- Commonwealth Care Alliance (Boston, MA)
- …Mgmt **Position Summary:** Reporting to the Manager Utilization Management, the Nurse Utilization Management ( UM ) Reviewer is responsible for day-to-day ... timely clinical and service authorization review for medical necessity and decision-making. The ...applicable)), an OIG Report and verification of a valid MA/ RN license (if applicable). Commonwealth Care Alliance… more
- Commonwealth Care Alliance (Boston, MA)
- …for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible for conducting centralized clinical ... Audits, or EQRO reviews). - Hire, train and mentor UM staff, including nurse reviewers and support...applicable)), an OIG Report and verification of a valid MA/ RN license (if applicable). Commonwealth Care Alliance… more
- Tufts Medicine (Burlington, MA)
- …due to medically neuticessary care and/or if there is disagreement between UM RN and attending Physician in determining appropriate patient status. 13. ... issues related to the utilization of resources, coordination of care across the continuum and utilization review ...management (ACM, CCM, CMAC) 4. Seven (7) years of UM /Case Management experience in an acute- care hospital… more
- Highmark Health (Boston, MA)
- …in a clinical setting **Preferred** + Experience in UM /CM/QA/Managed Care **LICENSES AND CERTIFICATIONS** **Required** + Current RN state licensure ... :** **JOB SUMMARY** This job implements effective utilization management strategies including: review of appropriateness of health care services, application of… more
- Evolent (Boston, MA)
- …+ Performs other duties as assigned. **The Experience You'll Need (Required):** + Registered Nurse or Licensed Practical/Vocational Nurse with a current, ... issues to UM Leadership. + Appropriately identifies potential cases for Care Management programs + Collaborates with physicians and other providers to facilitate… more
- Commonwealth Care Alliance (Boston, MA)
- …for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible for conducting centralized clinical ... Audits, or EQRO reviews). * Hire, train and mentor UM staff, including nurse reviewers and support...applicable)), an OIG Report and verification of a valid MA/ RN license (if applicable). Commonwealth Care Alliance… more
- Elevance Health (Woburn, MA)
- **Behavioral Health - Care Manager II** **Location** : _Virtual:_ This role enables associate to work virtually full-time, with the exception of required in-person ... granted as required by law. The **Behavioral Health - Care Manager II** is responsible for managing psychiatric and...outpatient professional treatment health benefits through telephonic or written review . **How you will make an impact:** + Uses… more
- Highmark Health (Boston, MA)
- …and/or triaging members to appropriate resources for additional support. + Implement care management review processes that are consistent with established ... in a clinical setting **Preferred** + 5 years in UM /CM/QA/Managed Care + 1 year in advanced...in addressing targeted populations **LICENSES or CERTIFICATIONS** **Required** + RN license in PA or WV or DE or… more
- Commonwealth Care Alliance (Boston, MA)
- …and driving record, (if applicable)), an OIG Report and verification of a valid MA/ RN license (if applicable). Commonwealth Care Alliance is an equal opportunity ... Translate regulatory updates into operational actions, collaborating with Claims, Appeals, UM , and Provider Services. * Conduct internal audits and retrospective… more
