- Commonwealth Care Alliance (Boston, MA)
- …to the Manager Utilization Management, the Nurse Utilization Management ( UM ) Reviewer is responsible for day-to-day timely clinical and service authorization ... does not have direct reports. **Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior authorization in a… more
- BroadPath Healthcare Solutions (Tucson, AZ)
- …** UM RN Appeals Coordinator.** This role collaborates with clinical review staff, medical directors/physician reviewers, network physicians, and ... evenings and weekends, to address pharmacy-related denials + Educates physician reviewers and clinical review staff on managed care and Medicaid policies and… more
- Premera Blue Cross (Mountlake Terrace, WA)
- …serve through our Healthsource blog: https://healthsource.premera.com/ . The **Senior Clinical Pharmacist,** **Oncology Program** will lead and help develop ... appropriate and cost-effective use of medication, aligning with and supporting Premera's clinical and financial goals. Join us to shape and lead a pioneering… more
- Stony Brook University (Stony Brook, NY)
- …Case Manager** is a valuable member of our team, who provides clinical services to our patient population. Qualified candidates will demonstrate superior patient ... may include the following but are not limited to:** + Completes Utilization review screen for inpatient and observation cases. Activity includes UR from the… more
- Centers Plan for Healthy Living (Margate, FL)
- …applications for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer works within a multidisciplinary team to help ... in their home to improve their quality of life. Utilization Management Clinical Reviewer will assess and process all authorization requests to determine medical… more
- Molina Healthcare (Salt Lake City, UT)
- **JOB DESCRIPTION** **Job Summary** The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals requests are ... regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and… more
- CVS Health (Hartford, CT)
- …manages the implementation of strategic initiatives for the Utilization Management ( UM ) Clinical Services organization. These initiatives leverage technical ... standards and other healthcare integration standards + Familiarity with clinical workflows, utilization review processes, and InterQual/MCG guidelines.… more
- UCLA Health (Los Angeles, CA)
- …clinical documentation related to prior authorization requests for medical services. The UM Review Nurse applies clinical judgment, regulatory standards, ... Description At UCLA Health, the Utilization Management ( UM ) Review Nurse plays a vital...benefit coverage. + Applies UCLA Health protocols and national clinical guidelines (eg, InterQual, Milliman) in review … more
- CareFirst (Baltimore, MD)
- …+ Provide deep subject matter expertise in all areas of Utilization Management ( UM ), including pre-service, concurrent review , and inpatient management, with a ... experience in business development, operational technology support, Utilization Management ( UM ) operations, Clinical Product Configuration, Health Plan… more
- Veterans Affairs, Veterans Health Administration (Johnson City, TN)
- …of medical records and can retrieve pertinent information from multiple sources for case review . Liaisons with the clinical staff to facilitate quality of care ... health care providers to obtain or verify data for review to formulate a plan of care. Has thorough...clothing in isolation situations or operative/invasive procedures. The QM Clinical Nurse Analyst/ UM Nurse may occasionally be… more
- Point32Health (MA)
- …issues with pharmacy technicians and confer with other clinical pharmacist on review questions + Communicate with UM staff and providers when issues arise ... . **Job Summary** Under the direction of the Pharmacy Utilization Management ( UM ) Supervisor, the Clinical Pharmacist is responsible for reviewing, processing… more
- MVP Health Care (Tarrytown, NY)
- …and continuous improvement. To achieve this, we're looking for a **Professional, Sub-Acute RN UM Reviewer - Medicare** to join #TeamMVP. If you have a passion ... for patient-centered advocacy, clinical precision and regulatory compliance this is an opportunity...+ Experience with electronic medical record (EMR) systems and UM platforms. + Familiarity with CMS regulations and appeals… more
- Humana (Bismarck, ND)
- …support assignments. Performs computations. Typically works on semi-routine assignments. The UM Administration Coordinator 2 provides non- clinical support for ... a part of our caring community and help us put health first** The UM Administration Coordinator 2 contributes to administration of utilization management. The UM … more
- Elevance Health (Walnut Creek, CA)
- …necessary quality behavioral healthcare in a cost effective setting in accordance with UM Clinical Guidelines and contract. + Refers cases to Peer Reviewers ... companies, Carelon Behavioral Health, formerly Beacon Health Options, offers superior clinical mental health and substance use disorder management, a comprehensive… more
- Elevance Health (Costa Mesa, CA)
- …necessary quality behavioral healthcare in a cost effective setting in accordance with UM Clinical Guidelines and contract. + Refers cases to Peer Reviewers ... Health family of companies, **Carelon Behavioral Health** , offers superior clinical mental health and substance use disorder management, a comprehensive employee… more
- CVS Health (Hartford, CT)
- …supports the implementation of strategic initiatives for the Utilization Management ( UM ) Clinical Services organization. These initiatives leverage advanced ... in Utilization Management or clinical operations. + Familiarity with clinical workflows, utilization review processes, and InterQual/MCG guidelines. +… more
- Elevance Health (NC)
- …necessary quality behavioral healthcare in a cost effective setting in accordance with UM Clinical Guidelines and contract. + Refers cases to Peer Reviewers ... and outpatient professional treatment health benefits through telephonic or written review . **How you will make an impact:** Primary duties may include… more
- Elevance Health (Metairie, LA)
- …medically necessary quality behavioral healthcare in a cost-effective setting in accordance with UM Clinical Guidelines and contract. + Refers cases to Peer ... facility-based and outpatient professional treatment health benefits through telephonic or written review . Primary duties may include but are not limited to: + Uses… more
- Elevance Health (FL)
- …medically necessary quality behavioral healthcare in a cost-effective setting in accordance with UM Clinical Guidelines and contract. + Refers cases to Peer ... outpatient professional treatment health benefits through telephonic or written review . The BH Care Manager ( UM ) job...an impact:** + Uses appropriate screening criteria knowledge and clinical judgment to assess member needs to ensure access… more
- University of Southern California (Alhambra, CA)
- …disposition form for medicare patients timely. + Consultant 1. Demonstrates sound clinical knowledge base regarding CM standards, UM standards, clinical ... competency testing. 8. Perform telephonic, and if appropriate, on-site initial/concurrent review on identified in-patient members. Direct pertinent clinical … more
