- Veterans Affairs, Veterans Health Administration (Houston, TX)
- …and record relevant patient information. Completed work should need only a general review by a registered nurse (RN) or physician (MD/DO) for appropriateness ... Summary This Licensed Vocational Nurse position is within the Community Care Service...documentation packets. He/she discusses eligibility for programs or specific claims with vendors, veterans, and/or service officers. Must have… more
- Elevance Health (Grand Prairie, TX)
- …guidelines and to identify opportunities for fraud and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to ... **Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU**...Skills, Qualifications, and Experiences:** + Fraud and Abuse experienced Nurse with a CPC are highly desired. For candidates… more
- Molina Healthcare (San Antonio, TX)
- …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, or ... outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously denied cases… more
- Elevance Health (Grand Prairie, TX)
- **Telephonic Nurse Case Manager II** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...as applicable. + Assists in problem solving with providers, claims or service issues. + Assists with development of… more
- Elevance Health (Houston, TX)
- **Telephonic Nurse Case Manager Senior** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager Senior** is responsible for care management...as applicable. + Assists in problem solving with providers, claims or service issues. + Assists with development of… more
- CVS Health (Austin, TX)
- …frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management ... and support safe transitions. **REQUIRED EXPERIENCE** - 2 years Licensed Vocational Nurse (LVN) nursing experience - Active and unrestricted TX Compact License -… more
- CVS Health (Austin, TX)
- …through integration. - Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit plan eligibility and ... including co-morbid and multiple diagnoses that impact functionality. - Reviews prior claims to address potential impact on current case management and eligibility.… more
- Molina Healthcare (TX)
- …experience, including hospital acute care/medical experience (STRONGLY DESIRED)** + **Registered Nurse with Claims and CIC coding experience (STRONGLY DESIRED)** ... **_For this position we are seeking a (RN) Registered Nurse who must be licensed for the state of...Payment Integrity strategies through both pre-payment and post payment claims reviews, aligning with industry and corporate standards as… more
- Sedgwick (Houston, TX)
- …for absence from work. **ESSENTIAL FUNCTIONS and RESPONSIBILITIES** + Performs clinical review of referred claims ; documents decision rationale; and completes ... medical review of all claims to ensure information substantiates disability. + Provides clear...change the duties of the position at any time. \# nurse #casemanagementspecialist Sedgwick is an Equal Opportunity Employer and… more
- Elevance Health (Grand Prairie, TX)
- …clinical documentation supports the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims . **How you will ... make an impact:** + Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical… more