- Molina Healthcare (Salt Lake City, UT)
- **JOB DESCRIPTION** **Job Summary** The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that ... regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and… more
- LA Care Health Plan (Los Angeles, CA)
- Registered Nurse (RN) Manager, Appeals and Grievances General Operations ( Clinical ) Job Category: Clinical Department: CSC Appeals & Grievances ... (A&G) & General Operations ( Clinical ) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals & Grievances… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Supervisor directs and coordinates the accurate implementation of the clinical appeal process for ... and serves as a resource for associates within the Clinical Appeals and Analysis unit. We are...performance as needed. **Licenses/Certifications** : + RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon… more
- Actalent (New York, NY)
- Job Title: Medical Necessity Appeals and Denials FacilitatorJob Description This role involves facilitating medical necessity appeals and denials, managing ... notification letters for denials, and reviewing clinical information to determine if medical necessity criteria are met. Responsibilities + Review clinical data… more
- BJC HealthCare (St. Louis, MO)
- …work experience) **Additional Information About the Role** BJC HealthCare is seeking a Clinical Appeals Specialist to assist with hospital billing for government ... and commercial plans. This individual will be handling clinical denials and sending them to a nurse...clinical denials for BJC hospitals and payors. The Clinical Appeals Specialist must be able to… more
- McLaren Health Care (Grand Blanc, MI)
- …of the patient care team. Educates health team colleagues about complex clinical appeals /denials, utilization review, including role, responsibilities tools, and ... management, clinical documentation, or utilization review experience + Five years of clinical nurse experience in an acute care setting + American Case… more
- AmeriHealth Caritas (Philadelphia, PA)
- **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with regulatory ... a case for determination, interacting directly with providers to obtain additional clinical information, and with members or their advocates to understand the full… more
- St. Luke's University Health Network (Allentown, PA)
- …regardless of a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, claims data ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- Charter Care Health Partners (Providence, RI)
- Summary: The Clinical Appeals - Author performs appeals and denials management and represents the hospital where claims were denied by either governmental ... contractors or commercial payers. Completes comprehensive reviews of clinical documentation to determine if an appeal is warranted. Writes compelling clinically… more
- CommonSpirit Health (Centennial, CO)
- …to help you flourish and leaders who care about your success. The RN Clinical Denials Appeals Specialist functions as a revenue management liaison for all ... need the following: Required Education: BSN required Minimum Experience required: 4 years clinical experience as a Registered Nurse . 3 years with progressive… more
- Nuvance Health (Danbury, CT)
- …Days, Evenings, Nights available* *Summary:* The purpose of the Denial Prevention Nurse is to ensure that all patient admissions are appropriately status within ... in preventing payment denials by providing timely and accurate clinical information to all payers, while ensuring compliance with...notice of conversion, etc. * Tracking and trending all appeals and communicating on a daily/regular basis with the… more
- BronxCare Health System (Bronx, NY)
- …arrive in letter and electronic format. Collaborating with the Department Denial and Appeals Coordinators, Physician Advisors, and the clinical staff, the Appeal ... Overview The Appeals Manager is responsible to assist in the...for timely response by the department physician advisors and clinical staff. Qualifications - NYS Registered Nurse … more
- LA Care Health Plan (Los Angeles, CA)
- …in Nursing for Registered Nurses Experience Required: At least 8 years of clinical appeals and grievances experience in a managed care, utilization management ... Lead Customer Solution Center Appeals and Grievances RN Job Category: Clinical Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, 90017… more
- McLaren Health Care (Mount Pleasant, MI)
- …outcomes and fulfills the obligation and responsibilities of the role to support the clinical team. 3. Collaborates with the Denials Appeals RN to ensure payer ... . Provides support to both internal and external customers for denial/ appeals activities and audits. Assists with monitoring and auditing activities, reviews… more
- Baylor Scott & White Health (Temple, TX)
- …all expedited and external case reviews, and prepares final case submissions. Refers clinical appeal cases to Medical Nurse Auditors or Pharmacy Technicians for ... **JOB SUMMARY** The Appeals and Grievance Specialist performs reviews, within operational...within operational aspects, of the member and provider complaints, appeals and grievance cases for products for all lines… more
- Providence (Torrance, CA)
- **Description** ** Appeals RN - Care Manager Remote. This position is Per Diem and will work 8-hour, Day shifts.** The Care Management Recovery Advocate (CMRA) is ... responsible for providing overall management and communication of clinically-based appeals between Providence Health and Services, California Region (PH&S) outside… more
- Cognizant (Annapolis, MD)
- …cycle or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and concurrent reviews . ... have to be considered** . Educational background - Registered Nurse (RN) . 2-3 years combined clinical ...stand out** . Epic experience . Experience in drafting appeals disputing inpatient clinical validations audits is… more
- Johns Hopkins University (Baltimore, MD)
- …in the Johns Hopkins system. + Experience with EPIC. Classified Title: Clinical Nurse Role/Level/Range: ACRP/03/ME Starting Salary Range: $64,600 - $113,300 ... a **_Clinical Nurse_** who will coordinate and provide the various clinical activities and nursing case management services to patients across sub-specialties… more
- Stanford Health Care (Palo Alto, CA)
- …role in the Revenue Cycle Denials Management Department by managing and resolving clinical appeals related to government audits and denials. This position ... regulations, payor policies, and industry best practices related to clinical appeals and denials management. Evaluate internal...Spec required within 180 Days + RN - Registered Nurse - State Licensure And/Or Compact State Licensure preferred… more
- State of Colorado (Denver, CO)
- Charge Nurse RN II - CO Mental Health Hospital in Fort Logan (S. Denver) Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5142375) Apply Charge ... Nurse RN II - CO Mental Health Hospital in...coordinates and implements medical and psychiatric crisis intervention in clinical emergencies assuring compliance with nursing standards and policies/procedures.… more
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