- US Tech Solutions (Canton, MA)
- …This is Fully remote, but Massachusetts RN license required.** **Job Summary The Clinical Reviewer is a licensed professional -a Registered Nurse preferred- that ... for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for making the determination of medical… more
- The Cigna Group (Sacramento, CA)
- …and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select outpatient services. May review initial liability disability claims to ... acuity cases, and/or account sensitive cases involving largest reserves. Utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate… more
- Centene Corporation (Frankfort, KY)
- …testing or other services requiring review by a PhD/PsyD. + Facilitate outpatient rounds offering clinical input and oversight related to outpatient ... the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified,… more
- Centene Corporation (Frankfort, KY)
- …testing or other services requiring review by a PhD/PsyD + Facilitate outpatient rounds offering clinical input and oversight related to outpatient ... appeals, and occasional peer-to-peer consultations, as well as participating in Utilization Management clinical rounds.** **We're seeking candidates who:** +… more
- Centene Corporation (Phoenix, AZ)
- …testing or other services requiring review by a PhD/PsyD + Facilitate outpatient rounds offering clinical input and oversight related to outpatient ... the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified,… more
- Centene Corporation (Tallahassee, FL)
- …testing or other services requiring review by a PhD/PsyD + Facilitate outpatient rounds offering clinical input and oversight related to outpatient ... the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified,… more
- AmeriHealth Caritas (LA)
- …us at www.amerihealthcaritas.com. **Responsibilities:** Under the direction of a supervisor, the Clinical Care Reviewer - Utilization Management evaluates ... turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment. ;The Clinical Care Reviewer - Utilization Management will also be… more
- AmeriHealth Caritas (Washington, DC)
- **Role Overview** Under the direction of a supervisor, the Clinical Care Reviewer - Utilization Management evaluates medical necessity for inpatient and ... to efficiently document and assess patient cases + Strong understanding of utilization review processes, including medical necessity criteria, care coordination,… more
- Houston Methodist (The Woodlands, TX)
- At Houston Methodist, the Utilization Review Specialist Nurse (URSN) position is a licensed registered nurse (RN) who comprehensively conducts point of entry and ... this position is able to cover a multitude of utilization review functions through point of entry,...regarding any claim issues or concern that may require clinical review during the pre-bill, audit, or… more
- Houston Methodist (The Woodlands, TX)
- At Houston Methodist, the Utilization Review Nurse (URN) position is a licensed registered nurse (RN) who comprehensively conducts point of entry and concurrent ... regarding any claim issues or concerns that may require clinical review during the pre-bill, audit, or...work experience in a hospital or insurance company providing utilization review services + Knowledge of Medicare,… more
- Beth Israel Lahey Health (Burlington, MA)
- …making a difference in people's lives.** Joint role of Case Manager and Utilization Review Nurse **Job Description:** The Inpatient Registered Nurse (RN) Case ... Manager for Hospital at Home Care Transitions coordinates utilization review , discharge planning and monitors quality...the Clinic to accurately determine appropriateness for inpatient and outpatient care. 3) Utilizes clinical expertise to… more
- Actalent (Sunrise, FL)
- …present reports on department activities as assigned. Essential Skills + Proficiency in clinical review and utilization management. + Knowledge of Interqual ... Job Title: Behavioral Health Utilization Review SpecialistJob Description The Behavioral...planning discharges and aftercare, and referring members for continued outpatient care. Responsibilities + Review prior authorization… more
- Alameda Health System (Oakland, CA)
- System Utilization Management SUM Utilization Review RN + Oakland, CA + Highland General Hospital + SYS Utilization Management + Services As Needed / Per ... Req #:41846-31001 + FTE:0.01 + Posted:May 15, 2025 **Summary** **SUMMARY:** The System Utilization Management [SUM] Utilization Review RN is responsible for… more
- Prime Healthcare (Ontario, CA)
- …Administration, or another relevant field + A minimum of seven (7) years' experience in Clinical Utilization Review or Case Management with a large Health ... California Applicants:https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf Responsibilities The Corporate Director of Clinical Utilization Management (UM) provides… more
- BriteLife Recovery (Englewood, NJ)
- What you will be doing? The Utilization Review (UR) Specialist is a critical member of the administrative team at Advanced Revenue Solutions and is responsible ... for overseeing and coordinating all aspects of utilization review and insurance authorization for clients receiving substance use disorder (SUD) treatment at… more
- Covenant Health Inc. (Knoxville, TN)
- …meetings between physicians and payors as applicable. + Completes daily work lists for utilization review meeting the time frames set forth by Covenant Health. + ... expertise in utilization management. + Provides monitoring and oversight of non- clinical utilization staff activities. + Provides advice and counsel to non-… more
- Albany Medical Center (Albany, NY)
- …continued stays, and documents findings based on Departmental standards.* While performing utilization review identifies areas for clinical documentation ... payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with...Basic knowledge of computer systems with skills applicable to utilization review process.* Excellent written and verbal… more
- Riverside Community Care (Lynnfield, MA)
- …oversight for assigned clinicians, including case consultation/ review , ongoing clinical supervision, utilization review / clinical documentation, ... Riverside Community Care Love what you do! Clinical Team Manager - Lynnfield Outpatient Riverside seeks a Clinical Team Manager for the Lynnfield … more
- HonorHealth (AZ)
- …care through comprehensive review for medical necessity of extended stay, outpatient observation, and inpatient stays and the utilization of ancillary ... here -- because it does. Learn more at HonorHealth.com. Responsibilities Job Summary The Utilization Review RN Specialist reviews and monitors utilization of… more
- BJC HealthCare (St. Louis, MO)
- …nurse experience performing care for hospitalized patients. + 2 years of utilization review (UR) experience reviewing hospital admissions for medical necessity ... appropriate and cost-effective use of health care resources. **Responsibilities** + Uses clinical and analytical skills to review and interpret diagnostic test… more