- CenterWell (Harrisburg, PA)
- …actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that ... experience. + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Intelligence + Ability to… more
- Deloitte (Philadelphia, PA)
- …+ Experience as clinical registered nurse, physician, physician assistant, case manager , clinical documentation specialist, utilization review , informatics ... RN, Quality, DRG Validation and health IT preferred + Knowledge of Medicare reimbursement system and coding structures preferred + In-depth knowledge and experience in medical terminology, medical coding, and ICD-10-CM/PCS, IPPS payment system is a plus' +… more
- Guthrie (Troy, PA)
- …years of experience in an acute care setting with strong care management, utilization review , and payer knowledge. A Case Management certification or obtaining ... recommendations for alternate levels of care. The Acute Case Manager also performs Utilization Management throughout the continuum of care in collaboration with… more
- UPMC (Murrysville, PA)
- …you are caring for? UPMC Health Plan is hiring a full-time Clinical Care Manager to support our partnership with various physician practices. This role will support ... through Friday with no evenings, weekends, or holidays! The Clinical Care Manager is responsible for care coordination and health education with identified Health… more
- UPMC (Pittsburgh, PA)
- …an opportunity for you! UPMC Health Plan is hiring a full-time Clinical Care Manager to work onsite at General Academic Pediatric office in Oakland. This role will ... daylight hours with no evenings, weekend, or holidays! The Clinical Care Manager is responsible for care coordination and health education with identified Health… more
- CenterWell (Lancaster, PA)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and ... at our Lancaster, PA branch location.** The **RN Clinical Manager ** coordinates and oversees all direct care patient services...requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking… more
- CenterWell (Lancaster, PA)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and ... at our Lancaster, PA branch location.** The **RN Clinical Manager ** coordinates and oversees all direct care patient services...requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking… more
- Healthfirst (PA)
- The Case Manager , Utilization Management coordinates the care plan for assigned members and conducts pre-certification, concurrent review , discharge ... planning, and case management as assigned. The Case Manager , Utilization Management is also responsible for efficient utilization of health services and… more
- Highmark Health (Pittsburgh, PA)
- …including but not limited to: appropriateness of care, documentation requirements, utilization review principles and criteria, insurance benefits and ... outcomes, engages patients/caregivers in their healthcare, and supports effective resource utilization . Serves as key team members in the management of readmissions,… more
- Highmark Health (Monroeville, PA)
- …Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory ... etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental commercial payer guidelines. Adheres to… more