- Optum (San Juan, PR)
- …and internal standards. Ensure timely resolution to meet required deadlines Collect, review , and validate supporting documentation for appeals . Conduct thorough ... Optum is a global organization that delivers care , aided by technology to help millions of...needed to make an appropriate determination Determine if appeal review is clinical or administrative Research and… more
- UnitedHealth Group (Cypress, CA)
- … Review medical records and verify if the requested service meets criteria Review pre-service appeals for clinical eligibility for coverage as prescribed ... us to start Caring. Connecting. Growing together . The Clinical Appeals RN is responsible for providing...Medicare criteria 1+ years of Utilization Management, pre-authorization, concurrent review or appeals experience Appeals … more
- Pyramid Consulting, Inc. (Blacklick, OH)
- …entry, typing, call documentation. Experience in telephonic counseling and/or managed care setting preferred. Licensed Professional Counselor; Licensed Clinical ... Immediate need for a talented Appeals nurse (LPN). This is a 06+ months...with long-term potential and is located in Ohio(Remote). Please review the job description below and contact me ASAP… more
- The Emily Program (Atlanta, GA)
- …the facilitation of peer-to-peer insurance reviews, determination of appropriate levels of care , arbitration of clinical appeals , etc. Provide education ... care . Frequency of visits should be dictated by clinical need, and facilitate appropriate psychiatric care for the clinical severity and in accordance… more
- UC Davis Health (Sacramento, CA)
- The Clinical Case Manager integrates and coordinates utilization management, care facilitation and discharge planning functions. In addition, the Clinical ... safe discharge plan. Facilitates the collaborative management of patient care across the continuum, completing utilization review ...as necessary to remove barriers to timely and efficient care delivery and reimbursement. The Clinical Case… more
- Appcast (Albany, NY)
- …as the strategic and operational leader for departments that include Access, Utilization Review , Denials and Appeals , Care Coordination, Discharge Planning, ... departmental operations, staffing, budget planning, and performance metricsLeading utilization review , discharge planning, and transitional care strategiesMaintaining… more
- Telligen (Boston, MA)
- …services given are appropriate and necessary. Serves as the medical expert with peer review and appeals processes. Works closely with assigned teams to meet ... other physicians and clinical support staff on clinical policy, process, and improvement of health care...functions. Serves as a technical expert on the peer review and appeals processes. Represents Telligen policies… more
- State of Colorado (Denver, CO)
- …provision of patient care . Provides support for the delivery of patient care and provides clinical leadership. Assures the provision of adequate staff ... to the position through continuing education, clinical supervision, clinical /administrative supervision, and literature review to ensure that nursing… more
- Pyramid Consulting, Inc. (St. Louis, MO)
- … care management teams to optimize outcomes. Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants ... in the development and implementation of physician education with respect to clinical issues and policies. Identifies utilization review studies and evaluates… more
- Woundlocal (Austin, TX)
- …Freenet Health Corp is now hiring a billing team to service the mobile wound care practice Woundlocal . Hiring : a clinical back certified medical billing ... provide real-time feedback to the medical team, ensure timely submission to payers, review claim denials, submit appeals , and bill secondary insurance. All… more
- Baptist Memorial Health Care Corporation (Jackson, MS)
- …required actions to resolve the account balance promptly by submitting appeals , correcting account information, coordinating requests for medical records, requesting ... based by state specified requirements. Ability to recognize and communicate to clinical staff or designee when insurance companies require additional review … more
- Regal Medical Group, Inc. (Northridge, CA)
- …of medical directors, nurses and coordinators, participate in the pre-service medical necessity review of patient care . Review prior authorization requests ... is responsible for actively participating and guiding in the review process of pre-service requests for services, and to...all processes and procedures, while working to deliver excellent care in a cost-effective manner based on medical management… more
- Trinity Health (Silver Spring, MD)
- …for appropriateness of hospitalization, LOC status, LOS management, continued stay decisions, clinical review of patients, utilization review activities, ... (LOC), length of stay (LOS) management, patient flow/throughput management, appropriate clinical documentation, and CDI. Engages physicians in care coordination,… more
- Sonder Health Plans, Inc. (Atlanta, GA)
- …effectively. The main goal of this position is to provide operational support and clinical expertise in the areas of health care services, member benefits and ... creating a customer-centric experience that gets our members the care they need when they need it. If you...*Coordinate case management on complex cases that require additional clinical management support *Conducts initial review of… more
- Blue Shield of California (Rancho Cordova, CA)
- … to adapt to changes occurring over time and through various settings. Conducts member care review with medical groups or individual providers for continuity of ... and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating MDs. The Case Management… more
- Valley Health System (Paramus, NJ)
- …management. Accountable for directing the day-to-day operations for Concurrent Utilization Review processes for Medicare, Medicaid, Managed Care and Commercial ... Payors, Oversight of all inpatient Denials and Appeals activity ie Medicare RAC Denials, Managed ...maximize revenue for every patient bed in collaboration with clinical and financial teams. Interfaces extensively with insurance companies… more
- State of Colorado (Denver, CO)
- …of the data warehouse; the maintenance of critical budget-management, personnel, clinical , and forensic information management systems; the migration of continuing ... Substitutions, Conditions of Employment & Appeal Rights Important Note: Please review your application to ensure completion. For the most equitable applicant… more
- AndHealth (Anderson, IN)
- …psoriatic arthritis, pulmonary arterial hypertension rheumatoid arthritis, and transplant. Regularly review and be familiar with clinical guidelines and ... are driven by the goal of making world-class specialty care accessible and affordable to all. We partner with...Review payor formularies and complete prior authorizations and appeals as necessary for patients. Obtain and document all… more
- Community Health Systems (Franklin, TN)
- …payment discrepancies, revenue opportunities, and performance metrics for management review . Collaborates with financial, clinical , and operational teams ... by identifying variances between posted and expected revenue for managed care , government contracts, and other payers. This role includes analyzing contract… more
- Elevance Health (Chicago, IL)
- …Health, is a benefit-management leader in Illinois. Our platform delivers significant cost-of- care savings across an expanding set of clinical domains, including ... Date: 2025-07-31 Position Title: Associate Medical Director Job Description: Clinical Operations Associate Medical Director Carelon Medical Benefits Management… more
