- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …a member's benefit coverage while working remotely. Primary Responsibilities * Performs behavioral health clinical utilization reviews using evidenced based ... About The Role BHPS provides Utilization Management services to its clients....* Experience with both inpatient and outpatient reviews for Behavioral Health (examples: TMS, ECT, ABA, Psychotherapy,… more
- Humana (Raleigh, NC)
- …a part of our caring community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills ... documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Behavioral Health Nurse 2… more
- CVS Health (Raleigh, NC)
- …working within the mental health system. + Previous experience with utilization management . + Ability to collaborate with various internal departments. + ... management program. + Conduct clinical reviews for adult inpatient behavioral health cases, applying established medical necessity criteria to ensure… more
- Elevance Health (Durham, NC)
- ** Utilization Management Medical Director- NC Medicaid** Location: This role enables associates to work virtually full-time, with the exception of required ... be considered. The **Medical Director** will be responsible for utilization review case management for North Carolina...For Health Solutions and Carelon organizations (including behavioral health ) only, minimum of 5 years… more
- CenterWell (Raleigh, NC)
- …+ Experience with Home Health preferred + Previous experience in utilization management within Insurance industry a plus + Previous Medicare ... clinical experience. + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Intelligence +… more
- Humana (Raleigh, NC)
- …value-based care, quality metrics, population health , and disease or care management . The Behavioral Health Medical Director may develop procedures, ... part of our caring community and help us put health first** The Behavioral Health ...management , utilization management , case management , discharge planning and/or home health or… more
- UNC Health Care (Raleigh, NC)
- … and well-being of the unique communities we serve. Summary: A Social Worker - Behavioral Health II is an integral member of the healthcare team, providing ... **Job Details** Legal Employer: NCHEALTH Entity: Health Alliance Organization Unit: Pop Health Care Management Work Type: Full Time Standard Hours Per Week:… more
- CVS Health (Raleigh, NC)
- … Management background preferred. **Education** + Master's degree in behavioral health field. **Anticipated Weekly Hours** 40 **Time Type** Full ... **Required Qualifications** + Unrestricted independent state licensure in a behavioral health field (LMHC, LMFT, LCSW, LICSW,...+ Human Resource and/or Supervisory experience. + Case management , Utilization Review, or Utilization… more
- Highmark Health (Raleigh, NC)
- …:** **JOB SUMMARY** This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and ... (DO) **Substitutions** + None **Preferred** + Master's Degree in Business Administration/ Management or Public Health **EXPERIENCE** **Required** + 5 years… more
- UNC Health Care (Morrisville, NC)
- …of patients based on various factors such as medical conditions, social determinants of health , and behavioral health needs. b. Develop strategies to ... **Description** UNC Health Alliance is UNC Health 's statewide...Payer Communication: a. Collaborate with payers, insurance companies, and utilization management teams to optimize reimbursement and… more
- CVS Health (Raleigh, NC)
- …advanced clinical judgment and critical thinking, the RN coordinates physical and behavioral health services, collaborates with providers, and ensures access to ... psychosocial support services. The goal is to optimize resource utilization and drive positive health outcomes. The...management . + Identify and address social determinants of health impacting care. + Refer members to appropriate care… more
- Highmark Health (Raleigh, NC)
- …of clinical, case/ utilization management and/or disease/condition management experience, or provider operations and/or health insurance experience ... health status/severity and clinical needs; and assesses health management needs of the assigned member...first 6 months of employment. **Preferred** + Certification in utilization management or a related field +… more
- Elevance Health (Durham, NC)
- … Health OP services. + Mentors Behavioral Health Care Management staff by assisting in training, attending utilization management rounds, and ... will make an impact:** + Partners with internal UR staff and external Behavioral Health Providers to ensure appropriate and consistent utilization of plan… more
- COOLSOFT (Raleigh, NC)
- …Authorizations, Drug Utilization Review (DUR) and pharmacy lock-in related processes, Behavioral health , and A+ kids, Preferred Drug List (PDL) and Medicaid ... Business Analysis Product Management Excellent Communication Skills HIPPA Speciali Requirement id... Review (DUR) and pharmacy lock-in related processes o Behavioral health , and A+ kids. o Preferred… more
- Highmark Health (Raleigh, NC)
- …impact corporate performance + Researches, manipulates, and prepares data related to Health Management programs that document program activities and the results ... the impact of Highmark's business decisions on Informatics, personnel utilization , and the use and planning of technology. The role...of Health Management… more
- CVS Health (Raleigh, NC)
- …state licensure a plus. **Preferred Qualifications:** Previous Experience in Utilization Management / Claims Determination with another Health Plan / Payor ... and New Jersey** offering a variety of physical and behavioral health programs and services to its...can be done from your laptop. **Fundamental Components:** * Utilization management - The medical director will… more
- CVS Health (Raleigh, NC)
- …. Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health /Substance Abuse or Maternity/ Obstetrics experience.… more
- UNC Health Care (Chapel Hill, NC)
- …of patients based on various factors such as medical conditions, social determinants of health , and behavioral health needs. b. Develop strategies to ... 7. Payer Communication: a. Collaborate with payers, insurance companies, and utilization management teams to optimize reimbursement and facilitate timely… more
- Highmark Health (Raleigh, NC)
- …of internal clinical and value-based evaluation committees that drive formulary and utilization management functions. + Participate in product specific Pharmacy ... value of implemented initiatives. + Lead product based pharmacy trend management discussions with internal partners including senior executives. + Support… more
- Highmark Health (Raleigh, NC)
- …terms through regular on-site audits. Apply an active role in network management , training, monitoring and enforcement of company policies and procedures while ... confidentiality agreements. Monitor financial performance of contracts by tracking utilization and competitive environment, including group specific performance guarantees.… more