- Commonwealth Care Alliance (Boston, MA)
- …clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA ... CCA-Auth & Utilization Mgmt **Position Summary:** Reporting to the Manager Utilization Management, the Nurse Utilization Management (UM) Reviewer is… more
- Beth Israel Lahey Health (Plymouth, MA)
- …using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal clinical denials related to the care provided to ... years recent, broad clinical experience in the hospital setting + Experience with utilization management within the last 3 years required + An understanding of the… more
- Cognizant (Providence, RI)
- …Monday to Friday - Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced level work ... to have to be considered** . Educational background - Registered Nurse (RN) . 2-3 years combined...Nurse (RN) . 2-3 years combined clinical and/or utilization management experience with managed health care plan .… more
- Humana (Providence, RI)
- …SRO **Use your skills to make an impact** **Required Qualifications** + Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action ... caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing...who will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The… more
- Veterans Affairs, Veterans Health Administration (Providence, RI)
- …EDRP application. Former EDRP participants ineligible to apply. Responsibilities This Registered Nurse -Outpatient(PACT) position is located in Primary Care ... hours per week. The Patient Aligned Care Team (PACT) Outpatient Staff Registered Nurse (RN) is responsible for providing competent, evidence-based… more
- Commonwealth Care Alliance (Boston, MA)
- …that require intensive care management and care delivery. Within the CIC Program, the Registered Nurse (RN) serves as an integral member of an interdisciplinary ... and based on the fluctuating needs of the defined panel of members, the Registered Nurse will engage in regular assessments, visits at regularly scheduled… more
- Humana (Providence, RI)
- …impact** **Use your skills to make an impact** **Required Qualifications** + **Licensed Registered Nurse (RN)** in the (appropriate state) with no disciplinary ... caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing...in an acute care setting + Previous experience in utilization management/ utilization review for a… more
- Beth Israel Lahey Health (Cambridge, MA)
- …reliability processes to reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review clinical charts, interpret ... Quality & Patient Safety, the Quality and Patient Safety nurse specialist plays a role in reviewing publicly reported...for reporting quality measures, including both concurrent medical record review and periodic medical record review for… more
- Fresenius Medical Center (Fairhaven, MA)
- …all FMS manuals. + Accountable for completion of the Annual Standing Order Review and ICD coding. + Checks correspondence whether electronic, paper or voice mail, ... supporting billing and collection activities. + Responsible for efficient utilization of medication, laboratory, inventory, supplies and equipment to achieve… more
- Humana (Providence, RI)
- …timeframe **Use your skills to make an impact** **Required Qualifications** + Licensed Registered Nurse (RN) Compact license, with no disciplinary action + 3 ... caring community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes...Complete medical record reviews + Assess discharge plans + Review and extract information from claims + Complete documentation… more
- Sharecare (Providence, RI)
- …to enable individuals with disabilities to perform the essential functions. + Current Registered Nurse multi-state compact license in the state in which they ... utilization and desired clinical outcomes. The Disease Management Nurse is also responsible during their interactions with participants for identification… more
- Beth Israel Lahey Health (Cambridge, MA)
- …Qualifications:** 1. Bachelor's degree preferred. 2. Current Massachusetts state license as a Registered Nurse (RN). 3. Two years of recent acute hospital ... with Harvard Medical School. The Inpatient Case Manager (CM) performs utilization reviews and coordinates discharge planning for MAH inpatient admissions. Inpatient… more
- Brockton Hospital (Brockton, MA)
- …delays through problem resolution and follow-up. Monitors on-site case managers and utilization review staff to ensure compliance with Signature Healthcare ... primary responsibilities. EDUCATION: + RN with Master's Degree + Current License as Registered Nurse in the Commonwealth of Massachusetts EXPOSURE CATEGORY: It… more
- Beth Israel Lahey Health (Plymouth, MA)
- …job that may reasonably be required._ **Education/Experience Required:** _Required_ + State of MA Registered Nurse (RN) + 3-5 years acute care nursing + Two ... 3) Decreasing unit cost, 4) reducing readmissions. **Duties/Responsibilities:** **A. Utilization Management** Performs review of anticipated admissions utilizing… more
- State of Massachusetts (Boston, MA)
- …placement along the continuum of care. This vital role encompasses Utilization Review , Performance Improvement, Risk Assessment, Infection Surveillance, and ... a general summary and not all inclusive):_**__*/* * /Oversee case coordination, utilization review , discharge planning, and resource allocation across assigned… more
- Charter Care Health Partners (North Providence, RI)
- …a specific patient population. Performs functions related to Patient Advocacy; Utilization Review ; Resource Management; Continuum of Care Management (Discharge ... (BSN preferred) with current license to practice as a Registered Nurse in the State of Rhode...recent experience with case management, patient navigation, case management, utilization review or discharge planning is strongly… more
- Charter Care Health Partners (North Providence, RI)
- …a specific patient population. Performs functions related to Patient Advocacy; Utilization Review ; Resource Management; Continuum of Care Management (Discharge ... (BSN preferred) with current license to practice as a Registered Nurse in the State of Rhode...recent experience with case management, patient navigation, case management, utilization review or discharge planning is strongly… more
- Datavant (Providence, RI)
- …with clinical knowledge and expertise successfully. Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in DRG downgrade ... of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of...by management Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well… more
- Highmark Health (Providence, RI)
- …years of experience in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder or related **SKILLS** ... and the proper action to complete the retrospective claim review with the goal of proper and timely payment...data to assure appropriate level of payment and resource utilization . It is also used to identify issues which… more
- Children's Hospital Boston (Boston, MA)
- …in lab pre-analytical techniques preferred Licensure: + Current Massachusetts license as a Registered Nurse required OR + Current Massachusetts license as a ... (ASCP) Certification/Registration Required: + No certification requirement if licensed as a Registered Nurse OR + National Provider Identifier (NPI) number AND… more
