- CenterWell (Phoenix, AZ)
- …our caring community and help us put health first** The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical ... **Required Qualifications** + Must be a licensed Registered Compact Nurse license (RN) with no disciplinary action and ability...Lung or Critical Care Nursing experience required + Prior clinical experience preferably in an acute care, skilled or… more
- Molina Healthcare (Phoenix, AZ)
- …medical necessity, ensuring timeliness, and supporting the consistency of clinical decision-making across markets. Participates in a team-based, physician-led model ... that aligns with national clinical oversight standards and enterprise behavioral health initiatives. Contributes to overarching strategy to provide quality and… more
- CVS Health (Phoenix, AZ)
- …healthcare for members. **Position Summary** We are seeking a dedicated Utilization Management ( UM ) Nurse to join our remote team. In this role, you'll ... be at the forefront of clinical decision-making, applying your expertise in Behavioral Health to...+ Flexibility to provide coverage for other Utilization Management ( UM ) Nurses across various UM specialty teams… more
- CVS Health (Phoenix, AZ)
- …the lives of patients facing complex medical journeys. As a Utilization Management ( UM ) Nurse Consultant specializing in Oncology and Transplant, you'll play a ... in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote position offers… more
- Humana (Phoenix, AZ)
- …us put health first** Full-Time, Remote Telephonic opportunity The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation… more
- Humana (Phoenix, AZ)
- …a part of our caring community and help us put health first** The Telephonic Nurse Case Manager will be a member of the In-Home Case Management Team, providing a ... beneficiary's capacity for self- care, to cost-effectively achieve desired clinical outcomes and to enhance quality of medical care....and to enhance quality of medical care. The **Telephonic Nurse Case Manager** will collect and document data to… more
- Highmark Health (Phoenix, AZ)
- …experience, or provider operations and/or health insurance experience + 1 year in a clinical setting **Preferred** + 5 years in UM /CM/QA/Managed Care + 1 year ... over a specified panel of members that range in health status/severity and clinical needs; and assesses health management needs of the assigned member panel and… more
- Molina Healthcare (Phoenix, AZ)
- …national, state, and local laws and regulatory requirements affecting the medical and clinical staff. + Marketplace UM reviews + MD licenses required for ... appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership… more
- Molina Healthcare (Phoenix, AZ)
- …Job Summary The Care Review Clinician RN provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...a candidate with a RN licensure that has previous UM and Inpatient Hospital experience. Candidates with MCO experience… more
- Datavant (Phoenix, AZ)
- …recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully. Ideal candidate should be a Licensed ... Practical Nurse or Registered Nurse well versed in...denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines. **You will:** +… more
- Molina Healthcare (Phoenix, AZ)
- For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is a Remote position, home office with internet connectivity of high ... review, and medical coding. JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that… more
- Molina Healthcare (Phoenix, AZ)
- JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary ... and align with established clinical guidelines, insurance policies, and regulations - ensuring members...the Molina care model. * Adheres to utilization management ( UM ) policies and procedures. Required Qualifications * At least… more
- Molina Healthcare (Phoenix, AZ)
- …**Job Summary** The RN Care Review Clinician provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through… more
- Molina Healthcare (Phoenix, AZ)
- JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary ... and align with established clinical guidelines, insurance policies, and regulations - ensuring members...the Molina care model. * Adheres to utilization management ( UM ) policies and procedures. Required Qualifications * At least… more
- Molina Healthcare (Phoenix, AZ)
- …at the most effective setting. *Evaluates effectiveness of utilization management ( UM ) practices - actively monitoring for over and under-utilization. * Educates ... and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical … more
- Molina Healthcare (Phoenix, AZ)
- …compliance with all state and federal regulations and guidelines. + Analyzes clinical service requests from members or providers against evidence based clinical ... and efficient manner. + Makes appropriate referrals to other clinical programs. + Collaborates with multidisciplinary teams to promote...teams to promote Molina Care Model + Adheres to UM policies and procedures. + Occasional travel to other… more