- Commonwealth Care Alliance (Boston, MA)
- …timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role ... Utilization Management , the Nurse Utilization Management (UM) Reviewer is...**Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior authorization in a variety… more
- US Tech Solutions (Canton, MA)
- …all aspects of clinical decision making and support needed to perform utilization management , medical necessity determinations and benefit determinations using ... criteria through participation in the IMPAC. + Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM… more
- Commonwealth Care Alliance (Boston, MA)
- … Management is responsible for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible ... reports to the Director of Utilization Management * Oversees clinical decision review for...reviews). * Hire, train and mentor UM staff, including nurse reviewers and support personnel. * Act as liaison… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …TeamAs an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will serve as a liaison and business expert for member and ... your true colors to blue. The RoleThe Clinical Appeals Nurse Reviewer is responsible for applying sound...provider submitted appeals. Working collaboratively with Physician review unit, Utilization Management ,… more
- Beth Israel Lahey Health (Plymouth, MA)
- …years recent, broad clinical experience in the hospital setting + Experience with utilization management within the last 3 years required + An understanding ... using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal clinical denials related to the care provided to… more
- Beth Israel Lahey Health (Plymouth, MA)
- …years recent, broad clinical experience in the hospital setting + Experience with utilization management within the last 3 years required + An understanding ... using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal clinical denials related to the care provided to… more
- Children's Hospital Boston (Boston, MA)
- …Posting Title:Per Diem RN Case Manager, Utilization Management /ReviewDepartment:Patient Services-Patient Care OperationsAutoReqId:80451BRStatus:Part-TimeStandard ... + Experience as a Case Manager (Discharge Planning and or Utilization Management ) preferred. Licensure/ Certifications: + Current Massachusetts license… more
- Amergis (Canton, MA)
- …to facility wide personnel. + Demonstrated understanding of external agency interface with Utilization Review , Case Management , Patient Safety and Quality ... / Week Amergis Healthcare is seeking an experienced Registered Nurse and self-motivated individual to provide data collection and...collection and related activities for Quality Improvement (QI) and Utilization Review as well as completion of… more
- Veterans Affairs, Veterans Health Administration (Providence, RI)
- …promotion, health education and coaching on wellness, disease prevention, and chronic care management . The nurse will assist in directing the provision of ... determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible to apply.… more
- CVS Health (Providence, RI)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... Pharmacy or Oncology.** **Preferred Qualifications** + 1+ years' Case Management experience or discharge planning, nurse navigator...lower levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC… more
- CVS Health (Providence, RI)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... using a keyboard **Preferred Qualifications** - 1+ years' Case Management experience or discharge planning, nurse navigator...lower levels of care - 1+ years' experience in Utilization Review - CCM and/or other URAC… more
- Humana (Boston, MA)
- …Qualifications** + Bachelor's or Master's degree in Nursing + Prior/current experience in Utilization Management / Utilization Review with MCG + Direct ... community and help us put health first** The **Telephonic Nurse Case Manager** will be a member of the...Case Manager** will be a member of the Case Management Team, providing a comprehensive, holistic approach for case… more
- Sharecare (Providence, RI)
- …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
- Fresenius Medical Center (Lincoln, RI)
- …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
- Commonwealth Care Alliance (Boston, MA)
- …is strongly preferred. + Experience in Medicaid/Medicare grievances and appeals and/or Utilization Review is strongly preferred. **Required Knowledge, Skills & ... and summarizes medical information for medical director, consultants, and other external review . + Prepares recommendations to either uphold or deny appeal and… more
- Brockton Hospital (Brockton, MA)
- … management experience Proven experience in coordinating discharge planning and utilization review experience required. Prior management experience ... delays through problem resolution and follow-up. Monitors on-site case managers and utilization review staff to ensure compliance with Signature Healthcare… more
- Beth Israel Lahey Health (Plymouth, MA)
- …stay, 3) Decreasing unit cost, 4) reducing readmissions. **Duties/Responsibilities:** **A. Utilization Management ** Performs review of anticipated admissions ... patient care status. This role is structured around four major functions + Utilization Management + Care Coordination + Discharge Planning + Preventing… more
- Beth Israel Lahey Health (Boston, MA)
- …daily schedule to expedite surgical cases or personnel. Works in collaboration with the Nurse in Charge and Anesthesia, but is ultimately responsible to the OR ... Nurse Manager. **Job Description:** PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:...during which hours, the substitution of cases and the utilization of specific rooms for specific cases. + Assures… more
- Molina Healthcare (Boston, MA)
- …integrated) performing one or more of the following activities: care review / utilization management (prior authorizations, inpatient/outpatient medical ... including 3 or more years in one or more of the following areas: utilization management , case management , care transition and/or disease management… more
- Charter Care Health Partners (North Providence, RI)
- …progress of a specific patient population. Performs functions related to Patient Advocacy; Utilization Review ; Resource Management ; Continuum of Care ... preferred) with current license to practice as a Registered Nurse in the State of Rhode Island or in...experience with case management , patient navigation, case management , utilization review or discharge… more