- Zelis (St. Petersburg, FL)
- …role with production and quality metric goals. What you'll do: + Review provider disputes for DRG Coding and Clinical Validation (MS and APR) ... and maintain claim review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies and Dispute Rationales + Perform… more
- ChenMed (Miami, FL)
- …to join our team. The Physician Reviewer is the primary physician reviewer for Utilization Management/ Clinical Appropriateness review cases in our ... for our patients. The position will also participate in Process and Quality improvement in our developing area of Delegated Utilization Management. **ESSENTIAL JOB… more
- Evolent (Tallahassee, FL)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- Zelis (FL)
- …found and justifying the revised choices of new codes and DRG, based on the clinical evidence obtained during the review + Document all aspect of audits ... interests that shape who you are. Position Overview The Inpatient DRG Reviewer will be primarily responsible for conducting post-service, pre-payment and post pay… more
- Actalent (Orlando, FL)
- Remote Clinical Review Nurse - Prior Authorization Location: Must be located in Central or Eastern time zones Employment Type: Full‑Time About the Role We ... our team within a leading Managed Care Organization. This role is fully remote and focuses on reviewing clinical documentation to determine medical necessity,… more
- Prime Therapeutics (Tallahassee, FL)
- …build the future of pharmacy with us. **Job Posting Title** Georgia Medicaid Clinical Account Manager - Remote **Job Description** Innovative business clinician ... visa or residency sponsorship **Additional Qualifications** + 3-5 years' experience in clinical operations, quality , network, pharmacy or project management OR a… more
- Evolent (Tallahassee, FL)
- …when available, within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the ... clinical professionals. + A role that values innovation, continuous improvement, and clinical excellence. + **This position is 100% Remote and can be… more
- Molina Healthcare (Jacksonville, FL)
- …strategic plans and objectives. Contributes to overarching strategy to provide quality and cost-effective member care. This position will support operations until ... that goals are achieved. + Manages and evaluates performance of various clinical outreach management activities. + Aligns with leadership, to ensure operational… more
- Molina Healthcare (Miami, FL)
- …appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. **ESSENTIAL JOB DUTIES:** + Facilitates ... Summary** Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and...clinical /medical reviews of retrospective medical claim reviews, medical claims… more
- University of Miami (Miami, FL)
- …a roadmap and schedule to ensure timely completion of projects. + Analyzes clinical quality data, identifies opportunities, and develops and implements action ... to apply for a faculty or staff position, please review this tip sheet (https://my.it.miami.edu/wda/erpsec/tipsheets/ER\_eRecruiting\_ApplyforaJob.pdf) . The Quality… more