- NHS Management (Prattville, AL)
- …services at the highest practicable level for each resident. Provides case management services for certain high-risk Medicare Part A residents to ensure services ... with the assessment and the plan of care. QUALIFICATIONS Must be a Registered Nurse in good standing in the state(s) in which assigned Must be knowledgeable in… more
- University of Washington (Seattle, WA)
- …least one of the following: certified healthcare chart auditor, certified professional in utilization review (or utilization management or healthcare ... Medicine's Patient Financial Services Department** has an outstanding opportunity for a **Clinical Appeals and Disputes Nurse .** **WORK SCHEDULE** + 100% FTE +… more
- Evolent (Springfield, IL)
- …and accomplishments. **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to ... and as an RN - **Required** + Minimum of 5 years in Utilization Management , health care Appeals , compliance and/or grievances/complaints in a quality… more
- CareFirst (Baltimore, MD)
- …terminology. + Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management , and systems ... **Resp & Qualifications** **PURPOSE:** The Clinical Appeals Nurse completes research, basic analysis,...healthcare payor organization. 2 years' experience in Medical Review, Utilization Management or Case Management … more
- CVS Health (Columbus, OH)
- …with heart, each and every day. **Position Summary** CVS Aetna is seeking a dedicated ** Appeals Nurse Consultant** to join our remote team. In this role, you ... state of residence. + 3+ years clinical experience. **Preferred Qualifications** + Appeals , Managed Care, or Utilization Review experience. + Pre Certification… more
- BronxCare Health System (Bronx, NY)
- …assist the department's leadership develop strategies for denial prevention, improved utilization management , documentation of medical necessity and identify ... avoidable day and barriers to discharge processes pertaining to utilization management . - Liaisons and coordinates with...On the job or formal training in certified case management , denial and appeals management … more
- LA Care Health Plan (Los Angeles, CA)
- …least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting, At least 2 years in ... Lead Customer Solution Center Appeals and Grievances RN Job Category: Clinical Department:...position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and… more
- CareFirst (Baltimore, MD)
- …(KSAs)** + Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management , and systems ... of members for Commercial lines of business. Ensures quality management of the clinical appeal process to reduce the...goals resulting in the full and fair review of appeals and designed to achieve corporate objectives and advance… more
- Centene Corporation (Austin, TX)
- …Knowledge of NCQA, Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. **License/Certification:** + LPN - ... 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, national organization offering competitive… more
- CareFirst (Baltimore, MD)
- …**Knowledge, Skills and Abilities (KSAs)** + Knowledge of NCQA requirements of utilization review, Case Management standards and guidelines, appeal rights and ... We are looking for a Director, Medical Review & Appeals for our Government Programs lines of business. The...strategic clinical projects that span organizational boundaries, responsible for management of corporate care cost directives and goals. +… more
- McLaren Health Care (Mount Pleasant, MI)
- …education sessions to maintain competency and knowledge of regulations in denials, utilization management , care management , clinical documentation, and ... . Provides support to both internal and external customers for denial/ appeals activities and audits. Assists with monitoring and auditing activities, reviews… more
- Nuvance Health (Danbury, CT)
- …in Milliman and InterQual Guidelines required * Minimum of 2-3 years experience as Utilization Management Nurse in an acute care setting required, minimum ... *Description* *Summary:* The purpose of the Denial Prevention Nurse is to ensure that all patient admissions...the interdisciplinary care team * Current working knowledge of utilization management , performance improvement and managed care… more
- Northwell Health (Melville, NY)
- … Review standard and regulations. + Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria; conducts ... + Inpatient clinical experience; 4+ years preferred. + Prior Acute Case Management and/or Utilization Review experience, preferred. + Must have experience… more
- Northwell Health (Melville, NY)
- … Review standard and regulations. Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria; conducts ... current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect patient's severity of illness… more
- Rochester Regional Health (Rochester, NY)
- …class as needed. Responsibilities include concurrent (as needed) and retrospective reviews. The Utilization Management Nurse will act as a resource on ... Job Title: Registered Nurse I Department: Utilization Management...UM review findings, initiate and 1st, 2nd, and/or arbitration appeals as needed. Document in all areas that an… more
- UNC Health Care (Kinston, NC)
- …applied clinical experience as a Registered Nurse required. + 2 years utilization review, care management , or compliance experience preferred. + Minimum 1 ... support the clinical documentation specialists and Patient Financial Services. Supports the Utilization Review Nurse team when necessary by applying established… more
- Minnesota Visiting Nurse Agency (Minneapolis, MN)
- **12/2/2025 - REVISED FTE *_SUMMARY:_* We are currently seeking a*Staff Nurse *to join our Utilization Management department for the/Emergency Department / ... *Assessment:* * Collects, reviews, and documents clinical data relevant to utilization management , including patient status, treatment plans, and healthcare… more
- Sanford Health (Rapid City, SD)
- …providing direct supervision of all departmental staff. Maintains a standardization of utilization management process to ensure all policies and procedures are ... Full time **Weekly Hours:** 40.00 **Department Details** Join our team as a Utilization Review and Case Management Manager and lead a high-impact, data-driven… more
- Guthrie (Cortland, NY)
- …for those with less than one year of experience) Summary The LPN Utilization Management (UM) Reviewer, in collaboration with Care Coordination, Guthrie Clinic ... Packer Hospital Business Office, is responsible for the coordination of Utilization Management (UM) processes and requirements of prior… more
- Huron Consulting Group (Chicago, IL)
- …the expert you are now and create your future. The Manager of Utilization Management is responsible for planning, organizing, developing, and directing ... Review Plan and the overall operation of the Utilization Management Department in accordance with federal,...Performance Tracking and Improvement: Provides analysis and reports of utilization , denials, and appeals KPIs, trends, patterns,… more
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