- Molina Healthcare (TX)
- …appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously ... **_For this position we are seeking a REGISTERED NURSE (RN) with prior experience in Utilization Review...Active and unrestricted Certified Clinical Coder + Certified Medical Audit Specialist + Certified Case Manager +… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …BHPS provides Utilization Management services to its clients. The Utilization Review Appeals Nurse performs daily appeal reviews and clinical quality oversite. ... nationally recognized clinical criteria and internal policies/procedures. + Identify case issues, assist in developing quality initiatives and policy development.… more
- CareFirst (Baltimore, MD)
- …of the Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs and Quality of Care Complaint Unit. May lead ... that week. **ESSENTIAL FUNCTIONS:** + Directs the Medical Review and Appeals units and manages multiple strategic clinical projects that span organizational… more
- UNC Health Care (Rocky Mount, NC)
- …the health and well-being of the unique communities we serve. **Summary:** The Recovery Audit Nurse will work closely with other Business Office staff members to ... with primary focus on managed-care and commercial payers (will work closely with Case Management / Utilization Review staff), and 3) reviews and appeals … more
- The Cigna Group (Nashville, TN)
- …regarding Medicare appeals and related issues, implications and decisions. The Case Management Analyst reports to the Supervisor/Manager of Appeals and will ... not limited to:** + Must have experience in Medicare Appeals , Utilization Case Management or Compliance in...benefit information. . + Assist with monitoring, inquiries, and audit activities as needed. + Additional duties as assigned.… more
- Hackensack Meridian Health (Hackensack, NJ)
- …efficient reviews and appeals . + May be required to Facilitates payer audit requests, ie Equiclaim, RAC, etc. for medical necessity denials. + Participate in all ... serve as a leader of positive change. The **Appeal Nurse Specialist** will be responsible for the timely review...be responsible for the timely review and submission of appeals for denied managed care inpatient and/or outpatient claims… more
- Houston Methodist (Nassau Bay, TX)
- …(UM) programs including Medical Claims Review, Precertification and Reconsiderations and Appeals . Collaborates with the Director of Case Management/Social Svcs ... At Houston Methodist, the Manager Case Mgmt Social Svcs position is responsible for...to identify trends and opportunities for process improvement. Develops audit reports to identify quality issues and areas for… more
- Medical Mutual of Ohio (OH)
- …a Registered Nurse , including 1 year in a clinical quality review nurse role, care management, utilization management, medical case review or similar role. ... with management, external vendors, and Information Systems to define, develop, test, audit and implement new business systems and processes. Identifies and solves… more
- Martin's Point Health Care (Portland, ME)
- …as a "Great Place to Work" since 2015. Position Summary The Utilization Review Nurse works as a member of the Utilization Review Team and is responsible for ... for services requiring clinical review prior to payment. The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical… more
- Ellis Medicine (Schenectady, NY)
- …(SW). The Discharge Planner's primary function is to work with the Social Worker, Nurse Case Manager, or Utilization Management Nurse to facilitate patient ... assist in utilization management activities under the direction of a registered nurse and/or social worker. Responsibilities include maintaining case files,… more
- Highland General Hospital (Oakland, CA)
- …and internal compliance studies. + Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals . ... all other duties as assigned. + Performs daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and… more
- Highland General Hospital (Oakland, CA)
- …Medicare and internal compliance studies. -Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals ... all other duties as assigned. -Performs daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and… more
- State of Nevada (NV)
- …18 Mins The Position Under direction, the Compliance Specialist - Registered Nurse provides medical expertise for the Division of Industrial Relations, Workers' ... employers, and in Permanent Partial Disability (PPD) reports; supervise lower-level Compliance/ Audit Investigators; and oversee the Medical Unit in their assigned… more
- Point32Health (MA)
- …. **Job Summary** The Clinical Program Manager is a Registered Nurse who performs program oversight activities to optimize the quality of ... the required frequency (eg, quarterly, semi-annual, annual) focused, and periodic audit /review activities timely and thoroughly. + Develops and conducts ongoing… more