- Stryker (San Jose, CA)
- …vendors (Optum, Premier, etc) to gather and review evidence development builds ( retrospective claims analysis, health economic models, etc.) to support market access ... requirements. + Possess a strong understanding of Commercial payors, Medicare and state Medicaid plans + Understanding of all data required on a Health Care… more
- AmeriHealth Caritas (Newark, DE)
- …reporting/analytics for UM DE, and serves as SME for clinical components DE Medicaid Utilization Management Program . Works in close collaboration with all ... **Utilization Management Plan Oversight Manager ,** Location: Newark, DE Primary Job Function: Medical Management ID**: 34207 Your career starts now. We are looking… more
- AdventHealth (Maitland, FL)
- …role you'll contribute:** The Population Health Services Organization (PHSO) Senior Manager of Clinical Documentation Integrity (CDI) will be responsible to manage, ... for the AdventHealth Population Health Ri Clinical Documentation Integrity Program . This will include but not be limited to...(SME) in meetings. + Responsible to comply with State Medicaid and CMS regulations with respect to Risk Adjustment… more
- Virginia Mason Franciscan Health (Bremerton, WA)
- …market(s) development, implementation, evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care ... department processes authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity;… more
- Trinity Health (Syracuse, NY)
- …outliers and audit risks. Perform provider targeted and focused prospective and retrospective audits of documentation compared to services billed for new and ... issues detected through audits/reviews and compliance monitoring to their Regional Manager . Responsible for writing reports that document the findings from… more
- Immigration and Customs Enforcement (IN)
- …Utilization Review Consultant will report directly to the IHSC Regional Utilization Manager with the Utilization Management Program Administrator. This is a ... CONTROLS: The Senior URC reports directly to the assigned IHSC Regional Utilization Manager (RUM) with the Utilization Management Program Administrator (UMPA) as… more
- The Cigna Group (Bloomfield, CT)
- …job family. Handles moderately-complex cases. Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and ... select outpatient services. Ensures that case management program objectives are met by evaluating the effectiveness of alternative care services and that cost… more
- LA Care Health Plan (Los Angeles, CA)
- …to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and ... retrospective claims medical review. Monitors and oversees the collection...Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM… more
- Northwell Health (Bay Shore, NY)
- …make referrals to the Supervisor and the department involved. + * Performs retrospective reviews as required. + * Participates in the maintenance of Utilization ... Acts as a liaison with patient's insurance carrier (case manager , utilization reviewer) to coordinate post hospital services and...* Assists in identifying patient incidents through the NYPORTS program . + * Performs any and all related duties… more
- CareOregon (Portland, OR)
- …Wisconsin. Job Title Senior Clinical Pharmacist Exemption Status Exempt Department Pharmacy Manager Title Director of Pharmacy - Clinical Services Direct Reports n/a ... quality improvement programs related to medication use and other pharmacy program activities as assigned. Essential Responsibilities + Prepare drug utilization… more
- UNC Health Care (Rocky Mount, NC)
- … retrospective or prospective review, ie - Medicare and Medicaid RA (Recovery Auditor) programs. **Responsibilities:** + Ensuring compliant billing guidelines ... + Assistance with hospital denial management program + Assistance with hospital audit response ...Healthcare/Medical setting + 1 year of HealthCare/Medical - Case Manager in Case Management, UR, Hospital Billing, Compliance, Charge… more
- LA Care Health Plan (Los Angeles, CA)
- …management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent ... Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM.… more