- CenterWell (Austin, TX)
- …our caring community and help us put health first** The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical ... **Required Qualifications** + Must be a licensed Registered Compact Nurse license (RN) with no disciplinary action and ability...Lung or Critical Care Nursing experience required + Prior clinical experience preferably in an acute care, skilled or… more
- Molina Healthcare (Austin, TX)
- **JOB DESCRIPTION** **Job Summary** The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals requests ... regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and… more
- Molina Healthcare (Austin, TX)
- …**Job Summary** The RN Care Review Clinician provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...intensive care unit, or in a telemetry type setting. UM medical review experience highly preferred. Work Hours: Monday… more
- Evolent (Austin, TX)
- …with clinical decision-making criteria sets (ie Milliman, InterQual) + UM Experience + Strong interpersonal, oral and written communication skills. + Possess ... for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are… more
- Humana (Austin, TX)
- …us put health first** Full-Time, Remote Telephonic opportunity The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation… more
- Health Care Service Corporation (Austin, TX)
- …education/local resource information and encourage member (self) education functioning in a clinical care advisory role, the primary nurse case administrator ... all other entities involved in managing specialty care. The primary nurse case administrator performs care coordination; identifies alternate treatment programs;… more
- Humana (Austin, TX)
- …a part of our caring community and help us put health first** The Telephonic Nurse Case Manager will be a member of the In-Home Case Management Team, providing a ... beneficiary's capacity for self- care, to cost-effectively achieve desired clinical outcomes and to enhance quality of medical care....and to enhance quality of medical care. The **Telephonic Nurse Case Manager** will collect and document data to… more
- Highmark Health (Austin, TX)
- …experience, or provider operations and/or health insurance experience + 1 year in a clinical setting **Preferred** + 5 years in UM /CM/QA/Managed Care + 1 year ... 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… more
- Molina Healthcare (Austin, TX)
- …Utilization Management experience to join our Prior Authorization reviewing team. Previous UM experience with MCG/Interqual guidelines as well as working within ... UM in an MCO is highly preferred, but we...Teams, and One Note. Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying… more
- Molina Healthcare (Austin, TX)
- …national, state, and local laws and regulatory requirements affecting the medical and clinical staff. + Marketplace UM reviews + MD licenses required for ... appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership… more
- Molina Healthcare (Austin, TX)
- …**Job Summary** The Care Review Clinician (RN) provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...a candidate with a RN licensure that has previous UM and Inpatient Hospital experience. Candidates with MCO experience… more
- Datavant (Austin, TX)
- …recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully. Ideal candidate should be a Licensed ... Practical Nurse or Registered Nurse well versed in...denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines. **You will:** +… more
- Molina Healthcare (Austin, TX)
- For this position we are seeking a (RN) Registered Nurse who must be licensed for the state they reside This role will be doing Utilization review for our Ohio ... Medicaid population, looking for clinicians with strong inpatient clinical experience WORK SCHEDULE: Tuesday to Saturday - 8 AM to 5 PM Wednesday to Sunday - 8 AM to… more
- Molina Healthcare (Austin, TX)
- For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is a Remote position, home office with internet connectivity of high ... review, and medical coding. JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that… more
- Molina Healthcare (Austin, TX)
- JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically ... necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...the Molina care model. * Adheres to utilization management ( UM ) policies and procedures. Required Qualifications * At least… more
- Molina Healthcare (Austin, TX)
- JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically ... necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...the Molina care model. * Adheres to utilization management ( UM ) policies and procedures. Required Qualifications * At least… more
- Molina Healthcare (Austin, TX)
- …at the most effective setting. *Evaluates effectiveness of utilization management ( UM ) practices - actively monitoring for over and under-utilization. * Educates ... and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical … more
- Molina Healthcare (Austin, TX)
- …compliance with all state and federal regulations and guidelines. + Analyzes clinical service requests from members or providers against evidence based clinical ... and efficient manner. + Makes appropriate referrals to other clinical programs. + Collaborates with multidisciplinary teams to promote...teams to promote Molina Care Model + Adheres to UM policies and procedures. + Occasional travel to other… more