- Molina Healthcare (Cincinnati, OH)
- …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... the likelihood of a formal appeal being submitted. + Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge,… more
- CVS Health (Columbus, OH)
- …+ 3+ years clinical nursing experience, with 1-3 years managed care experience in Utilization Review , Medical Claims Review , or other specific program ... weekends depending on business needs** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in… more
- Elevance Health (Cincinnati, OH)
- **Telephonic Nurse Case Manager I** **Sign On Bonus: $3000** **Location: This role enables associates to work virtually full-time, with the exception of required ... in different states; therefore Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager I** is responsible for performing care management within… more
- Sedgwick (Columbus, OH)
- …review process including making a recommendation of specialty for the Independent Medical Review process. + Developing and delivering training materials and ... Best Workplaces in Financial Services & Insurance Sr VP Medical Director (Hourly) The ideal candidate would work 8-20...the following: + Conducting reviews on cases where the nurse is seeking treatment plan clarification, claim … more
- CVS Health (Columbus, OH)
- …for guiding the team in determining correct coding and appropriate documentation during the review of medical records. This role requires a strong focus on ... coding reviews and resolve intricate issues with sensitivity, including claim reviews for legal, compliance, or rework projects. +...projects. + Ensure staff provide detailed written summaries of medical record review findings and ensure the… more
- Medical Mutual of Ohio (OH)
- Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million ... planning coordination and facilitation. Works with IT and Clinical Nurse staff to aid in the loading of HEDIS...in the loading of HEDIS data and collection of medical records. Works closely with HEDIS vendor support to… more
- CVS Health (Columbus, OH)
- …issues. -Explains member's rights and responsibilities in accordance with contract. -Processes claim referrals, new claim handoffs, nurse reviews, complaints ... in preparation of complaint trend reports. -Assists in compiling claim data for customer audits. -Determines medical ...requests for appeals and pre-authorizations not handled by Clinical Claim Management. -Performs review of member … more
- Sedgwick (Columbus, OH)
- … review of referred claims ; documents decision rationale; and completes medical review of all claims to ensure information substantiates disability. ... + Provides clear and appropriate follow-up recommendations for ongoing medical management of claims ; ensures appropriate recommendations are made on claims .… more
- Molina Healthcare (Akron, OH)
- …retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as ... Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial… more
- Elevance Health (Mason, OH)
- …experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing ... the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims...you will make an impact:** + Analyzes and audits claims by integrating medical chart coding principles,… more
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