- CenterWell (Atlanta, GA)
- …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 (Atlanta, GA)
- …**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
- Evolent (Atlanta, GA)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. ... policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member...medical management activities in a managed care environment + UM /UR experience + Clinical experience in Oncology,… more
- Humana (Atlanta, GA)
- …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
- Highmark Health (Atlanta, GA)
- …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 ... panel of members that range in health status/severity and clinical needs; and assesses health management needs of the...RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) or WV or DE or… more
- Waystar (Atlanta, GA)
- **ABOUT THIS POSITION** The Clinical Product Consultant for Utilization Management is a member of the Customer Success Organization who will provide clinical ... complexity of our AI technology is married with the clinical perspective and needs of our clients through data...workflows. We are specifically seeking an experienced Utilization Review Nurse who will serve as an integral contributor in… more
- Molina Healthcare (Atlanta, GA)
- 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 (Atlanta, GA)
- JOB DESCRIPTION Job Summary 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...the Molina care model. * Adheres to utilization management ( UM ) policies and procedures. Required Qualifications * At least… more
- Molina Healthcare (Atlanta, GA)
- …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
- Elevance Health (Atlanta, GA)
- …will make an impact:** + Coordinates specific health coaching as directed by nurse case manager to address objectives and goals as identified during assessment. + ... ways to overcome those barriers. + Coordinates with the nurse case manager to provide feedback on member goal...manager to provide feedback on member goal attainment and clinical issues. + Identify and address HEDIS/STARS gaps in… more