- Evolent (Santa Fe, NM)
- …scheduled. + Determines medical necessity and appropriateness of services using clinical review criteria. + Accurately documents all review ... for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks… more
- Molina Healthcare (Santa Fe, NM)
- …will work on set schedule) Looking for a RN with experience with appeals, claims review , and medical coding. **Job Summary** Provides support for medical ... and cost-effective member care. **ESSENTIAL JOB DUTIES:** + Facilitates clinical / medical reviews of retrospective medical ...nursing experience, including at least 1 year of utilization review , medical claims review , long-term… more
- Humana (Santa Fe, NM)
- …Manager, Fraud and Waste Investigator: Nurse Audit/ Review performs clinical audit/validation processes to ensure that medical record documentation and ... approach, resources, schedules and goals. The Manager, Fraud and Waste Investigator: Nurse Audit/ Review validates and interprets medical documentation to… more
- Humana (Santa Fe, NM)
- …needs and by providing guidance along the healthcare continuum. You will perform clinical case review on members during an inpatient hospital admission. You ... us put health first** The NICU Care Manager, Telephonic Nurse 2, in a telephonic environment, assesses and evaluates...+ Bilingual is a plus - preferably Spanish + Clinical claim review experience **Additional Information** +… more
- Highmark Health (Santa Fe, NM)
- …over a specified panel of members that range in health status/severity and clinical needs; and assesses health management needs of the assigned member panel and ... utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent conducts… more
- Molina Healthcare (Santa Fe, NM)
- …or master's degree in a healthcare field, such as social work or clinical counselor (for Behavioral Health Care Review Clinicians only). **Required Experience** ... **JOB DESCRIPTION** Opportunity for experienced Utilization Review RN (preferred) or LPN with a compact...Nurse (LPN) license in good standing OR a clinical license in good standing, such as LCSW, LPCC… more
- Cardinal Health (Santa Fe, NM)
- …to ensure a positive and satisfactory experience for all customers. The Supervisor, Clinical Operations monitors nurse to patient contact quality and provides ... manufacturers to rethink the reach and impact of their products. The Supervisor, Clinical Operations provides management and clinical oversight to a team of… more
- Fujifilm (Santa Fe, NM)
- **Position Overview** The Clinical Consultant, MI - I shall be responsible for providing clinical consulting for the project, report configuration (CV), workflow ... go-live support to Synapse PACS/MI projects. In addition, provide clinical support for sales and company team members with...HCUS team to gain customer acceptance of the FUJIFILM Medical Systems solution. + Participates in teaching and training… more
- Molina Healthcare (Santa Fe, NM)
- …records and other data in support of annual HEDIS project management and ongoing review of medical records submitted by providers. + Implements Molina Healthcare ... completion of any of the following programs: + Registered Nurse (RN) or State Licensed Vocational Nurse ... records collection and abstraction * 2+ years of medical record review experience **REQU** **I** **RED… more
- Molina Healthcare (Santa Fe, NM)
- …, and medical coding. JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that ... For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is...services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members… more
- Molina Healthcare (Santa Fe, NM)
- JOB DESCRIPTION **Job Summary** The Care Review Clinician (RN) provides support for clinical member services review assessment processes. Responsible for ... verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired… more
- Molina Healthcare (Santa Fe, NM)
- JOB DESCRIPTION **Job Summary** The RN Care Review Clinician provides support for clinical member services review assessment processes. Responsible for ... verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired… more
- Molina Healthcare (Santa Fe, NM)
- JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically ... necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...requests within required timelines. * Refers appropriate cases to medical directors (MDs) and presents them in a consistent… more
- Molina Healthcare (Santa Fe, NM)
- JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically ... necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...requests within required timelines. * Refers appropriate cases to medical directors (MDs) and presents them in a consistent… more
- Molina Healthcare (Santa Fe, NM)
- …compliance with all state and federal regulations and guidelines. + Analyzes clinical service requests from members or providers against evidence based clinical ... within required timelines. + Refers appropriate prior authorization requests to Medical Directors. + Requests additional information from members or providers in… more
- Molina Healthcare (Santa Fe, NM)
- …of applicable national, state, and local laws and regulatory requirements affecting the medical and clinical staff. + Marketplace UM reviews + MD licenses ... quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality...Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review ,… more
- Molina Healthcare (Santa Fe, NM)
- … medical officer. * Evaluates authorization requests in timely support of nurse reviewers, reviews cases requiring concurrent review and manages the denial ... practice patterns and recommends corrective actions as needed. * Fosters clinical practice guideline implementation and evidence-based medical practices. *… more
- Intermountain Health (Santa Fe, NM)
- …or registrations: Registered Medical Assistant (RMA) of AMT, National Certified Medical Assistant (NCMA), Certified Clinical Medical Assistant (CCMA) or ... that invests in your growth** -with many career paths to explore, like Medical Assistant Senior, Registered Nurse , Practice Manager, and more! + **Intermountain… more
- Humana (Santa Fe, NM)
- …our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... documentation and communication of medical services and/or benefit administration...of the appropriate courses of action. The Utilization Management Nurse 2 uses clinical knowledge, communication skills,… more
- Molina Healthcare (Santa Fe, NM)
- … clinical nursing experience in claims auditing, quality assurance, recovery auditing, DRG/ clinical validation, utilization review and/or medical claims ... high-quality, high-value concepts and or process improvements, tools, etc. * Integrates medical chart coding principles, clinical guidelines, and objectivity in… more