- 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 (Harrisburg, PA)
- …, 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 (Harrisburg, PA)
- …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
- Highmark Health (Pittsburgh, PA)
- …and contractual requirements. + Documents, monitors, intervenes/resolves and reports clinical denials/ appeals and retrospective payer audit denials. ... outcomes. Interviews and collects patient specified data and chart review related to readmission. + Knowledgeable of and complies...lieu of a degree + 3 years in a clinical nursing role + Current State of PA RN… more
- St. Luke's University Health Network (Allentown, PA)
- …regardless of a patient's ability to pay for health care. The Coding Appeals Specialist analyzes patient medical records, claims data and coding on all diagnosis ... Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that… more
- Humana (Harrisburg, PA)
- …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 (Harrisburg, PA)
- …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 (Harrisburg, PA)
- …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 (Harrisburg, PA)
- …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 (Harrisburg, PA)
- …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 (Harrisburg, PA)
- …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 (Harrisburg, PA)
- …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 (Harrisburg, PA)
- …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 (Harrisburg, PA)
- …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 (Harrisburg, PA)
- …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 (Harrisburg, PA)
- …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
- UPMC (Pittsburgh, PA)
- …The Prior Authorization Pharmacist primary responsibilities include: + Perform the clinical review of Prior Authorization, Step Therapy, Quantity Limit, ... UPMC Health Plan is hiring a full-time Clinical Pharmacy Specialist to support the Prior Authorization...accurate and professional manner. + Participate in the pharmacy appeals process through the review of denied… more
- Devereux Advanced Behavioral Health (Malvern, PA)
- …then consider joining our Devereux Advanced Behavioral Health team! Being a Utilization Review Specialist at Devereux has its Advantages! You will work with other ... Behavioral Health Center (DCBHC) is currently seeking a Utilization Review Specialist to work at their acute psychiatric inpatient...inpatient level of care youth. + Works closely with Clinical and Admissions teams regarding the MCO and insurance… more
- Highmark Health (Harrisburg, PA)
- …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
- Globus Medical, Inc. (Collegeville, PA)
- …customers from the initial processing of received documentation through prior authorization, appeals support, detailed claims review , and hotline support. The ... of exceptional response by partnering with researchers and educators to transform clinical insights into tangible solutions. Our solutions improve the techniques and… more