- AmeriHealth Caritas (Philadelphia, PA)
- **Role Overview: ;** The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with ... appeals , ensuring compliance with all regulatory milestones + Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation,… more
- CenterWell (Trenton, NJ)
- …this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review ... An aspect of the role includes an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and… more
- Humana (Trenton, NJ)
- …this knowledge in their daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, review of ... resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and… more
- Humana (Trenton, NJ)
- …this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review ... but may not be limited to, an overview of coding practices and clinical documentation, grievance and appeals processes (including pharmacy), and reviews for… more
- Evolent (Trenton, NJ)
- …of the request and provides clinical rationale for standard and expedited appeals . . Utilizes medical/ clinical review guidelines and parameters to assure ... to make a difference in patients lives, in a non- clinical environment. You can enjoy better work- life balance...Will Be Doing:** . Serve as the Physician match reviewer in Advanced Imaging cases, that do not initially… more
- Evolent (Trenton, NJ)
- …of the request and provides clinical rationale for standard and expedited appeals . + Utilizes medical/ clinical review guidelines and parameters to assure ... to make a difference in patients lives, in a non- clinical environment. You can enjoy better work- life balance...Will Be Doing:** + Serve as the Physician match reviewer in Imaging cases, that do not initially meet… more
- Evolent (Trenton, NJ)
- …of the request. + Provides clinical rationale for standard and expedited appeals . + Utilizes medical/ clinical review guidelines and parameters to assure ... to make a difference in patients' lives, in a non- clinical environment. You can enjoy better work- life balance...Will Be Doing:** + Serve as the specialty match reviewer in Vascular cases, that do not initially meet… more
- Evolent (Trenton, NJ)
- …when available, within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the ... guidance and expertise to ensure the application of best practices. + Provides clinical rationale for standard and expedited appeals . + Discusses determinations… more
- Evolent (Trenton, NJ)
- …for the mission. Stay for the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer , Interventional Pain Management, you will be a key member of ... You Will Be Doing:** + Serve as the Physician Clinical Reviewer for Interventional Pain Management, reviewing...within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure… more
- Evolent (Trenton, NJ)
- …when available, within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the ... Will Be Doing:** + Serve as the specialty match reviewer in Cardiology cases, that do not initially meet...be completed by the subject matter expert. + Provides clinical rationale for standard and expedited appeals .… more
- Highmark Health (Trenton, NJ)
- …and efficient delivery of Pharmacy call center services. Serves as first line reviewer in monitoring and ensuring adherence to the health plan's state and federal ... the department. + Prioritize requests for drug authorizations or denials. + Review of prior authorization criteria for drug products. + Recommend staffing… more
- Globus Medical, Inc. (Collegeville, PA)
- …customers from the initial processing of received documentation through prior authorization, appeals support, detailed claims review , and hotline support. The ... of exceptional response by partnering with researchers and educators to transform clinical insights into tangible solutions. Our solutions improve the techniques and… more
- CVS Health (Trenton, NJ)
- …and consistent responses to members and providers related to precertification, concurrent review , and appeal request. The medical director is a work-at-home position ... reviews with peer to peer coverage of denials. * Appeals - The medical director will perform appeals...lead daily rounds. **Required Qualifications:** Minimum 3-5 years of clinical practice experience. Two (2) + years of experience… more
- CVS Health (Trenton, NJ)
- …to ensure successful Provider Relationships, and Network Performance including Clinical and Affordability Targeted Improvements as identified. That includes, but ... and community groups. Promotes collaboration with internal partners. + Continuous review of value based provider performance and movement of providers along… more
- Highmark Health (Trenton, NJ)
- …to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. ... are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical… more