- Novo Nordisk Inc. (Boston, MA)
- …centers, HCPs and other stakeholders in a given geography. Utilizing approved clinical resources to support provider efforts to deliver appropriate care for ... growth of the therapeutic market. This is not a clinical patient-facing role. Relationships The CM Educator is an...range of HCPs and local stakeholders to enhance cardiometabolic management across the territory and region. Additionally, the role… more
- US Tech Solutions (Canton, MA)
- …of clinical decision making and support needed to perform utilization management , medical necessity determinations and benefit determinations using ... remote, but Massachusetts RN license required.** **Job Summary The Clinical Reviewer is a licensed professional -a...unrestricted Massachusetts license required + Minimum of five years clinical experience in utilization management ,… more
- Commonwealth Care Alliance (Boston, MA)
- … Utilization Management reports to the Director of Utilization Management * Oversees clinical decision review for services requiring prior ... for overseeing and managing the daily operation of the Utilization Management Review Nurse and... Nurse and Specialist staff responsible for conducting centralized clinical review and authorization creation for centrally… more
- Evolent (Boston, MA)
- …from providers per guidelines. + Utilizing clinical guidelines approved by the Utilization Management Committee (UMC), the URN has the authority to authorize ... cost-effective care. **Collaboration Opportunities** : As a Radiation Technologist in the Utilization Management department, you will work closely with other… more
- Commonwealth Care Alliance (Boston, MA)
- … and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA ... Manager Utilization Management , the Nurse Utilization Management (UM) Reviewer is...direct reports. **Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …us transform healthcare? Bring your true colors to blue. The Role The RN Utilization Management Reviewer is responsible for facilitating care for members ... provide the best quality care. The Team The RN Utilization Management Reviewer is part...and retrospective reviews with emphasis on utilization management , discharge planning, care coordination, clinical outcomes,… more
- Commonwealth Care Alliance (Boston, MA)
- …local regulatory guidelines. + Serve as the lead for CCA's Utilization Review functions working closely with other medical management team members. + Support ... review findings, actions, and outcomes in accordance with Utilization + Management policies; meets health plan...a clinical resource and coach for the utilization management team + Is available and… more
- Evolent (Boston, MA)
- …Join Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Pain Management Clinical Reviewer , Nurse, you will be a key member of the ... utilization management team. We can offer you...while providing better health outcomes. **Collaboration Opportunities:** As a Clinical Reviewer , Nurse, you will routinely interact… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …business expert for member and provider submitted appeals. Working collaboratively with Physician review unit, Utilization Management , Case Management , ... Nurse Reviewer is responsible for applying sound clinical judgement to review provider and member...Member appeals and Grievance, Provider Service, Claims, Network Management , and Medical Policy teams. This role is eligible… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …the Home Infusion Therapy, Specialty Pharmacy Network and Medical Utilization Management for pharmaceuticals programs + Partner with clinical and non- ... the Retail Pharmacy, Medicare Advantage Part D, Home Infusion Therapy, and Medical Utilization Management benefits. This position is eligible for the Flex… more
- Evolent (Boston, MA)
- …the mission. Stay for the culture. **What You'll Be Doing:** **Cardiovascular Utilization Management Reviewer (Interventional Cardiologist)** Are you ready ... make a meaningful impact on patient care in a non- clinical setting? Join our Utilization Management...within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure… more
- Evolent (Boston, MA)
- …clinical expertise in developing cardiovascular programs that include improvements to clinical effectiveness of utilization management (UM) and risk-based ... critical role in **Performance Suite risk arrangements with payers and strategic utilization management initiatives.** This is an opportunity for a… more
- Beth Israel Lahey Health (Burlington, MA)
- …the multidisciplinary team to ensure a timely process. Registered Nurses (RNs) with utilization review experience, case management experience, and med/surg ... in people's lives.** Joint role of Case Manager and Utilization Review Nurse **Job Description:** The Inpatient...of medical/surgical nursing care experience. -Two years of Case Management or Utilization Management experience… more
- Humana (Boston, MA)
- …Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a medical ... their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Humana (Boston, MA)
- …Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a medical ... daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Humana (Boston, MA)
- …Delivery Systems, health insurance, other healthcare providers, clinical group practice management . + Utilization management experience in a medical ... their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …to blue. The Role:The Medical Clinical Program Manager will focus on utilization management compliance and audit readiness activities such as evaluating and ... Management 's (HMM) and delegate's compliance with the applicable NCQA utilization management standards and state and federal regulations. This position… more
- Children's Hospital Boston (Boston, MA)
- …Posting Title:Per Diem RN Case Manager, Utilization Management /ReviewDepartment:Patient Services-Patient Care OperationsAutoReqId:80451BRStatus:Part-TimeStandard ... + Experience as a Case Manager (Discharge Planning and or Utilization Management ) preferred. Licensure/ Certifications: + Current Massachusetts license… more
- Beth Israel Lahey Health (Burlington, MA)
- …taking a job, you're making a difference in people's lives.** Manages the Utilization Management (UM) team, maintaining effective and efficient processes for ... collaboration with the Physician Advisors, Collaborates and helps facilitate the Utilization Review Committee. Continuously monitors processes for opportunities… more
- Elevance Health (Woburn, MA)
- …Provider Finder and follows up with provider on referrals given. + Refers cases requiring clinical review to a nurse reviewer ; and handles referrals for ... ** Utilization Management Representative II** **Virtual:** This...+ Processes incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and… more
