- 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
- UnitedHealth Group (Sugar Land, TX)
- …via fax or telephone, from providers' offices and pharmacists. The position provides clinical review for authorizations in keeping with legal and contractual ... Realistic Job Preview Video Optum is a global organization that delivers care , aided by technology to help millions of people live healthier lives. The work you do… 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
- Elevance Health (Durham, NC)
- …more Medical Directors in ensuring clinical integrity of broad and significant clinical programs. May perform clinical review and participate at ... guidelines within scope of license. Conducts pre-certification, concurrent review , and appeals of Behavioral Health OP...minimum of 5 years of experience in a Behavioral Health/ Clinical setting and managed care experience which… more
- WakeMed (Raleigh, NC)
- …to maximize service to patients. Provides timely, pertinent insurance benefits information to clinical staff so that they will provide care within patients? ... by insurance companies. Assists in the implementation of the Hospital Utilization Review Plan. Provides consultation and/or education to clinical staff regarding… more
- CommuniCare Family of Companies (Columbus, OH)
- …the Columbus, OH area is recruiting a licensed clinician to lead our Utilization Review team. The Utilization Review Director oversees the Utilization Review ... process, peer to peer reviews, and appeal. The Utilization Review Director will ensure an appropriate discharge plan is...report the authorization status of patients and denials and appeals status to the CEO, CFO, and Business Office… more
- Beth Israel Lahey Health (Plymouth, MA)
- …to establish the appropriate level of care using Interqual criteria. Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal ... clinical denials related to the care provided to the hospitalized patient. Conducts concurrent reviews...to assess and improve the denial management, documentation, and appeals process. Collaborates with UR Manager and/or physician advisor… more
- CHPW (Seattle, WA)
- …Responsibilities: Conduct review of hospital notification or prior authorization care requests against established clinical guidelines and health plan ... review . Regularly communicates with the UM Manager, Medical Director, physician advisor/ reviewer and primary care physician for support, problem resolution… more
- University Hospitals (Beachwood, OH)
- …care *Decreased denials *Appropriate reimbursement Perform timely and accurate review , denial communications and construct appeals , including remaining ... Bachelor's Degree in Nursing (Preferred) Work Experience 3+ years Clinical experience in acute care setting (Required)...setting (Required) and 3+ years Of experience in managed care or utilization review (Preferred) and Experience… 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
- NYULMC (New York, NY)
- …access to necessary and appropriate health care services. Maintains current clinical knowledge in area of review and patient population. Achieves and ... providing focused care coordination across the acute care continuum. Evaluates appropriate clinical resource utilization,...to the patients diagnosis and condition when providing a clinical review to the payor to prevent… more
- Aware Recovery Care, Inc. (Cincinnati, OH)
- The Business Development Manager is a key position within the Aware Recovery Care model. You are responsible for being the primary point of contact for all ... professional conferences, seminars, and networking events to promote Aware Recovery care and connect with potential referents Inform industry professionals and… more
- UofL Health (Louisville, KY)
- …the health of the communities we serve through compassionate, innovative, patient-centered care . The Utilization Review RN performs activities which support the ... members-physicians, surgeons, nurses, pharmacists and other highly skilled health care professionals-UofL Health is focused on one mission: delivering… more
- Wellmark, Inc. (Des Moines, IA)
- … reasoning in areas of where the evidence is not definitive; and (c) review of clinical documents submitted by the requesting provider. c. Provide leadership ... affordability and experience. d. Responsible to perform oversight of independent review organization appeals and ensure effectiveness of end-to-end process… more
- Elevance Health (Woodland Hills, CA)
- …Position Title: Associate Medical Director - Physical Medicine and Rehab/Post Acute Care Job Description: Clinical Operations Associate Medical Director Carelon ... focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve. The Clinical Operations Associate Medical… more
- Tenet Healthcare Corporation (Detroit, MI)
- …care in an effective and timely manner, at the most appropriate level of care . Performs continuous review of services to assure patient progress and maintains ... care , diagnostic testing and procedures performed, quality and clinical risk issues, and participates in continuous performance improvement activities. Directs… more
- Jaz Staffing Agency (Houston, TX)
- …needed. Uses quality screens to identify potential issues and forwards information to Clinical Quality Review Department. Ensures that all elements critical to ... support the physician, primary medical homes, and interdisciplinary teams. Facilitates patient care , with the underlying objective of enhancing the quality of … more
- NavitsPartners (Boston, MA)
- … within the past 4 years Working knowledge of InterQual(R) or equivalent clinical review system Case Management certification (CCM, CPUM, or specialty) preferred ... Complete initial assessments and reassessments using InterQual(R) within specified timelines Review appropriateness of admissions and levels of care ; follow… more
- Kaiser Permanente (Denver, CO)
- …denial for member reimbursement requests including analysis of Out of Area and/or Urgent Care situations Partners with medical review to review and determine ... and ST). Review cases to determine if benefit exception applies. Appeals and escalated issues for members and providers: Receive CEP (customer experience portal)… more
- Inland Empire Health Plan (Rancho Cucamonga, CA)
- …committee participation. The Medical Director of Behavioral Health oversees the inpatient/concurrent review process, care integration efforts, and all levels of ... services, medication management, and coordination of behavioral health services and primary care . Provides direction of current clinical practices for behavioral… more
