- AmeriHealth Caritas (Philadelphia, PA)
- **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with ... appeals , ensuring compliance with all regulatory milestones + Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation,… more
- Cognizant (Trenton, NJ)
- …, and retro-authorization as well as timely filing deadlines and processes. . Review clinical denials including but not limited to referral, preauthorization, ... cycle or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and concurrent reviews .… more
- Evolent (Trenton, NJ)
- …to Standard processing, documenting accordingly. + Works closely with the appeals -dedicated Clinical Reviewers to ensure timely adjudication of processed ... for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a...work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators… more
- Humana (Trenton, NJ)
- …Medical Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Represents Humana at Administrative… more
- Humana (Trenton, NJ)
- …health first** The Corporate Medical Director (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director ... CMD represents Humana at Administrative Law Judge hearings; exercises independent clinical judgment and decision making on complex issues regarding job duties… more
- Humana (Trenton, NJ)
- …this knowledge in their daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, review of ... resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and… more
- Humana (Trenton, NJ)
- …this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review ... resolution skills. Some roles include an overview of coding practices and clinical documentation, dispute, grievance, and appeals processes, and outpatient… more
- Humana (Trenton, NJ)
- …this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review ... provider. Some roles include an overview of coding practices and clinical documentation, dispute/grievance and appeals processes, and outpatient services… more
- Evolent (Trenton, NJ)
- …of the request and provides clinical rationale for standard and expedited appeals . + Utilizes medical/ clinical review guidelines and parameters to assure ... to make a difference in patients lives, in a non- clinical environment. You can enjoy better work- life balance...Will Be Doing:** + Serve as the Physician match reviewer in Imaging cases, that do not initially meet… more
- Evolent (Trenton, NJ)
- …of the request and provides clinical rationale for standard and expedited appeals . . Utilizes medical/ clinical review guidelines and parameters to assure ... to make a difference in patients lives, in a non- clinical environment. You can enjoy better work- life balance...Will Be Doing:** . Serve as the Physician match reviewer in Advanced Imaging cases, that do not initially… more
- Evolent (Trenton, NJ)
- …of the request. + Provides clinical rationale for standard and expedited appeals . + Utilizes medical/ clinical review guidelines and parameters to assure ... to make a difference in patients' lives, in a non- clinical environment. You can enjoy better work- life balance...Will Be Doing:** + Serve as the specialty match reviewer in Vascular cases, that do not initially meet… more
- Evolent (Trenton, NJ)
- …when available, within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the ... guidance and expertise to ensure the application of best practices. + Provides clinical rationale for standard and expedited appeals . + Discusses determinations… more
- Evolent (Trenton, NJ)
- …for the mission. Stay for the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer , Interventional Pain Management, you will be a key member of ... You Will Be Doing:** + Serve as the Physician Clinical Reviewer for Interventional Pain Management, reviewing...within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure… more
- Evolent (Trenton, NJ)
- …when available, within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the ... Will Be Doing:** + Serve as the specialty match reviewer in Cardiology cases, that do not initially meet...be completed by the subject matter expert. + Provides clinical rationale for standard and expedited appeals .… more
- Highmark Health (Trenton, NJ)
- …to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. ... are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical… more
- Virtua Health (Mount Laurel, NJ)
- …Coding Audit Response: Conducts Trains new coders to utilize the medical record, clinical , coding and abstracting systems, in conjunction with UHDDS and other rules ... appropriate feedback.exit interviews with external auditors, prepares rebuttals and appeals , take appropriate action with responses (including correcting data and… more
- Highmark Health (Trenton, NJ)
- …and efficient delivery of Pharmacy call center services. Serves as first line reviewer in monitoring and ensuring adherence to the health plan's state and federal ... the department. + Prioritize requests for drug authorizations or denials. + Review of prior authorization criteria for drug products. + Recommend staffing… more
- Humana (Trenton, NJ)
- …and work is assisted by diverse resources, which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, ... reviewing of all submitted medical records, synthesizing complex hospital-based clinical scenarios, and providing expert decisioning on the requested services.… more
- Humana (Trenton, NJ)
- …of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Begins to influence department's ... are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. The ideal candidate supports… more
- Intermountain Health (Trenton, NJ)
- …provides advanced training to hospital coding staff, compliance, CDI, physicians, and clinical staff. This Coordinator serves as a subject matter expert for all ... of hospital coding. The coordinator works with providers and clinical staff to make critical coding decisions based on...compliance and the CDI team. + Audits and creates appeals for all payer and regulatory denials and downgrades… more