- Elevance Health (Durham, NC)
- ** Nurse Appeals RN-Quality of Care** **Hybrid 1:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, ... Work Hours:** Monday-Friday, 8:00AM -5:00 PM Eastern Standard Time The ** Nurse Appeals ** is responsible for investigating and processing and medical necessity … more
- Evolent (Raleigh, NC)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of ... a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and… more
- Cognizant (Raleigh, NC)
- …to Friday - Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced level work related to clinical ... . Maintain working knowledge of applicable health insurers' internal claims, appeals , and retro-authorization as well as timely filing deadlines and processes.… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in ... timely and accurate decisions + Ensure strict adherence to Appeals and Utilization Management (UM) processes and regulatory and...employment + Minimum of 5 years' experience in Clinical Appeals and Grievances within a managed care or payor… more
- Sharecare (Raleigh, NC)
- …enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited to medical, ... 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status +...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …all Clinical Services (CS) functions (prior authorization, concurrent review, appeals , case management, disease management, population health) per defined Client ... all WC State Reporting and audits. Essential Qualifications + Currently licensed Registered Nurse (RN), Nurse Practitioner (NP), or Physician Assistant (PA) with… more