- Commonwealth Care Alliance (Boston, MA)
- …timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role ... Utilization Management , the Nurse Utilization Management (UM) Reviewer is...**Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior authorization in a variety… more
- Commonwealth Care Alliance (Boston, MA)
- … Management is responsible for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible ... reports to the Director of Utilization Management * Oversees clinical decision review for...reviews). * Hire, train and mentor UM staff, including nurse reviewers and support personnel. * Act as liaison… more
- US Tech Solutions (Canton, MA)
- …all aspects of clinical decision making and support needed to perform utilization management , medical necessity determinations and benefit determinations using ... criteria through participation in the IMPAC. + Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM… more
- Beth Israel Lahey Health (Plymouth, MA)
- …years recent, broad clinical experience in the hospital setting + Experience with utilization management within the last 3 years required + An understanding ... using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal clinical denials related to the care provided to… more
- Beth Israel Lahey Health (Burlington, MA)
- …you're making a difference in people's lives.** Joint role of Case Manager and Utilization Review Nurse **Job Description:** The Inpatient Registered ... the multidisciplinary team to ensure a timely process. Registered Nurses (RNs) with utilization review experience, case management experience, and med/surg… more
- Zurich NA (Boston, MA)
- …+ Experience in development and implementation of cost containment programs + Case management , utilization review , catastrophic or disability experience + 5 ... AVP, Utilization Review & Pharmacy 123092 Zurich...recruiting and retaining team members. + Drive the performance management process by communicating job expectations, monitoring and evaluating… more
- Beth Israel Lahey Health (Plymouth, MA)
- …years recent, broad clinical experience in the hospital setting + Experience with utilization management within the last 3 years required + An understanding ... using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal clinical denials related to the care provided to… more
- Beth Israel Lahey Health (Burlington, MA)
- …taking a job, you're making a difference in people's lives.** Manages the Utilization Management (UM) team, maintaining effective and efficient processes for ... collaboration with the Physician Advisors, Collaborates and helps facilitate the Utilization Review Committee. Continuously monitors processes for opportunities… more
- Evolent (Boston, MA)
- …appeals. **What You Bring:** + 1-3 years' experience in clinical Appeals Review or Utilization Management Review as an LPN or LVN is required. + Must ... team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and client policies and… more
- State of Massachusetts (Boston, MA)
- …social workers, physicians, and professional staff, while also participating in Census and Utilization Review Committees under the guidance of the Director of ... for complex admissions, ensuring access for special populations./ * /Prepare reports for utilization review and census meetings./ * /Assist the CEO with public… more
- Prime Therapeutics (Boston, MA)
- …pharmacist clinical reviewer . + Practices and maintains the principles of utilization management by adhering to the company policies and procedures. Upholds ... achieving revenue goals and operational objectives. Responsible for executing utilization management programs on behalf of health...to nurse , pharmacist or physician on the utilization review clinical team when further … more
- Baystate Health (Springfield, MA)
- …Health Center** The **ACO Nurse Care Manager i** s responsible for the management of care for a defined group of patients including complex care management , ... Nurse Care Manager, Community...management application is required and is vital. Care management program metrics including, emergency room utilization ,… more
- Sharecare (Boston, MA)
- …total healthcare management and ensure cost effective, appropriate resource utilization and quality outcomes. The Clinical Registered Nurse is also ... the participants and their Primary Care Provider according to the disease management program intervention guidelines. A Clinical Registered Nurse is supervised… more
- Lincoln Financial (Boston, MA)
- …Care, Orthopedics, Coronary Care, , Trauma , Disability, Workman's comp or case management or Utilization review **Application Deadline** **What's it like ... Role at a Glance** We are excited to bring on a highly motivated Nurse Disability Consultant to our clinical organization. This position will be responsible for… 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
- 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
- Cambridge Health Alliance (Cambridge, MA)
- …team leader in multi-disciplinary team discussion regarding treatment planning, treatment review , quality assurance and utilization review ... Nurse Practitioner - Clinical Specialist II (APRN), Psychiatry...to nursing policy and procedure. + Communicate effectively with management , peers, and health team members. + Interact effectively… more
- Fresenius Medical Center (Springfield, 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
- Tufts Medicine (Burlington, MA)
- …The position provides day to day support and oversight to Utilization Review departments and UM vendor management . The UM Operations Manager is responsible ... Utilization Review and Discharge Planning including implementation and annual review of the Utilization Management Plan and assisting with the… more
- Brockton Hospital (Brockton, MA)
- … management experience Proven experience in coordinating discharge planning and utilization review experience required. Prior management experience ... delays through problem resolution and follow-up. Monitors on-site case managers and utilization review staff to ensure compliance with Signature Healthcare… more