- Molina Healthcare (Atlanta, GA)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... **Job Duties** + Performs clinical/ medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which… more
- CVS Health (Atlanta, GA)
- …+ Perform medical necessity reviews. **Required Qualifications** + 5+ years' experience as a Registered Nurse ( RN ) with at least 1 year of experience in ... of residence.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS...a hospital setting. + A Registered Nurse that holds an active, unrestricted… more
- CVS Health (Atlanta, GA)
- …- Perform medical necessity reviews. **Required Qualifications** - 5+ years' experience as a Registered Nurse ( RN ) with at least 1 year of experience in ... of residence.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS...a hospital setting. - A Registered Nurse that holds an active, unrestricted… more
- Public Consulting Group (Atlanta, GA)
- …sector. To learn more, visit www.publicconsultinggroup.com . PCG is currently seeking a qualified Registered Nurse to perform as a Case Manager. The Case Manager ... Proven working experience in case management, including as a nurse , medical , mental health care manager or...plans. + Current license, certification or registration as a Registered Nurse or Social Worker **Working Conditions**… more
- Molina Healthcare (Atlanta, GA)
- …to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. ... nursing experience with broad clinical knowledge. + Five years experience conducting medical review and coding/billing audits involving professional and facility… more
- Molina Healthcare (Atlanta, GA)
- …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse ( RN ) performs clinical/ medical reviews of… more
- Guardian Life (Atlanta, GA)
- …providing comprehensive medical reviews and analysis of long-term disability claims . The RN Clinical Consultant identifies restrictions, limitations and ... duration impacting functional capacity based on medical data, to assist the Claim Managers...The RN Clinical Consultant reviews long-term disability claims to determine the impact of claimants' medical… more
- Elevance Health (Atlanta, GA)
- …and efficiency recommendations. **Minimum Requirements:** + Requires current, active, unrestricted Registered Nurse license in applicable state(s). + Requires a ... experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing… more
- Sedgwick (Atlanta, GA)
- …accredited college or university preferred. Current Certified Rehabilitation Counselor (CRC) or Registered Nurse ( RN ) license required. Current license, ... clinical evaluations on claims that require additional review based on medical condition, client requirement,... management of claims , including comprehension of medical terminology and substantiating claim decisions. **ADDITIONAL… more
- Centene Corporation (Atlanta, GA)
- …State Licensure required or + LVN - Licensed Vocational Nurse required or + RN - Registered Nurse - State Licensure and/or Compact State Licensure ... Experience in appeals and denials + Background in utilization management and claims review If you're detail-oriented, comfortable making clinical determinations,… more
- Lincoln Financial (Atlanta, GA)
- …as indicated **What we're looking for** * 4 Year/Bachelor's Degree in Nursing * Registered Nurse License - Current, unrestricted license in the state where the ... organization. This position will be responsible for reviewing, analyzing, and interpreting medical information available for disability claims . In this role you… more
- PruittHealth (Norcross, GA)
- …Oasis C-2 Certification within 9 months from hire date** + Current and unrestricted Registered Nurse ( RN ) licensure in state of practice. **ADDITIONAL ... Coordination (DEAC), the Episode Assessment Coordinator (EAC) is responsible for prospective review of episode related documents. The EAC ensures all services and… more
- Otsuka America Pharmaceutical Inc. (Atlanta, GA)
- …to travel up to 25%.** **Educational Qualifications** Required: + Bachelor's Degree or Registered Nurse ( RN ). Minimum of 10 years industry experience ... and guidance, ICH/GCP, and Otsuka SOPs.** **Contribute to the development and review of all critical clinical study documents, including clinical protocols, informed… more
- Lincoln Financial (Atlanta, GA)
- …duties as required. **What we're looking for** * Minimum of 5 years of disability claims experience * Current Registered Nurse license or Licensure in ... you will be responsible for leading and managing a team of nurse disability consultants and behavioral health consultants. This includes partnering closely with… more
- State of Georgia (Fulton County, GA)
- …additional experience in the analysis of medical services documentation and related claims 2) Utilization Review 3) Case Management 4) Analysis of CPT codes ... Nurse Investigator Georgia - Fulton - Atlanta (https://careers.georgia.gov/jobs/64040/other-jobs-matching/location-only)...clinical experience AND one (1) year experience working with medical claims . Preference will be given to… more
- Lincoln Financial (Atlanta, GA)
- …at a Glance** We are excited to bring on a Clinical Director to our claim 's organization. This role will be remote, or hybrid based on the proximity to Charlotte ... stakeholders that require collaboration with resources from clinical and claims . * Directs operational workforce & volume analysis, including analysis… more
- Evolent (Atlanta, GA)
- …+ Performs other duties as assigned. **Qualifications: Required and Preferred:** + Licensed registered nurse or LVN/LPN (current and unrestricted) + Minimum of ... and write clearly. + Reviews adverse determinations against criteria and medical policies + Creates adverse determination notifications that meet all accreditation,… more
- Sedgwick (Atlanta, GA)
- …new business plan with goals and objectives for assigned locations/offices; provides expert medical and product support to Sedgwick claims and clinical staff. ... cost effective, and high quality delivery of case management and utilization review services to clients for multiple business lines; and to provide expertise… more
- Emory Healthcare/Emory University (Atlanta, GA)
- …risk areas. + Implements policies, strategies, and workflows to ensure accurate medical record documentation, professional billing and coding compliance. + Serves as ... + Leads education sessions with departments, coders and/or providers, as applicable, to review audit results. + Conducts sample and focused reviews to ensure coding… more
- Elevance Health (Atlanta, GA)
- **Telephonic Nurse Case Manager II** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training ... different states; therefore, Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager II** is responsible for performing care management within… more