- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- Ready to help us transform healthcare? Bring your true colors to blue. The RoleThe RN Utilization Management Reviewer is responsible for facilitating ... benefit to provide the best quality care. The TeamThe RN Utilization Management Reviewer...+ Licensure in additional states a plus. + For registered nurses only: a bachelor's degree in (BSN) preferred.… more
- CVS Health (Boston, MA)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... reviews. **Required Qualifications** + 5+ years' experience as a Registered Nurse with at least 1 year...lower levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC… more
- Beth Israel Lahey Health (Burlington, MA)
- …the medical necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue integrity, these specialized ... Analyst works with physicians, the payers and inpatient case management team to validate the medical necessity of the...necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue… more
- Massachusetts Institute of Technology (Cambridge, MA)
- …patients, families, providers, and community agencies. PREFERRED: two years of case management , utilization review , and discharge planning experience. ... Registered Nurse , Care Coordinator + Job... Registered Nurse , Care Coordinator + Job Number: 25320 +...Graduate of an accredited nursing program; bachelor's degree; current RN license in Massachusetts; CPR Certified; a minimum of… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …and 3-5 years in a managed care health plan setting. + Strong understanding of Utilization Review , Care Management and Medical Polices. + Knowledge of APR ... concerns Key Qualifications + Strong clinical skills and understanding of HMM's Utilization Management , Case Management and operational procedures, Medical… more
- Fresenius Medical Center (Peabody, MA)
- …auditing activities. + Accountable for completion of the Annual Standing Order Review and Internal Classification of Disease (ICD) coding. + Manages clinic ... financials including efficient utilization of supplies or equipment and regular profits and...of supplies or equipment and regular profits and loss review . + Responsible for all required network reporting and… more
- Evolent (Boston, MA)
- …the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- Highmark Health (Boston, MA)
- …triaging members to appropriate resources for additional support. + Implement care management review processes that are consistent with established industry, ... Nursing **EXPERIENCE** **Required** + 7 years in any combination of clinical, case/ utilization management and/or disease/condition management experience, or… more
- Evolent (Boston, MA)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and ... work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators...Be Doing:** + Practices and maintains the principles of utilization management and appeals management … more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …health care settings (Inpatient, outpatient, or differing levels of care). * Utilization Management experience, preferred * Active licensure in Massachusetts is ... standards to create, follow and appropriately document comprehensive care management plans. * Review medication list and...required, appropriate to position ( RN /PT) o Licensure in additional states a plus. o… more
- Highmark Health (Boston, MA)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... and the proper action to complete the retrospective claim review with the goal of proper and timely payment...experience in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder… more
- Atrius Health (Newton, MA)
- …. Minimum 5 years nursing experience, which includes a minimum of 3 years in utilization management or case management . . Minimum of 3-5 years clinical ... Case Management (CCM) or CCM eligible preferred. Current unrestricted RN licensure to practice professional nursing in the Commonwealth of Massachusetts… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …Minimum Experience: 1 year of clinical and/or related experience required. Case Management , Utilization Review and/or Prior Authorization experience is ... preferred. Certification/Licensure/Registration: Licensed as a Registered Nurse in the Commonwealth of Massachusetts preferred. **KNOWLEDGE, SKILLS, AND… more
- Humana (Boston, MA)
- …**Use your skills to make an impact** **Required Qualifications** + Licensed as a Registered Nurse in the State of Wisconsin, including compact license. + Two ... put health first** Humana is seeking a Prior Authorization RN to join the Wisconsin Medicaid Market (iCare) team....the lives of others. **Essential Duties and Responsibilities:** + Review PA requests for home health services, durable medical… more
- Deloitte (Boston, MA)
- …Bachelor's degree in nursing, medical degree, or physician assistant required + Current Registered Nurse ( RN ) license required + Certified Clinical ... nurse , physician, physician assistant, case manager, clinical documentation specialist, utilization review , informatics RN , Quality, DRG Validation and… more
- Beth Israel Lahey Health (Cambridge, MA)
- …**Minimum Qualifications:** 1. Bachelor's degree preferred. 2. Current Massachusetts state license as a Registered Nurse ( RN ). 3. Two years of recent acute ... with Harvard Medical School. The Inpatient Case Manager (CM) performs utilization reviews and coordinates discharge planning for MAH inpatient admissions. Inpatient… more
- Parexel (Boston, MA)
- …mitigations and drive resolution with cross-functional stakeholders as part of the Risk Management Plan. + Review and analyze metrics to derive meaningful ... practices like version control and literate programming. + BSN, RN , RPh, Pharm D, PA, MPH, or other applicable...project-level resourcing of staff and staff assignments. + Regularly review and update Data Management resources to… more
- Beth Israel Lahey Health (Wakefield, MA)
- …Minimum License required: Active, unrestricted Massachusetts or New Hampshire LPN or RN license. Certification in Case Management (CCM) preferred. Experience: 1. ... population health and is responsible to ensure that quality and efficient care management services are provided to the BILHPN provider's risk populations. The Care… more