- Commonwealth Care Alliance (Boston, MA)
- …have direct reports. **Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior authorization in a ... ( UM ) Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization… more
- Stony Brook University (Stony Brook, NY)
- …with the transferring hospital, Patient Access and physicians and payers for authorization prior to transfer from other hospitals. + Consistent documentation ... of care from initial assess point. Follows cases for authorization for in patient stay. + Staff review...their work and follow up with cases. **Preferred:** CM, UM , Quality, Coding, Risk or MCG Certification Working knowledge… more
- UCLA Health (Los Angeles, CA)
- …is responsible for reviewing and evaluating clinical documentation related to prior authorization requests for medical services. The UM Review Nurse ... Description At UCLA Health, the Utilization Management ( UM ) Review Nurse plays a vital...of resources. Key Responsibilities: + Conducts clinical reviews of prior authorization requests to evaluate medical necessity… more
- Molina Healthcare (Syracuse, NY)
- …* At least 2 years experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination of ... stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its members. *… more
- Humana (Bismarck, ND)
- …utilizing electronic medical record and documentation programs + Experience with Utilization Review and/or Prior Authorization , preferably within a managed ... + Knowledge of Medical Terminology and/or ICD-10 codes + Experience with Utilization Review and/or Prior Authorization , preferably within a managed care… more
- Centene Corporation (Des Moines, IA)
- …to target unique populations. + Oversees performance of all UM functions ( prior authorization , concurrent review ) for the market per the defined ... partnership agreement + Orchestrates all elements of the population health strategy for the business + Drives HBR initiatives locally through strong partnership and routine with + Partners with MDs to translate the needs of the members into intentional… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …across all lines of business including Medicare D to determine what type of prior authorization review is required, documents any relevant medication history ... permitted by law including the initial level processing and review of prior authorization requests...coverage for incoming calls as required to support the UM process. This may include authorization inquiries… more
- Molina Healthcare (MS)
- …benefits and eligibility for requested treatments and/or procedures. + Conducts prior authorization reviews to determine financial responsibility for Molina ... + Processes requests within required timelines. + Refers appropriate prior authorization requests to Medical Directors. +...teams to promote Molina Care Model + Adheres to UM policies and procedures. + Occasional travel to other… more
- Highmark Health (Monroeville, PA)
- …administration of effective and efficient processing for pharmacy benefits prior authorization processes, insurance evaluations, addressing patient medication ... medication reconciliation, and overseeing referral screening/management. **ESSENTIAL RESPONSIBILITIES** + Prior Authorization & Utilization Management: Reviews pharmacy… more
- Molina Healthcare (Meridian, ID)
- …* At least 2 years experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination of ... JOB DESCRIPTION **Job Summary** The Care Review Clinician (RN) provides support for clinical member...requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its… more
- Martin's Point Health Care (Portland, ME)
- …prevent or reduce hospital admissions where appropriate. Job Description Key Outcomes: + Review prior authorization requests ( prior authorization ... a need for inpatient/ outpatient authorizations. This position receives and reviews prior authorization requests for specific inpatient and outpatient medical… more
- US Tech Solutions (Chicago, IL)
- …as an RN + Registered Nurse in state of residence + Must have prior authorization utilization experience + Experience with Medcompass **Skills:** + MUST HAVE ... MANAGED CARE exp and Medicare/Medicaid knowledge. + MUST HAVE UM experience, inpatient utilization management review . +...knowledge of Milliman/MCG. + MUST HAVE 6 months of Prior Authorization . **Education:** + Active and unrestricted… more
- Molina Healthcare (Dayton, OH)
- …* At least 2 years experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination of ... stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its members. *… more
- Molina Healthcare (San Diego, CA)
- …* At least 2 years experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination of ... stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its members. *… more
- Molina Healthcare (Vancouver, WA)
- …2 years health care experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination ... stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its members. *… more
- Molina Healthcare (Louisville, KY)
- …in KY or have a compact RN license. The Care Review Clinician Inpatient Review BH will provide prior authorization for outpatient and inpatient services ... of stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization / financial responsibility for Molina and its members. *… more
- Molina Healthcare (Long Beach, CA)
- …2 years health care experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination ... stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its members. *… more
- Molina Healthcare (CA)
- …* At least 2 years experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination of ... stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its members. *… more
- Molina Healthcare (Phoenix, AZ)
- …* At least 2 years experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination of ... stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its members. *… more
- Molina Healthcare (Spokane, WA)
- …* At least 2 years experience, including experience in hospital acute care, inpatient review , prior authorization , managed care, or equivalent combination of ... JOB DESCRIPTION Job Summary The Care Review Clinician (RN) provides support for clinical member...requested treatments and/or procedures. * Conducts reviews to determine prior authorization /financial responsibility for Molina and its… more
