- AmeriHealth Caritas (Dover, DE)
- …Under the direction of a supervisor, the Clinical Care Reviewer - Utilization Management evaluates medical necessity for inpatient and outpatient services, ... in a fast-paced environment. ;The Clinical Care Reviewer - Utilization Management will also be counted upon...document and assess patient cases. + Strong understanding of utilization review processes, including medical necessity criteria,… more
- AmeriHealth Caritas (Philadelphia, PA)
- …pediatric patients in a clinical setting. + Minimum of 3 years of Utilization Management experience, preferably within a managed care organization. + Experience ... it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other… more
- Humana (Dover, DE)
- …part of our caring community and help us put health first** The SNF Utilization Management Nurse uses clinical knowledge, communication skills, and ... where needed. Follows established guidelines and procedures. The SNF Utilization Management Nurse uses clinical...Skilled nursing facility experience and /or skilled nursing facility utilization management review experience. +… more
- Zurich NA (Dover, DE)
- …+ Experience in development and implementation of cost containment programs + Case management , utilization review , catastrophic or disability experience + 5 ... AVP, Utilization Review & Pharmacy 123092 Zurich...recruiting and retaining team members. + Drive the performance management process by communicating job expectations, monitoring and evaluating… more
- Evolent (Dover, DE)
- …appeals. **What You Bring:** + 1-3 years' experience in clinical Appeals Review or Utilization Management Review as an LPN or LVN is required. + Must ... the culture. **What You'll Be Doing:** The Evolent Appeals Nurse team offers candidates the opportunity to make a...appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and… more
- Veterans Affairs, Veterans Health Administration (Coatesville, PA)
- …determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible to apply. ... Responsibilities The Nurse Practitioner reports to the Associate Chief of Staff-Primary...mission. The NP provides advanced clinical practice, consultation, and management . The NP is a licensed independent practitioner with… more
- ChenMed (Philadelphia, PA)
- …explain nurse practitioner role. + Facilitates patient/family conferences to review treatment goals, optimize resource utilization , provide family education ... with guidelines. This position may require participation in risk and quality management programs, clinical meetings and other meetings.The Nurse Practitioner… more
- Insight Global (Philadelphia, PA)
- …License or Active LPN License 2-3 years of clinical experience ( Utilization management or utilization review ) Strong computer skills Ability to ... of medical records assigned by a Clinical Quality Lead nurse . Miles will be reimbursed for any travel. Computer...Previous HEDIS review experience or experience with Utilization Review , Quality, Medical Record auditing Bachelors… more
- Sharecare (Dover, DE)
- …total healthcare management and ensure cost effective, appropriate resource utilization and quality outcomes. The Clinical Registered Nurse is also ... the participants and their Primary Care Provider according to the disease management program intervention guidelines. A Clinical Registered Nurse is supervised… more
- Evolent (Dover, DE)
- …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
- Highmark Health (Dover, DE)
- …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
- Penn Medicine (Bala Cynwyd, PA)
- …Functions monitored will include, but are not limited to, nursing case management , regulatory compliance, direct clinical care, new product and service development, ... and management of Human Resources related items for RN staff...that all regulatory requirements are met. + Ensures effective utilization of materials, staff, and financial resources. + Sponsors… more
- Fresenius Medical Center (Dover, DE)
- …and acts as the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member eligibility. Facilitate timely ... workup of patients for access management , dialysis services, patient education, hospitalizations, and kidney transplantation as appropriate, and ensures coordination… more
- ChenMed (Philadelphia, PA)
- …engagement with patient and family. + Facilitates patient/family conferences to review treatment goals and optimize resource utilization ; provides family ... join our team. The RN Case Manager (Community Care Nurse ) is an on-site role within our Primary Care...achieving desired clinical outcomes within specific timeframe. + Conducts review for appropriate utilization of services from… more
- Penn Medicine (Philadelphia, PA)
- …+ 5yrs prior experience as a Nurse Case Manager with knowledge of utilization review and 3rd Party Payors (Required) + Pennsylvania State Licensed Nurse ... not limited to admissions, patient financial services, clinical resource management and provider medical staff and designees.Assist in preparation...a nurse case manager with knowledge of utilization review and third party payors. We… more
- Penn Medicine (Philadelphia, PA)
- …skills and being a strong patient advocate. The case manager conducts utilization management activities, communication with insurers, team, and physician ... fearful you will miss patient contact? If so, our nurse case manager role at Penn Medicine is the...community resources, transportation, and quality data collection and risk management referral. + Responsibilities: Utilization management… more
- Sunrise Senior Living (Haverford, PA)
- …per state regulations. + A minimum of two (2) years' experience in a nurse management position within a skilled nursing environment including hiring staff, ... The Director of Nursing Services is responsible for providing leadership and management to the skilled nursing operations. Responsible for planning, organizing and… more
- Trinity Health (Wilmington, DE)
- …complex problems in the areas of census verification, bed assignment and utilization review . + Ensures compliance with hospital departmental policies and ... about the hospital's bed availability + Ensure proper bed utilization and management throughout the hospital. +...acute care setting required + Previous Supervisor or Charge Nurse experience required + Must possess sound computer literacy.… more
- Virtua Health (Marlton, NJ)
- …for the assessment, planning, implementation, monitoring and evaluation of case management services through the appropriate utilization of resources. Application ... over 2,850 skilled and compassionate doctors, physician assistants, and nurse practitioners equipped with the latest technologies, treatments, and techniques… more
- Virtua Health (Marlton, NJ)
- …and Palliative Care and Hospice Team members to assure that clinical protocols, utilization review , case management , quality assurance, and compliance ... over 2,850 skilled and compassionate doctors, physician assistants, and nurse practitioners equipped with the latest technologies, treatments, and techniques… more