- Evolent (Augusta, ME)
- …Evolent for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior ... policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as... medical necessity and appropriateness of services using clinical review criteria. + Accurately documents all… more
- Northern Light Health (Pittsfield, ME)
- Northern Light Sebasticook Valley Hospital Department: Medical Surgical Unit Position is located: {Location} Work Type: Full Time Hours Per Week: 36 Hours per Week ... (minus tax) sign on bonus that is paid out incrementally. Summary: The Registered Nurse I is a Registered Nurse who is a beginning professional caregiver,… more
- Humana (Augusta, ME)
- …and help us put health first** The Nurse Auditor 2 performs clinical audit/validation processes to ensure that medical record documentation and diagnosis ... independent determination of the appropriate courses of action. The Nurse Auditor 2 validates and interprets medical ...coding experience to conduct a clinical validation review of the inpatient medical record to… more
- CVS Health (Augusta, ME)
- …benefit overall claim management. + Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to ... in the US with virtual training.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993,… more
- CenterWell (Augusta, ME)
- …When working weekends, it will allow for off-days during the week.** The ** Clinical Care Coordinator/Care Manager, Telephonic Nurse ** helps to ensure optimal ... clinical level of care determination based on discussion, medical records, and any other pertinent clinical ...Health, Hospice, and Palliative Care Services. + Assist with clinical eligibility review for alternate services +… more
- Humana (Augusta, ME)
- …effectively communicate a meaningful narrative with those findings + Proven ability to perform clinical reviews and review medical records + Ability to ... of our caring community and help us put health first** The Senior Clinical Medical /Financial Risk Evaluation Professional is responsible for supporting the… more
- Humana (Augusta, ME)
- …of our caring community and help us put health first** The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following ... services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and… more
- Datavant (Augusta, ME)
- …years of CDI experience + 3+ years of clinical experience in an academic medical center + Registered Nurse license, Bachelor's degree in Nursing + CCDS or ... realize our bold vision for healthcare. **What We're Looking For:** As a Clinical Documentation Quality Improvement (CDQI) Specialist, you will play a pivotal role… more
- Evolent (Augusta, ME)
- …The Specialty Appeal nurses work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators who set up the ... appeal, Physicians and other Clinicians who review the appeal, and managers for direction and leadership....to company policies and procedures. + Documents communications with medical office staff and/or MD provider as required. +… more
- Oracle (Augusta, ME)
- …+ Excellent communication, stakeholder engagement, and leadership skills. **Preferred Qualifications:** + Clinical experience as a nurse or physician with a deep ... **Job Description** The Clinical Note AI Agent Product Management Leader will...Gather and analyze information to define product specifications and review design specifications. Envision and communicate product strategy and… more
- Zurich NA (Augusta, ME)
- Sr Supplier Medical Process Specialist 128416 Zurich North America is seeking am experienced Sr. Supplier Medical Process Specialist to join our team in one of ... commitment to work/life balance, and outstanding culture. As a Sr. Supplier Medical Process Specialist, you will manage supplier performance and work product in… more
- CVS Health (Augusta, ME)
- …Manager role includes: -Collaborate with an interdisciplinary care management team ( nurse case managers, medical directors, dietitians, social workers) to ... of a care management team -Currently and on a daily basis applies clinical knowledge to review medications and resolve different disease management scenarios… more
- Oracle (Augusta, ME)
- …(ECD) alignments, Critical Care workflow implementation, Multi-Disciplinary Rounding, and various nurse chart review and documentation optimizations. The ideal ... of analysts providing support for operationally required changes and enhancements to clinical applications, and aa group of analysts leading projects that will… more
- Sedgwick (Augusta, ME)
- …**PRIMARY PURPOSE** **:** To manage complex high-exposure general liability claims; to review medical treatment records associated with general liability, bodily ... related clinical nursing experience to include two (2) years nurse consultant experience or equivalent combination of education and experience required.… more
- Highmark Health (Augusta, ME)
- …and retrospective claims review basis. Review process includes a review of medical documentation, itemized bills, and claims data to assure appropriate ... and the proper action to complete the retrospective claim review with the goal of proper and timely payment...in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder or… more
- Merck (Augusta, ME)
- …(Oncology group purchasing organizations, wholesalers, and specialty pharmacies). + Review and evaluate patterns for products purchased and prescribed (outpatient ... the in-scope customer team: Customer Team Leader, Key Account Manager, Nurse Educator, Field Reimbursement Associate, Medicare Account Executive, and more.… more
- Veterans Affairs, Veterans Health Administration (Togus, ME)
- …VHA Education Loan Repayment Services program office after EDRP application review . Former EDRP participants are ineligible to apply. Responsibilities In conjunction ... with the surgical or medical attending physician and other consultants, the Pulmonologist/Intensivist (hereafter PI) directs the care of all patients in the… more