- CHRISTUS Health (Alamogordo, NM)
- …and reporting individual cases and/or trends to the infection control nurse. Performs utilization management functions as required by payer source. Complies with ... of Participation, DNV standards, HIPAA, and reporting requirements. Submits appeals in a timely manner, upon request by the...the Utilization Management Plan. Requirements Education Required: Associate… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …BHPS provides Utilization Management services to its clients. The Utilization Review Appeals Nurse performs daily appeal reviews and clinical quality ... oversite. This position reports to the Clinical Program Manager . This job description is not designed to cover or contain a comprehensive listing of activities,… more
- LA Care Health Plan (Los Angeles, CA)
- …Collaborates with internal departments (Member Services, Provider Network Operations, Claims, Utilization Management , Pharmacy, and Quality Management ) to ... Manager , Customer Solution Center Appeals and...work collaboratively with multiple departments (Claims, Provider Network Operations, Utilization Management , Quality Management , Pharmacy)… more
- Trinity Health (Farmington Hills, MI)
- …healthcare financing and managed care. Comprehensive knowledge of and experience in case management and utilization management . In depth knowledge of ... in behaviors, practices, and decisions. Applying broad knowledge of many payers and appeals types, coordinates and may lead denial management processes (Clinical… more
- TEKsystems (Houston, TX)
- …of healthcare and/or health insurance + High-level customer service + QA + Utilization management + Appeals & Grievances Education/Experience: Requires a ... - $20/hr and up Description: + Assist in monitoring utilization of medical services to assure cost effective use...titles or background work well in this role? * Appeals Coordinator / Case Manager * Medical… more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + Req ... Resource Management issues, other issues including concerns involving under/over utilization , avoidable days and quality issues. 13. Responsible for all incoming… more
- LA Care Health Plan (Los Angeles, CA)
- …Skills Required: Knowledge of state, federal and regulatory requirements in Appeals /Care/Case/ Utilization Management /Quality. Strong verbal and written ... Supervisor, Appeals and Grievances Clinical Operations RN Job Category:...culturally diverse membership. The position supports the A&G Clinical Manager . This role also assists the A&G Leadership in… more
- Trinity Health (Farmington Hills, MI)
- …regulations and standards Knowledge of APC's including NCCI and OPPS error edits. Utilization management knowledge. Knowledge of and ability to perform medical ... responsibilities of the payment resolution/denials team handling the receipt, analysis, and appeals of denials received in order to achieve optimal area performance… more
- UNC Health Care (Chapel Hill, NC)
- …communities we serve. RN Utilization Manager position specifically for a Utilization Manager /Clinical Appeals Nurse. This person is based at the ... through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to… more
- DOCTORS HEALTHCARE PLANS, INC. (Coral Gables, FL)
- …in utilization of resources, avoidable days/denials. Works in collaboration with Appeals Management /Medical Director in the appeals process. + ... safe discharge coverage for all hospital units. + Participates in utilization management initiatives/opportunities for improvement through departmental committee… more
- Hackensack Meridian Health (Hackensack, NJ)
- …OBS vs. Inpatient c. Liaison to the Medical Staff supporting Utilization Management Committee processes d. Hospital Based Appeals Management e. Provides ... direction and support regarding CMS & NJDOH regulations governing Utilization Management & Clinical documentation. b. Oversight...documentation iv. Target DRGs Reviews v. Use of case manager as a resource 4. Uses guidelines to evaluate… more
- Virginia Mason Franciscan Health (Bremerton, WA)
- …annual bonus eligibility, and more! **Responsibilities** **Job Summary / Purpose** The Utilization Management (UM) Director is responsible for the market(s) ... development, implementation, evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care Coordination… more
- LA Care Health Plan (Los Angeles, CA)
- …least 4 years of experience in a patient care setting and/or combination in utilization management , appeals and grievances, delegation oversight, and/or CNA ... Utilization Management Nurse Specialist LVN II...implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service,… more
- Hackensack Meridian Health (Hackensack, NJ)
- …standards, and regulatory/payor requirements. The role integrates and coordinates utilization management , care coordination, discharge planning functions and ... for disciplinary action and performance improvement plans when appropriate in conjunction with Manager of Case Management . **Responsibilities** A day in the life… more
- Adecco US, Inc. (Dallas, TX)
- We are now in search of a dynamic Utilization Management Nurse for a Direct Hire role with our esteemed client in Dallas, Texas. Experience: + Mandatory five ... hospital setting. + Minimum of two years' experience in Utilization Management within an acute care setting....setting. + Proficiency with drafting and submitting reconsiderations and appeals to Medicare for a minimum of one year.… more
- Billings Clinic (Billings, MT)
- …leadership and Physician Advisor, per department process or procedure *Insurance and Utilization Management *Maintains working knowledge of CMS requirements and ... prior to starting. Click here (https://billingsclinic.csod.com/ats/careersite/search.aspx?site=15&c=billingsclinic) to learn more! Utilization Review RN CARE MANAGEMENT (Billings Clinic… more
- University of Utah Health (Salt Lake City, UT)
- …communication skills. + Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria. + The ability to ... and as a team member. **Qualifications** **Qualifications** **Required** + One year Utilization Review or Case Management experience. **Licenses Required** +… more
- Actalent (Sacramento, CA)
- LVN Outpatient Utilization Review - River City Medical Group Shift- Monday-Friday day shift Description: The Clinical Case Manager coordinates all ... approach, and cost-effective care for Managed Medi-cal patients. The Clinical Case Manager follows and manages the course of treatment for patients while… more
- UCLA Health (Los Angeles, CA)
- …laws/regulations. You will extrapolate and summarize essential information for the UM Manager and Medical Director and regularly meet with them for clinical guidance ... in resolving cases. You will also document appeals in the tracking system and maintain relevant statistical data. Salary Range: $22.03 - $43.68 HourlyQualifications… more
- Ventura County (Ventura, CA)
- …and in accordance with the business needs of the department. Behavioral Health Manager I/II are management classifications and are not eligible for overtime ... and implements interagency agreements; + Selects, trains, supervises and conducts performance management for quality assurance and utilization review staff; +… more
