- Molina Healthcare (Atlanta, GA)
- …will work on set schedule) Looking for a RN with experience with appeals, claims review , and medical coding. **Job Summary** Provides support for medical ... and cost-effective member care. **ESSENTIAL JOB DUTIES:** + Facilitates clinical / medical reviews of retrospective medical ...nursing experience, including at least 1 year of utilization review , medical claims review , long-term… more
- Cognizant (Atlanta, GA)
- …necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with Medicare, Medicaid, and ... as well as timely filing deadlines and processes. . Review clinical denials including but not limited...thinking skills to interpret guidelines of internal policies for clinical determination. . Medical Necessity Reviews can… more
- Molina Healthcare (Atlanta, GA)
- **JOB DESCRIPTION** **Job Summary** The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals requests ... Central time Remote position **Essential Job Duties** * Performs clinical / medical reviews of previously denied cases in...specific programs supported by the plan such as utilization review , medical claims review , long-term… more
- Elevance Health (Atlanta, GA)
- ** Nurse Audit Senior - Payment Integrity Complex and Clinical Audit** **Location:** This role enables associates to work virtually full-time, with the exception ... formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The ** Nurse Audit Senior** will be responsible… more
- Elevance Health (Atlanta, GA)
- ** Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU** **Location:** This role requires associates to be in-office 1 - 2 ... Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The ** Clinical Fraud Investigator II** is responsible… more
- Humana (Atlanta, GA)
- …Manager, Fraud and Waste Investigator: Nurse Audit/ Review performs clinical audit/validation processes to ensure that medical record documentation and ... approach, resources, schedules and goals. The Manager, Fraud and Waste Investigator: Nurse Audit/ Review validates and interprets medical documentation to… more
- Elevance Health (Atlanta, GA)
- …states; therefore, Multi-State Licensure will be required.** The ** Medical Management Nurse ** is responsible for review of the most complex or challenging ... ** Medical Management Nurse ** **Location: Virtual: This...management experience and requires a minimum of 2 years clinical , utilization review , or managed care experience;… more
- Elevance Health (Atlanta, GA)
- …states; therefore, Multi-State Licensure will be required.** The ** Medical Management Nurse ** is responsible for review of the most complex or challenging ... ** Medical Management Nurse ** **Location Virtual: This...management experience and requires a minimum of 2 years clinical , utilization review , or managed care experience;… more
- Gentiva (Alpharetta, GA)
- …(LCD) criteria per hospice policy and regulatory requirements. + Communicate clinical findings, review treatment plans, lab results, diagnostics, and ... Partnerships. Transform Hospice Care.** We are seeking a dedicated Hospice Nurse Practitioner to perform Face-to-Face (F2F) encounters essential for hospice… more
- Humana (Atlanta, GA)
- …in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The Nurse reviews the medical documentation, researching claims, ... and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to...Medical Directors on submitted G&A cases. The G&A Nurse will participate in initiatives which result in improved… more
- Dialysis Clinic, Inc. (Atlanta, GA)
- …experience; experience preferred **Benefits:** + Paid training with preceptor + Charge nurse continuing education classes + Comprehensive medical , dental and ... and document orders + Participate in patient care conferences, medical rounds and chart review ; document progress...as directed and supervised by the education coordinator, the clinical supervisor and/or the nurse manager +… more
- Humana (Atlanta, GA)
- …community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills to support the coordination, ... determination of the appropriate courses of action. The Utilization Management Behavioral Health Nurse 2 completes medical record reviews from medical … more
- Fresenius Medical Center (Marietta, GA)
- …to the Inpatient Program Manager, appropriately credentialed physician, patient hospital primary nurse and others as indicated. + Delivers safe, effective care in a ... May be assigned to in-center patient care on an as needed basis + Review and comply with the Code of Business Conduct and all applicable company policies… more
- Sunrise Senior Living (Acworth, GA)
- …NAME** Varenita of West Cobb **Job ID** 2025-235063 **JOB OVERVIEW** The Wellness Nurse is responsible for monitoring the health and well-being of our residents and ... administration, communication with resident support services and families, and maintaining clinical quality assurance while leading and demonstrating the Mission for… more
- Emory Healthcare/Emory University (Atlanta, GA)
- …to the excellence of our academic community. **Description** **Acute Care Nurse Practitioner Certificate Required** KEY RESPONSIBILITIES: + Assists in the evaluation ... + Documents the delivery of care in the individual's medical records. + Conducts patient interviews and documents patient...APP Wound Clinic + Perform Full Neuro Exam + Review Imaging (MRI/CT/XR) + Book Elective Cases + Consent… more
- CenterWell (Marietta, GA)
- …on teamwork and providing a positive and welcoming environment for all. The Nurse Practitioner (NP) or Physician Assistant (PA) works in our team-based care ... of doctors, advanced practice professionals, Pharm D, Care Coach Nurse , MA, Behavioral health specialist, Quality based Coder, Referral...accordance with standards of care. . Follows level of medical care and quality for patients and monitors care… more
- Humana (Atlanta, GA)
- …based on operational needs at the discretion of department leadership. The Telephonic Nurse provides medical guidance, assists with access to care concerns, ... medication adherence and is trained to act as a clinical concierge. The NAL Telephonic Nurse role...compliance, etc. Responsibilities include: + **Provide accurate and appropriate medical advice and right level of care guidance utilizing… more
- State of Georgia (Fulton County, GA)
- …and practices of medical documentation monitoring activities. + Reviews medical / clinical records for meeting criteria for authorized services. + Participates ... analysis of medical services documentation and related claims 2) Utilization Review 3) Case Management 4) Analysis of CPT codes and/or ICD-10 Diagnosis Codes;… more
- Vatica Health (Atlanta, GA)
- …is seeking clinically experienced and detailed-oriented nurses to join our team. As a Nurse Consultant, you will collect, review and analyze patient data to ... improve care coordination, quality metrics, and medical cost savings. The ideal candidate has a track...+ Minimum of 3 years of recent adult health clinical experience as a Registered Nurse (RN)-… more
- CVS Health (Atlanta, GA)
- … judgment and regulatory knowledge. **Key Responsibilities** + Responsible for the review and resolution of clinical appeals. + Reviews documentation and ... **Position Summary** CVS Aetna is seeking a dedicated **Appeals Nurse Consultant** to join our remote team. In this...interprets data obtained from clinical records to apply appropriate clinical criteria… more