- Veterans Affairs, Veterans Health Administration (Houston, TX)
- …Nurse position is within the Community Care Service at the Michael E. DeBakey Medical Center in Houston, Texas. The vocational nurse will be responsible for ... and record relevant patient information. Completed work should need only a general review by a registered nurse (RN) or physician (MD/DO) for appropriateness… more
- Molina Healthcare (San Antonio, TX)
- …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
- Elevance Health (Grand Prairie, TX)
- …and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to payment. Researches new healthcare-related questions ... **Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU**...Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Clinical Fraud Investigator II** is responsible… 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 ... hours of receipt and meet the criteria._** The **Telephonic 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
- Elevance Health (Houston, TX)
- **Telephonic Nurse Case Manager Senior** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training ... assessment within 48 hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager Senior** is responsible for care management within the scope of… more
- CVS Health (Austin, TX)
- …frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management ... and support safe transitions. **REQUIRED EXPERIENCE** - 2 years Licensed Vocational Nurse (LVN) nursing experience - Active and unrestricted TX Compact License -… more
- CVS Health (Austin, TX)
- …and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness. RN ... - 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
- Molina Healthcare (TX)
- …including hospital acute care/ medical experience (STRONGLY DESIRED)** + **Registered Nurse with Claims and CIC coding experience (STRONGLY DESIRED)** + ... **_For this position we are seeking a (RN) Registered Nurse who must be licensed for the state of...scope of a Payment Integrity Clinician. This includes assessing medical documentation, itemized bills, and claims data… more
- Sedgwick (Houston, TX)
- … 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 (Austin, TX)
- …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