- Molina Healthcare (Houston, TX)
- …At least 2 years clinical nursing experience, including at least 1 year of utilization review , medical claims review , long-term services and supports ... DESCRIPTION **Job Summary** Provides support for medical claim and internal appeals review activities -...clinical/ medical reviews of retrospective medical claim reviews, medical claims and… more
- Humana (Austin, TX)
- …in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The Nurse reviews the medical documentation, researching claims ... and Humana Medical Directors on submitted G&A cases. The G&A Nurse will participate in initiatives which result in improved member outcomes, operational… more
- Elevance Health (Grand Prairie, TX)
- …coding and medical policy guidelines strongly preferred + BA/BS preferred + Medical claims review with prior health care fraud audit/investigation ... you will make an impact:** + Investigates potential fraud and over-utilization by performing medical reviews via prepayment claims review and post payment… more
- CVS Health (Austin, TX)
- …in the US with virtual training.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, ... Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.… more
- CVS Health (TX)
- …and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness within ... + Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit...and multiple diagnoses that impact functionality. + Reviews prior claims to address potential impact on current case management… more
- Elevance Health (Grand Prairie, TX)
- **Telephonic Nurse Case Manager II** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training ... in different states; therefore Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager II** is responsible for care management within the scope… more
- Elevance Health (Grand Prairie, TX)
- ** Nurse Case Manager II** **Location** : This role enables associates to work virtually full-time, with the exception of required in-person training sessions, ... 48 hours of receipt and meet the criteria._** The ** Nurse Case Manager II** is responsible for care management...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Sedgwick (Austin, TX)
- …expertise and analytical skills to help evaluate medical -related components of claims . Completion of Legal Nurse Consultant certification or coursework is ... highly preferred.** **PRIMARY PURPOSE** **:** To handle complex or high exposure claim issues; to provide medical knowledge of the health care system and health… more
- Sedgwick (Irving, TX)
- …professional needs. **PRIMARY PURPOSE** : Provides disability case management and routine claim determinations based on medical documentation and the applicable ... system. + Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims . + Evaluates and arranges appropriate… more
- Houston Methodist (Katy, TX)
- …to department specifications. + Manages utilization management (UM) programs including Medical Claims Review , Precertification and Reconsiderations and ... At Houston Methodist, the Manager Centralized Utilization Review (UR) position is responsible for leading the...efficiency of admission, concurrent and retrospective utilization management and medical claims functions to meet and exceed… more