments from point of entry to ... the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate diagnosis review group (DRG) assignment, risk of mortality (ROM), and severity of… more
- SSM Health (MO)
- …to clinical staff regarding these requirements during the concurrent record review process. + Maintains knowledge of mortality models, observed rate/expected rate ... (O/E ratios), industry trends, variable and diagnosis review group (DRG) frequency. + Serves as a liaison...of Clinical Documentation Improvement Specialists (ACDIS) + Or + Physician Assistant in Medicine, Licensed - Illinois Department of… more
- Atlantic Health System (Morristown, NJ)
- …with the patients discharge plan. 5. Refers cases and issues to Physician Advisors or Designees in compliance with department procedures with timely follow ... for CMS required patient notices. 8. Completes and documents utilization reviews, physician advisor referrals and other communications related to assigned cases in… more
- Evolent (Lansing, MI)
- …the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are ... Medical Director's direction, using independent nursing judgement and decision-making, physician -developed medical policies, and clinical decision-making criteria sets. The… more
- Health Care Service Corporation (Nashville, TN)
- …in accordance with the medical contract and regulations, medical criteria, utilization review , and quality of care. **JOB REQUIREMENTS** **:** + LPN with valid, ... in the state of operations. + 3 years of clinical experience in physician office, hospital, or surgical setting. + Customer service oriented to assist… more