- Trinity Health (Darby, PA)
- …in collaboration with the RN Care Coordination Manager , provides support to the utilization management , denials and appeals process for the THMA South ... **Employment Type:** Full time **Shift:** Day Shift **Description:** The Appeals and Utilization Management Coordinator...support to the Emergency Department Case Manager , Utilization RNs, and Utilization Management … more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …BHPS provides Utilization Management services to its clients. The Utilization Review Appeals Nurse performs daily appeal reviews and clinical quality ... oversite. This position reports to the Clinical Program Manager . This job description is not designed to cover or contain a comprehensive listing of activities,… more
- LA Care Health Plan (Los Angeles, CA)
- …Collaborates with internal departments (Member Services, Provider Network Operations, Claims, Utilization Management , Pharmacy, and Quality Management ) to ... Manager , Customer Solution Center Appeals and...work collaboratively with multiple departments (Claims, Provider Network Operations, Utilization Management , Quality Management , Pharmacy)… more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + Req ... Resource Management issues, other issues including concerns involving under/over utilization , avoidable days and quality issues. 13. Responsible for all incoming… more
- LA Care Health Plan (Los Angeles, CA)
- …Skills Required: Knowledge of state, federal and regulatory requirements in Appeals /Care/Case/ Utilization Management /Quality. Strong verbal and written ... Supervisor, Appeals and Grievances Clinical Operations RN Job Category:...culturally diverse membership. The position supports the A&G Clinical Manager . This role also assists the A&G Leadership in… more
- UNC Health Care (Chapel Hill, NC)
- …communities we serve. RN Utilization Manager position specifically for a Utilization Manager /Clinical Appeals Nurse. This person is based at the ... through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to… more
- Huron Consulting Group (Chicago, IL)
- …the utilization management system. + Generate and analyze reports on utilization trends, denials, and appeals to identify areas for improvement. + Ensure ... as the expert you are now and create your future. **Qualifications** The Utilization Management Specialist is responsible for ensuring the appropriate … more
- Intermountain Health (Columbus, OH)
- **Job Description:** Physician will provide Physician Advisor Utilization Reviewer and Central Appeals Work services. Physician shall engage, educate, and coach ... for appeals in coordination with R1 Central Appeals Unit ("CAU"). + Attend System Utilization ...conjunction with System Physician Advisor. + Work with System Utilization Review Manager and others to adjust… more
- Hackensack Meridian Health (Hackensack, NJ)
- …OBS vs. Inpatient c. Liaison to the Medical Staff supporting Utilization Management Committee processes d. Hospital Based Appeals Management e. Provides ... direction and support regarding CMS & NJDOH regulations governing Utilization Management & Clinical documentation. b. Oversight...documentation iv. Target DRGs Reviews v. Use of case manager as a resource 4. Uses guidelines to evaluate… more
- Virginia Mason Franciscan Health (Bremerton, WA)
- …annual bonus eligibility, and more! **Responsibilities** **Job Summary / Purpose** The Utilization Management (UM) Director is responsible for the market(s) ... development, implementation, evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care Coordination… more
- LA Care Health Plan (Los Angeles, CA)
- …least 4 years of experience in a patient care setting and/or combination in utilization management , appeals and grievances, delegation oversight, and/or CNA ... Utilization Management Nurse Specialist LVN II...implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service,… more
- Cleveland Clinic (Stuart, FL)
- …only an excellent medical facility, but also a home away from home. As a Utilization Management (UM) RN Reviewer, you will work under the general supervision of ... the UM Team Manager to perform UM activities which include admission review,...a minimum of 85% on IRR quarterly. + Completes Utilization Management for assigned patients with a… more
- Cleveland Clinic (Weston, FL)
- …Miami-Fort Lauderdale metro area and remains a top hospital in Florida. As a Utilization Management (UM) Specialist, you will work under the general supervision ... of the UM Team Manager to perform UM activities which include admission review,...*Achieves a minimum of 85% on IRR quarterly. *Completes Utilization Management for assigned patients with a… more
- Hackensack Meridian Health (Hackensack, NJ)
- …standards, and regulatory/payor requirements. The role integrates and coordinates utilization management , care coordination, discharge planning functions and ... for disciplinary action and performance improvement plans when appropriate in conjunction with Manager of Case Management . **Responsibilities** A day in the life… more
- Billings Clinic (Billings, MT)
- …leadership and Physician Advisor, per department process or procedure *Insurance and Utilization Management *Maintains working knowledge of CMS requirements and ... starting. Click here (https://billingsclinic.csod.com/ats/careersite/search.aspx?site=15&c=billingsclinic) to learn more! RN - Utilization Review (Full-time/Billings) CARE MANAGEMENT (Billings Clinic… more
- Trinity Health (Livonia, MI)
- …/ MCG criteria to determine appropriate level of care. * Follows the hospital Utilization Review Plan to ensure effective and efficient use of hospital services. * ... patient discharge date and discharge plan. Mediates between case manager and payer to ensure a seamless transition in...to determine if a case should go to the Appeals Team. * Assists other departments in the reimbursement… more
- Ventura County (Ventura, CA)
- …and in accordance with the business needs of the department. Behavioral Health Manager I/II are management classifications and are not eligible for overtime ... and implements interagency agreements; + Selects, trains, supervises and conducts performance management for quality assurance and utilization review staff; +… more
- Alameda Health System (Oakland, CA)
- …the continuum. -Manages and assumes responsibility for day-to-day operations of utilization management , care coordination and discharge planning activities. ... Manager , Care Management + Oakland, CA...committees and in conjunction with the Director of Care Management identifies utilization issues affecting the quality… more
- Alameda Health System (Oakland, CA)
- …+ Manages and assumes responsibility for day to day operations of utilization management , care coordination and discharge planning activities. + Manages ... Manager , Care Management + Oakland, CA...committees and in conjunction with the Director of Care Management identifies utilization issues affecting the quality… more
- Healthfirst (IA)
- …in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management /case management . + ... staffs assignments and volume to ensure compliance + Triage and assign expedited appeals while helping standardize and optimize how Appeals and Grievances are… more