- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …within regulatory timeframes.The TeamAs an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will serve as a liaison and ... healthcare? Bring your true colors to blue. The RoleThe Clinical Appeals Nurse Reviewer... Reviewer is responsible for applying sound clinical judgement to review provider and member… more
- Beth Israel Lahey Health (Plymouth, MA)
- …data to establish the appropriate level of care using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal ... team to assess and improve the denial management, documentation, and appeals process. + Collaborates with UR Manager and/or physician advisor regarding… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …Immune Effector Cell (IEC) therapies, including benefit verification, pre-certification, concurrent review , appeals , and preparation of cost estimates for ... insurance waivers and non-covered services. + Collaborate closely with physicians, nurse coordinators, and interdisciplinary clinical teams to gather and… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …high volume, dynamic environment, the Clinical Authorization Specialist will bring clinical expertise to the prior authorization and appeals processes and ... clinical and/or related experience required. Case Management, Utilization Review and/or Prior Authorization experience is preferred. + **Certification/Licensure/Registration:**… more
- Beth Israel Lahey Health (Plymouth, MA)
- …data to establish the appropriate level of care using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal ... team to assess and improve the denial management, documentation, and appeals process. + Collaborates with UR Manager and/or physician advisor regarding… more
- Children's Hospital Boston (Boston, MA)
- …Posting Description:Department Summary: The UM Case Managers at Boston Children's review documentation within 1 business day of patient admission to assess ... for the appropriate level of care for admissions and with post-discharge appeals of payer denials. They identify and implement initiatives to manage utilization… more
- Beth Israel Lahey Health (Burlington, MA)
- …department in the context of other Revenue Cycle functions such as Denials & Appeals , Patient Access, Authorization Management & review , HIM, Coding & Billing. ... the Physician Advisors, Collaborates and helps facilitate the Utilization Review Committee. Continuously monitors processes for opportunities for improvement within… more
- Brockton Hospital (Brockton, MA)
- …external review agencies, to coordinate activities involved in medical record review , denials, appeals and reconsideration hearings. Works closely with the ... include the development and supervision of staff (RNs, LPN's,SWs and non- clinical support), evaluation and maintenance of case management skills and outcomes,… more
- Humana (Boston, MA)
- …a key enterprise leader, with responsibility for evolving Humana's Utilization Management of medical review by physician or nurse , with a focus on our 5+ million ... + Lead an operational team of Medical Directors to review authorizations and ensure clinical decision-making skills...the impactable drivers of prior authorization and look at appeals rate with denials and overturns. Deliver the upmost… more