- SUNSHINE ENTERPRISE USA LLC (Orange, CA)
- …Grievance & Appeals Nurse Specialist Department (s): Grievance and Appeals Resolution Services (GARS) Reports to: Manager Clinic Operations, Grievance & ... Preferably in the following related areas of responsibility: Grievances and Appeals , Utilization Management and/or Quality Management. An equivalent combination… more
- WakeMed (Raleigh, NC)
- Overview The Behavioral Health Case Manager for Utilization Review is responsible for assisting patients and families in recognizing and managing mental health, ... and thereby optimize third party payment for services. Assists physicians in preparing appeals when payment has been denied by insurance companies. Assists in the… more
- CHPW (Seattle, WA)
- …Create an equitable work environment. About the Role The Level I Utilization Management Clinician performs utilization review for medical or behavioral ... health requests using utilization review criteria, technologies, and tools. Identifies, coordinates, and implements high quality, cost-effective alternatives when… more
- University of Iowa Hospitals & Clinics (Iowa City, IA)
- …Maintain compliance with all hospital/departmental policies/procedures assigned by the department manager , including work hours, scheduling, and other ... billed. This role will conduct concurrent reviews as directed in the hospital's Utilization Review Plan and review of medical records to ensure criteria for… more
- Jaz Staffing Agency (Houston, TX)
- …financial indicators including case mix, LOS, cost per case, excess days, resource utilization , readmission rates, denials and appeals . Uses data to drive ... About the job Case Manager for The Texas Medical Center The purpose...information to payors. The role integrates and coordinates resource utilization management, care facilitation and discharge planning functions. In… more
- NYULMC (New York, NY)
- …outcomes of communication with payor and authorization status. Notifies departmental manager of all unresolved utilization problems/issues. Acts as ... to join our team as a Registered Nurse, Care Manager , Day Shift. In this role, the successful candidate...across the acute care continuum. Evaluates appropriate clinical resource utilization , and assesses patients for transitioning to the next… more
- Equiliem (Livermore, CA)
- …Provide support to staff as needed. Enroll in payer newsletters and advise manager of needs. Initiate appeals to payers following the guidelines outlined ... Able to toggle between computer screens. Exhibit competency in the utilization of computers, telephones, calculators, fax machines and devices-level of competency… more
- Elevance Health (Durham, NC)
- …staff and external Behavioral Health Providers to ensure appropriate and consistent utilization of plan benefits, out of network services, and clinical guidelines ... within scope of license. Conducts pre-certification, concurrent review, and appeals of Behavioral Health OP services. Provides guidance to Behavioral Health Care… more
- Rice County, MN (Faribault, MN)
- …Hourly Location : Faribault, MN Job Type: Full-Time Job Number: 2025-038 Department : Social Services Opening Date: 07/03/2025 Closing Date: Continuous Job Summary ** ... to appropriate agencies. Develops County childcare plan, ensures implementation and utilization of the plan, and monitors outcomes. Fosters effective local and… more
- Catholic Health Services (Melville, NY)
- …why Catholic Health was named Long Island's Top Workplace! Job Details The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews ... from payors for additional clinical documentation. Acts as liaison between the Utilization and Appeals Management Department and the physician of record, as… more
- LA Care Health Plan (Los Angeles, CA)
- Manager , Customer Solution Center Appeals and Grievances Job Category: Management/Executive Department : CSC Appeals & Grievances Location: Los Angeles, ... net required to achieve that purpose. Job Summary The Manager , Customer Solution Center Appeals and Grievances...in a manner consistent with regulatory requirements from the Department of Managed Health Care, Department of… more
- BronxCare Health System (Bronx, NY)
- Overview The Appeals Manager is responsible to assist in the analysis and preparation of response to denial notification letters that arrive in letter and ... to best respond to all hospital denials notification and documentation efforts. The Appeals Manager will provide timely tracking and trending of all denials… more
- Elevance Health (Cerritos, CA)
- … Analyst I** is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post ... **Title: Grievance/ Appeals Analyst I** **Virtual:** This role enables associates...requirements. + As such, the analyst will strictly follow department guidelines and tools to conduct their reviews. +… more
- Molina Healthcare (Midvale, UT)
- …Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/ Appeals . + Provides training, leadership and mentoring for less ... internet connectivity of high speed required._ **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical...has been made or upon request by another Molina department to reduce the likelihood of a formal appeal… more
- Munson Healthcare (Traverse City, MI)
- …customer service/interpersonal skills 6. Monitors and sorts incoming communication to the Utilization Management and Appeals department , including faxes, ... verbal communication skills. ORGANIZATIONAL RELATIONSHIP . Report to the Manager of Utilization Management and works closely... Utilization Management and works closely with the Utilization Management and Appeals team . Interacts… more
- Beth Israel Lahey Health (Burlington, MA)
- …Officer as part of an integrated Revenue Cycle model. + Ensures the Utilization Review department maintains documented, up-to-date policies and procedures and ... a job, you're making a difference in people's lives.** Manages the Utilization Management (UM) team, maintaining effective and efficient processes for determining… more
- Children's Mercy Kansas City (Kansas City, MO)
- …review functions utilizing InterQual and/or MCG screening guidelines, and clinical denials/ appeals oversight. Participates in department and hospital performance ... to integrated inpatient teams; assists Director in the management of department ; including personnel and fiscal management and development of, and training… more
- Mount Sinai Health System (New York, NY)
- …Nurse denial phone calls for UM Nurse to follow + Prioritizes work as per department protocol (IPRO Discharge Appeals / Insurance requests) + Support Appeals ... **Job Description** **Insurance Specialist Mount Sinai West Utilization Mgmt FT Days EOW** To maintain front...To maintain front end operations of the Case Management Department by monitoring all incoming correspondence and ensuring it… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** Manages the utilization of referral services. Enhances quality of care by assuring compliance with policies, including safety, ... **ESSENTIAL FUNCTIONS:** + Trains staff on standards of practice of Utilization Management and reimbursement methodologies and treatment coding. + Manages policies… more
- Children's Hospital Boston (Boston, MA)
- …Posting Title:Per Diem RN Case Manager , Utilization Management/ReviewDepartment:Patient Services-Patient Care OperationsAutoReqId:80451BRStatus:Part-TimeStandard ... experience required, pediatric experience preferred. + Experience as a Case Manager (Discharge Planning and or Utilization Management) preferred. Licensure/… more
