- BronxCare Health System (Bronx, NY)
- …the analysis and preparation of responses to payor denials and develop strong appeals for the purpose of securing reimbursement for acute care services provided to ... identification of patterns and trends identified during the course of appeals preparation. Conduct departmental performance improvement audits, analyze findings and… more
- University of Washington (Seattle, WA)
- …one of the following: certified healthcare chart auditor, certified professional in utilization review(or utilization management or healthcare management ... MEDICINE'S PATIENT FINANCIAL SERVICES Department** has an outstanding opportunity for a **CLINICAL APPEALS AND DISPUTES NURSE ** **Work Schedule** + 100% FTE +… more
- St. Mary's Healthcare (Amsterdam, NY)
- …denials and audit requests and coordinates attempts to overturn denials by drafting appeals , negotiating with payers, or following up with payer utilization ... medical staff and care coordination leaders to ensure ongoing compliance with utilization review guidelines. * Collaborates with managed care department to code… more
- Actalent (Rancho Cordova, CA)
- …Skills: Acute Care, Concurrent Review, Home Health, Long Term care, Health plan, Utilization Review, Utilization Management , Interqual Additional Skills & ... intervenes or as clinically appropriate + Provides referrals to Case Management , Disease Management , Appeals and Grievance and Quality Departments as… more
- VNS Health (Manhattan, NY)
- …in a Grievance and Appeals or related area such as medical or utilization management in a Managed Care setting required + Experience in a supervisory ... and prepares data reports and analysis of grievance and appeals for program management and committees, as...and current registration to practice as a registered professional nurse in New York State required Education: + Associate's… more
- VNS Health (Manhattan, NY)
- …grievance and appeals or related area such as medical or utilization management required + Proficient verbal/written communication skills required + ... OverviewResolves grievances, appeals and external reviews for one of the...professionals, health plan departments such as Claims and Medical Management , and the third party administrator staff and legal,… more
- CareFirst (Baltimore, MD)
- …(KSAs)** + Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management , and systems ... of members for all lines of business. Ensures quality management of the clinical appeal process to reduce the...goals resulting in the full and fair review of appeals and designed to achieve corporate objectives and advance… more
- LA Care Health Plan (Los Angeles, CA)
- …Skills Required: Knowledge of state, federal and regulatory requirements in Appeals /Care/Case/ Utilization Management /Quality. Strong verbal and written ... Supervisor, Appeals and Grievances Clinical Operations RN Job Category:...a lead/supervisory experience. Equivalency: Completion of the LA Care Management Certificate Training Program may substitute for the supervisory/… more
- Centene Corporation (Austin, TX)
- …Knowledge of NCQA, Medicare and Medicaid regulations is preferred. Knowledge of utilization management processes is preferred. **License/Certification:** + LPN - ... 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, national organization offering competitive… more
- CDPHP (Albany, NY)
- …values and invites you to be a part of that experience. The Clinical Appeals Specialist is responsible for adhering to a member/provider appeal and grievance process ... Using knowledge of clinical nursing and medical practices, the Clinical Appeals Specialist will review medical necessity requests, render determinations about… more
- SSM Health (OK)
- …care registered nurse experience, with one year experience in utilization review and/or case management PHYSICAL REQUIREMENTS + Frequent lifting/carrying ... IL, MO, OK, or WI)* Qualifications: 2+ years of Utilization Review experience, denials and appeals experience,...peer to peer, or formal appeal. + Collaborates with utilization management staff regarding possible reconsideration with… more
- Henry Ford Health System (Troy, MI)
- …experience . + Minimum of two (2) years of experience working on utilization management platform-processing authorizations. + Minimum of two (2) years of ... prompt and thorough investigation of medical, transportation, and pharmacy member appeals and grievances for Health Alliance Plan's (HAP's): Commercial, Medicare… more
- LA Care Health Plan (Los Angeles, CA)
- Utilization Management Nurse Specialist LVN II Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 ... net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist LVN...experience in a patient care setting and/or combination in utilization management , appeals and grievances,… more
- State of Connecticut, Department of Administrative Services (Middletown, CT)
- Utilization Review Nurse Coordinator (40 Hour) Office/On-site Recruitment # 240830-5613FP-001 Location Middletown, CT Date Opened 9/5/2024 12:00:00 AM Salary ... Hospital - is accepting applications for one (1) full-time Utilization Review Nurse Coordinator (https://www.jobapscloud.com/CT/specs/classspecdisplay.asp?ClassNumber=5613FP&R1=&R3=) position, in… more
- McLaren Health Care (Detroit, MI)
- **Department: Utilization Management ** **Daily Work Times: 7:00am-3:30pm** **Shift: Days** **Scheduled Bi-Weekly Hours: 40** **Position Summary:** Responsible ... as Assigned:** 1. Performs a variety of concurrent and retrospective utilization management -related reviews and functions to ensure that appropriate… more
- Molina Healthcare (Florence, KY)
- …to work a schedule using Pacific time zone. Previous experience working in utilization management for another MCO is preferred. This position is fully ... meetings. **JOB QUALIFICATIONS** **Required Education** Completion of an accredited Registered Nurse (RN). **Required Experience** 1-3 years of hospital or medical… more
- Elevance Health (Tampa, FL)
- …of Florida. + Requires minimum of 5 years acute care clinical experience, utilization management or managed care experience; or any combination of education ... Senior RN Utilization Review/ Management (Acute InPatient) JR116937 **Location:**...Friday. **2 Holidays** per year and **occasional** weekends. The ** Nurse Medical Management Sr** serves as **team… more
- Ascension Health (Birmingham, AL)
- …Birmingham, AL (remote) At least 3 years of acute care experience and utilization management experience **Benefits** Paid time off (PTO) Various health insurance ... and coordinate compliance to federally mandated and third party payer utilization management rules and regulations. **Requirements** Licensure / Certification… more
- Ascension Health (Manhattan, KS)
- **Details** + **Department:** Utilization Management + **Schedule:** Full Time, 40 hours weekly, Monday - Friday 7:30am - 4pm + **Hospital:** Ascension Via ... and coordinate compliance to federally mandated and third party payer utilization management rules and regulations. **Requirements** Licensure / Certification… more
- UCLA Health (Los Angeles, CA)
- …leader with: + Current CA LVN licensure required + Two or more years of utilization review/ utilization management experience in an HMO, MSO, IPA, or health ... Criteria + Experience with Flesch-Kincaid readability scoring + Knowledge of the appeals process + Experience with audit preparation + Basic computer skills UCLA… more