- Molina Healthcare (Sterling Heights, MI)
- JOB DESCRIPTION **Job Summary** The RN Clinical Appeals Nurse provides support for internal appeals clinical processes - ensuring that appeals ... regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and… more
- Evolent (Lansing, MI)
- …to Standard processing, documenting accordingly. + Works closely with the appeals -dedicated Clinical Reviewers to ensure timely adjudication of processed ... for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a...be able to exercise independent and sound judgment in clinical decision making. - **Preferred** + Able to navigate… more
- McLaren Health Care (Mount Pleasant, MI)
- …outcomes and fulfills the obligation and responsibilities of the role to support the clinical team. 3. Collaborates with the Denials Appeals RN to ensure payer ... . Provides support to both internal and external customers for denial/ appeals activities and audits. Assists with monitoring and auditing activities, reviews… more
- Cognizant (Lansing, MI)
- …cycle or clinic operations + Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and concurrent reviews + ... have to be considered** + Educational background - Registered Nurse (RN) + 2-3 years combined clinical ...stand out** + Epic experience + Experience in drafting appeals disputing inpatient clinical validations audits is… more
- Integra Partners (Troy, MI)
- …of UM authorization reviews, both verbally and in writing + Process administrative and clinical appeals and refer as needed to the Medical Director + Maintain ... care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This individual will play a key role in collaborating… more
- McLaren Health Care (Port Huron, MI)
- …(inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when ... requirement. 5. Documents in the electronic medical record (EMR): clinical reviews (medical necessity), payer authorizations, avoidable days, readmission risks,… more
- Molina Healthcare (Detroit, MI)
- …medical necessity. * Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for investigation of adverse ... and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical … more
- Molina Healthcare (Warren, MI)
- For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is a Remote position, home office with internet connectivity of high ... (Team will work on set schedule) Looking for a RN with experience with appeals , claims review, and medical coding. JOB DESCRIPTION Job SummaryProvides support for … more
- Corewell Health (Grand Rapids, MI)
- …discussions, and participation in denials management which include review of previous clinical decisions by Priority Health Medical Directors ( appeals ). There ... + Actively participate in support of medical management + Provide clinical oversight to nurse case management and utilization management. + Promote and advocate… more
- Corewell Health (Royal Oak, MI)
- …criteria, when appropriate. Works collaboratively with departmental, revenue cycle, and clinical appeals staff, physicians, and payers to obtain authorization ... adult and Level II pediatric trauma designations. The advanced capabilities and clinical expertise within this center have earned it Magnet designation four… more