- AmeriHealth Caritas (Washington, DC)
- …meet the patient's needs in the least restrictive and most effective manner. The Utilization Management Reviewer must maintain a strong working knowledge of ... **$5,000.00 SIGN ON BONUS** **Role Overview** Our Utilization Management Reviewers evaluate medical necessity...cases are escalated to the Medical Director for further review . The reviewer independently applies medical and… more
- Evolent (Washington, DC)
- …the mission. Stay for the culture. **What You'll Be Doing:** The **Coordinator, Intake Utilization Management ** at Evolent will serve as a point of contact for ... and client contractual agreements. **Collaboration Opportunities** : The Coordinator, Intake Utilization Management reports directly to the Manager, … more
- Humana (Washington, DC)
- …**Preferred Qualifications:** + Experience in managed care pharmacy, particularly in utilization management review **Additional Information:** **Interview ... our caring community and help us put health first** The Staff Utilization Management Pharmacist is a clinical expert responsible for conducting medical necessity… more
- Highmark Health (Washington, DC)
- …determination for prior authorization review and appeals. Through the Utilization Review system, the incumbent evaluates clinical information provided by ... requests for prior authorization or appeals against medical policy through the Utilization Review system. Update the system records appropriately to ensure… more
- Evolent (Washington, DC)
- …Reviewer , Interventional Pain Management , you will be a key member of the utilization management team. We can offer you a meaningful way to make a ... Will Be Doing:** + Serve as the Physician Clinical Reviewer for Interventional Pain Management , reviewing cases... and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National… more
- Humana (Washington, DC)
- …. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial ... their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Highmark Health (Washington, DC)
- …:** **JOB SUMMARY** This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and ... and DOL regulations at all times. In addition to utilization review , the incumbent participates as the...member of the multidisciplinary team for case and disease management . They will advise the multidisciplinary team on cases,… more
- Evolent (Washington, DC)
- …Stay for the culture. **What You'll Be Doing:** Job Description **Cardiovascular Utilization Management Reviewer (Interventional Cardiologist)** Are you ... on patient care in a non-clinical setting? Join our Utilization Management team as a Field Medical... and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National… more
- Evolent (Washington, DC)
- …As a Vascular Surgery, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
- Evolent (Washington, DC)
- …Doing:** As a Cardiology, Field Medical Director you will be a key member of the utilization management team. We can offer you a meaningful way to make a ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
- Highmark Health (Washington, DC)
- …residency program + 5 - 7 years in Pharmacy + 3 - 5 years in Pharmacist - Utilization Management + 3 - 5 years in Pharmacist - Medical Therapy Management ... to medication therapy are transitioned to a Pharmacist for Case & Disease Management (CMDM). The incumbent then conducts thorough research to evaluate the patient… more
- Evolent (Washington, DC)
- …As a Field Medical Director, MSK Surgery you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
- Evolent (Washington, DC)
- …Doing:** As a Field Medical Director, Oncology, you will be a key member of the utilization management team. We can offer you a meaningful way to make a ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
- RxBenefits (Washington, DC)
- …channel management , B/G classifications, specialty designations, rebate eligibility, utilization trend, Utilization Management (UM) implications, ... prospect member size, marketing agreements, broker commissions, and drug utilization . + Be the SME on dozens of medical...closed won groups into a client record for Account Management (AM) and Implementation including the initial gathering of… more
- Humana (Washington, DC)
- …of program changes and outcomes. Responsibilities include: + Oversee the development, review , and maintenance of Utilization Management (UM) policies ... complexity ranging from moderate to substantial. The Policy Governance Lead for Utilization Management (UM) is responsible for overseeing the development,… more
- Humana (Washington, DC)
- …. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial ... daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Highmark Health (Washington, DC)
- …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
- Evolent (Washington, DC)
- …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
- Evolent (Washington, DC)
- …the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care across the… more
- CVS Health (Washington, DC)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... training.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health....lower levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC… more