- UPMC (Pittsburgh, PA)
- …policies of the Health Plan. + Actively participates in the daily utilization management and quality improvement review processes, including concurrent, ... for assuring physician commitment and delivery of comprehensive high quality health care to UPMC Health Plan members. They oversee adherence to quality and… more
- Highmark Health (Wexford, PA)
- … utilization management (UM) coverage requests and prepares such cases for clinical review by a pharmacist and/or medical director when required. (20%) ... facts, and cites applicable internal policies and guidelines. (20%) + Resolves non- clinical issues independently and acts as a liaison between our customer and… more
- Guthrie (Sayre, PA)
- …five (5) years of experience in an acute care setting with strong care management, utilization review , and payer knowledge. A Case Management ... and educational activities. a) Incorporates available current evidence-based data for clinical care management. b) Demonstrates knowledge of federal, state… more
- Humana (Harrisburg, PA)
- …insurance, other healthcare providers, clinical group practice management. + Utilization management experience in a medical management review organization, ... daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical ...region or line of business. The Medical Director conducts Utilization Management of the care received by… more
- Sedgwick (Harrisburg, PA)
- …related line of business experience in telephonic case management (TCM) and/or utilization review or equivalent combination of education and experience required. ... Place to Work(R) Fortune Best Workplaces in Financial Services & Insurance Quality Review Nurse **PRIMARY PURPOSE** : To monitor team and colleague technical and… more
- Highmark Health (Harrisburg, PA)
- …and interdisciplinary team partners including but not limited to: appropriateness of care , documentation requirements, utilization review principles and ... safe plans for transition and care coordination. (20%) + Coordinates the clinical care with the patient, family, provider(s), and members of the… more
- UPMC (Pittsburgh, PA)
- … clinical and non- clinical disciplines across UPMC, including regular utilization review , spend analysis, product introductions and trials. + Supports ... clinical specialty committees focused on product introductions, value analysis and utilization review consistent with UPMC policies and procedures. +… more
- ChenMed (Philadelphia, PA)
- …assess and record patients' progress and adjust and plan accordingly + Understanding utilization review and how to leverage with inpatient staff for possible ... deficits. + Supports, collaborates and partners with the Complex Care and Clinical Strategy Teams on the...required + A minimum of one (1) year of utilization review and/or case management, home health,… more
- WellSpan Health (Mount Gretna, PA)
- …Day shift **General Summary** Performs a variety of duties to facilitate quality clinical care within the Inpatient Child/Adolescent and Adult Psychiatric Units. ... care progression in discharge readiness by rounding with care team, using clinical judgment to identify...with Case Management as indicated. + Participates in the review of policy and procedures on an ongoing basis… more
- Penn Medicine (Lancaster, PA)
- …Evidence Based Practice and Research, Leadership, Person and Family Centered Care , Professionalism, Safety, Teamwork and Technology/Informatics. The Clinical ... is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field… more