- Molina Healthcare (Miami, FL)
- …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
- Molina Healthcare (Miami, FL)
- …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 (Miami, FL)
- …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
- Elevance Health (Miami, FL)
- …network management input and dollar volume of provider. + Analyzes data to select claims to be reviewed, conducts reviews using medical charts, medical ... notes, and provider contracts. + Verifies dollar amount on claim is correct in claims system and...education and experience, which would provide an equivalent background. RN , LPN or medical coding certification strongly… more
- Elevance Health (Miami, FL)
- …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
- Elevance Health (Miami, FL)
- …enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims . + Responsible for independently ... Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Investigator Senior** is responsible for the independent… more
- MyFlorida (Fort Lauderdale, FL)
- …examination by a licensed physician, physician assistant, or licensed advanced practice registered nurse , based on specifications established by the commission. ... but are not limited to fraud against the Medicaid Program, false claims against the Medicaid program, investigating possible criminal violations of any applicable… more
- US Tech Solutions (Miami, FL)
- The RN Case Manager is responsible for telephonically and/or face to face assessing, planning, implementing, and coordinating all case management activities with ... members to evaluate the medical needs of the member to facilitate the member's...+ Through the use of clinical tools and information/data review , conducts an evaluation of member's need and benefit… more
- University of Miami (Miami, FL)
- …potentially compensable events to Chief Medical Risk Officer, Director of Medical Claims and Assistant General Counsel. + Conduct additional investigation ... + Minimum 5 years of relevant experience required; 7-10 years of experience preferred + Medical /Legal background is a plus + RN Training and licensure is a plus… more