- US Tech Solutions (Columbia, SC)
- …using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. **Responsibilities:** + 80% ... May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a… more
- Cognizant (Columbia, SC)
- …necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with Medicare, Medicaid, and ... as well as timely filing deadlines and processes. . Review clinical denials including but not limited...thinking skills to interpret guidelines of internal policies for clinical determination. . Medical Necessity Reviews can… more
- Humana (Columbia, SC)
- …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
- Fresenius Medical Center (Sumter, SC)
- …regulations at: https://content.intranet.fmcna.com/regulatory-affairs/wp-content/uploads/sites/46/2019/05/Pre-Licensed- Nurse -50-State- Review ... of the hemodialysis health care team as a Registered Nurse Applicant, under the direction or supervision of a...transcribes, and enters physician lab orders accurately into the Medical Information System. + Ensures appropriate preparation of lab… more
- Humana (Columbia, SC)
- …in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The Nurse reviews the medical documentation, researching claims, ... and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to...Medical Directors on submitted G&A cases. The G&A Nurse will participate in initiatives which result in improved… more
- InGenesis (Columbia, SC)
- …located in Columbia, SC. In this role you will review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria and assess and ... monitor medical necessity using your clinical proficiency and claims knowledge. This is a REMOTE...any questions you may have. Job Duties * Perform medical review /authorization process. * Ensure coverage for… more
- Humana (Columbia, SC)
- …community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills to support the coordination, ... determination of the appropriate courses of action. The Utilization Management Behavioral Health Nurse 2 completes medical record reviews from medical … more
- PruittHealth (Columbia, SC)
- …reviewing medical records and documentation. **KEY RESPONSIBILITIES:** 1. Coordinates clinical competency assessment and training needs of clinical staff, ... ** CLINICAL COMPETENCY COORDINATOR** **Join the PruittHealth family, where...conditions and acuity. 7. Meets regularly with DHS to review learning needs, coordinate training and to implement plans… more
- Humana (Columbia, SC)
- …based on operational needs at the discretion of department leadership. The Telephonic Nurse provides medical guidance, assists with access to care concerns, ... medication adherence and is trained to act as a clinical concierge. The NAL Telephonic Nurse role...compliance, etc. Responsibilities include: + **Provide accurate and appropriate medical advice and right level of care guidance utilizing… more
- InGenesis (Columbia, SC)
- …remotely with our client located in Columbia, SC. In this role, you will perform Medical Review of clinical information using established criteria or ... guidelines. In this role, you will provide support and review of medical claims and utilization practices....duties as assigned. Minimum Qualifications * Current Licensed Practical Nurse / LPN license in the State of South… more
- CenterWell (Columbia, SC)
- …complaints. + Makes clinical level of care determination based on discussion, medical records, and any other pertinent clinical data. Matches these needs to ... regarding Home Health, Hospice, and Palliative Care Services. + Assist with clinical eligibility review for alternate services + Participates in special… more
- Sedgwick (Columbia, SC)
- … Consultant) Certification or training preferred. **Experience** Five (5) years related clinical nursing experience and two (2) years nurse consultant experience ... Fortune Best Workplaces in Financial Services & Insurance Professional Liability Nurse Consultant **PRIMARY PURPOSE** **:** To handle complex or high exposure… more
- Datavant (Columbia, SC)
- …years of CDI experience + 3+ years of clinical experience in an academic medical center + Registered Nurse license, Bachelor's degree in Nursing + CCDS or ... realize our bold vision for healthcare. **What We're Looking For:** As a Clinical Documentation Quality Improvement (CDQI) Specialist, you will play a pivotal role… more
- US Tech Solutions (Columbia, SC)
- … experience or 2 years clinical experience plus 1 year utilization/ medical review , quality assurance, or home health. **Skills:** + Working knowledge ... reviews of previously denied services to determine if the medical necessity and contract provisions have been applied correctly...post-payment review appeal requests. + Provides thorough clinical review or benefit analysis to determine… more
- Surgery Care Affiliates (Columbia, SC)
- …do it. Each decision we make is rooted in seven core values: + Clinical quality + Integrity + Service excellence + Teamwork + Accountability + Continuous improvement ... package to support your health, well-being, and financial future. Our offerings include medical , dental, and vision coverage, 401k plan with company match, paid time… more
- Highmark Health (Columbia, SC)
- …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
- CenterWell (Columbia, SC)
- …will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review ... Compact Nursing License + A minimum of three years clinical RN experience; + Prior clinical experience,...extends outside of work. Among our benefits, Humana provides medical , dental and vision benefits, 401(k) retirement savings plan,… more
- CenterWell (Columbia, SC)
- …policies and standards. + Assesses staff education needs based on own the review of clinical documentation in addition to feedback and recommendations by ... hours spanning Friday afternoon through Sunday evening to support clinical operations across multiple branch locations.** The **Weekend Regional...Utilization Review staff. Upon completion of the assessment, creates and… more
- Fujifilm (Columbia, SC)
- **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
- Cardinal Health (Columbia, SC)
- …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