• Payment Integrity Clinician

    Highmark Health (Harrisburg, PA)
    …of the claim rejection and the proper action to complete the retrospective claim review with the goal of proper and timely payment to provider and member ... Payment Integrity strategies on a pre-payment and retrospective claims review basis. Review process includes a ...data to assure appropriate level of payment and resource utilization . It is also used to identify issues which… more
    Highmark Health (11/14/25)
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  • Licensed Practical Nurse -(LPN) Wound Care - Day

    WellSpan Health (Lebanon, PA)
    …providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. ... between visits. + Assists in the management of patient utilization of health care system and provides...care through our extensive WellSpan primary, specialty, ambulatory, and behavioral health care locations within the community.… more
    WellSpan Health (11/22/25)
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  • Medical Director, Medical Management

    Highmark Health (Harrisburg, PA)
    …NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review , the incumbent participates as the physician member of the ... **JOB SUMMARY** This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most… more
    Highmark Health (12/12/25)
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  • Supervisor Home Modification Specialist

    AmeriHealth Caritas (Philadelphia, PA)
    …managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover ... Review Home Modification Team and staff members within the LTSS Review Utilization Management Department. Responsibilities include providing technical and… more
    AmeriHealth Caritas (11/13/25)
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  • Telephonic Care Manager (RN) - HCBS Command Team

    UPMC (Pittsburgh, PA)
    …that include the medical, behavioral , pharmacy, and social needs of the member. Review UPMC Health Plan data for services the member has received and ... and modifies the care plan with member, caregivers, PCP, specialists, community resources, behavioral health contractor, and other health plan and system… more
    UPMC (12/12/25)
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  • RN Clinical Appeals (Part Time)- AHN

    Highmark Health (Harrisburg, PA)
    …Nurse Licensure Compact (eNLC) Preferred + Bachelor's Degree in Nursing + 1 year in Utilization Management or Utilization Review + 1 year in Case Management ... **Company :** Allegheny Health Network **Job Description :** **GENERAL OVERVIEW:** Responsible...activities to include but not limited to, clinical record review , composing comprehensive appeal letters and compiling minimum necessary… more
    Highmark Health (12/11/25)
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  • RN Case Manager Emergency (Nights), Allegheny…

    Highmark Health (Pittsburgh, PA)
    …with operational areas regarding issues related to supported technology. Manage utilization review , translation of foreign claims, coordination of benefits ... **Company :** Allegheny Health Network **Job Description :** REPOSTED: 20251114 REPOSTED: 20251112 Date Posted: 20250411 Location: Allegheny General Hospital… more
    Highmark Health (11/22/25)
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  • Dental Network Service Representative

    Highmark Health (Harrisburg, PA)
    …designs, competitive position, product development, network options, strategic partnerships, utilization review , local/national client demographics and dentist ... confidentiality agreements. Monitor financial performance of contracts by tracking utilization and competitive environment, including group specific performance guarantees.… more
    Highmark Health (11/14/25)
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  • Licensed Practical Nurse - Orthopedics Apple Hill…

    WellSpan Health (York, PA)
    …providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. ... management of patient care between visits. + Assists in the management of patient utilization of health care system and provides patient education relative to … more
    WellSpan Health (12/13/25)
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  • Licensed Practical Nurse, Outpatient - Pain…

    WellSpan Health (Chambersburg, PA)
    …providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. ... management of patient care between visits. + Assists in the management of patient utilization of health care system and provides patient education relative to … more
    WellSpan Health (12/09/25)
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