- Evolent (Augusta, ME)
- …scheduled. + Determines medical necessity and appropriateness of services using clinical review criteria. + Accurately documents all review ... for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks… more
- Humana (Augusta, ME)
- …Manager, Fraud and Waste Investigator: Nurse Audit/ Review performs clinical audit/validation processes to ensure that medical record documentation and ... approach, resources, schedules and goals. The Manager, Fraud and Waste Investigator: Nurse Audit/ Review validates and interprets medical documentation to… more
- Veterans Affairs, Veterans Health Administration (Togus, ME)
- …preceptor providing didactic and clinical instruction in anesthesia to student nurse anesthetists, medical and dental residents, and other health care ... determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible to apply.… more
- Humana (Augusta, ME)
- …in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The Nurse reviews the medical documentation, researching claims, ... and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to...Medical Directors on submitted G&A cases. The G&A Nurse will participate in initiatives which result in improved… more
- Veterans Affairs, Veterans Health Administration (Togus, ME)
- …determined by the VHA Education Loan Repayment Services program office after review of the EDRP application. Former EDRP participants ineligible to apply. ... Responsibilities This Registered Nurse - Outpatient Clinic Hospice and Palliative Care position...Provide education and collaborate with interdisciplinary teams throughout the Medical Center. Coordinate hospice and palliative care referrals for… more
- CVS Health (Augusta, ME)
- …benefit overall claim management. + Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to ... in the US with virtual training.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993,… more
- CenterWell (Augusta, ME)
- …complaints. + Makes clinical level of care determination based on discussion, medical records, and any other pertinent clinical data. Matches these needs to ... regarding Home Health, Hospice, and Palliative Care Services. + Assist with clinical eligibility review for alternate services + Participates in special… more
- Sedgwick (Augusta, ME)
- … Consultant) Certification or training preferred. **Experience** Five (5) years related clinical nursing experience and two (2) years nurse consultant experience ... Fortune Best Workplaces in Financial Services & Insurance Professional Liability Nurse Consultant **PRIMARY PURPOSE** **:** To handle complex or high exposure… more
- Datavant (Augusta, ME)
- …years of CDI experience + 3+ years of clinical experience in an academic medical center + Registered Nurse license, Bachelor's degree in Nursing + CCDS or ... realize our bold vision for healthcare. **What We're Looking For:** As a Clinical Documentation Quality Improvement (CDQI) Specialist, you will play a pivotal role… more
- CVS Health (Augusta, ME)
- …enhance a member's overall wellness through integration. **You will also:** + Use clinical tools and information/data review to conduct an evaluation of members' ... advocating for disengaged, vulnerable members who often have multiple medical , behavioral, and social challenges. We're uniquely positioned to...needs and benefits. + Apply clinical judgment to incorporate strategies designed to reduce risk… more
- Highmark Health (Augusta, ME)
- …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 ... utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent conducts… more
- CenterWell (Augusta, ME)
- …will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review ... Compact Nursing License + A minimum of three years clinical RN experience; + Prior clinical experience,...extends outside of work. Among our benefits, Humana provides medical , dental and vision benefits, 401(k) retirement savings plan,… more
- Cardinal Health (Augusta, ME)
- …to ensure a positive and satisfactory experience for all customers. The Supervisor, Clinical Operations monitors nurse to patient contact quality and provides ... manufacturers to rethink the reach and impact of their products. The Supervisor, Clinical Operations provides management and clinical oversight to a team of… more
- Fujifilm (Augusta, ME)
- **Position Overview** The Clinical Consultant, MI - I shall be responsible for providing clinical consulting for the project, report configuration (CV), workflow ... go-live support to Synapse PACS/MI projects. In addition, provide clinical support for sales and company team members with...HCUS team to gain customer acceptance of the FUJIFILM Medical Systems solution. + Participates in teaching and training… more
- Zurich NA (Augusta, ME)
- Sr Supplier Medical Process Specialist 128416 Zurich North America is seeking am experienced Sr. Supplier Medical Process Specialist to join our team in one of ... commitment to work/life balance, and outstanding culture. As a Sr. Supplier Medical Process Specialist, you will manage supplier performance and work product in… more
- Fresenius Medical Center (Gardiner, ME)
- …dialysis therapy for patients under the direct supervision of a licensed nurse in accordance with organization policies, procedures, and training and in compliance ... and/or change in patient condition directly to the registered nurse or supervisor. + Observe patient and conduct machine...activities. + Enters all treatment data into the designated clinical application in an accurate and timely manner. +… more
- Datavant (Augusta, ME)
- …Prevention Specialist is to effectively defend utilization of available health services, review of admissions for medical necessity and necessity of continued ... necessity criteria and standards of care, along with clinical knowledge and expertise successfully. Ideal candidate should be...to author appeal letter Identification of referrals to the medical director for review + Select appropriate… more
- Veterans Affairs, Veterans Health Administration (Togus, ME)
- …by the VHA Education Loan Repayment Services program office after complete review of the EDRP application. Contact VHA EDRP Program Support ###@va.gov, for ... care patients. The Assistant Primary Care Service Line Manager will have Clinical and Administrative Responsibilities for the CBOC's. All physicians comply with… more
- Highmark Health (Augusta, ME)
- …and retrospective claims review basis. Review process includes a review of medical documentation, itemized bills, and claims data to assure appropriate ... and the proper action to complete the retrospective claim review with the goal of proper and timely payment...in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder or… more
- CVS Health (Augusta, ME)
- …+ Coordinates and arranges for health care service delivery under the direction of nurse or medical direction in the appropriate setting at the most appropriate ... Care Management Associate you will be supporting comprehensive coordination of medical services including Care Team intake, screening and supporting the… more