- Humana (Harrisburg, PA)
- …conducting comprehensive reviews of medication care plans. This includes evaluating medical necessity, analyzing overall utilization , and identifying unusual ... Qualifications:** + Experience in managed care pharmacy, particularly in utilization management review **Additional Information:** **Interview Format**… more
- CenterWell (Harrisburg, PA)
- …will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review ... Prior clinical experience, managed care experience, DME, Florida Medicaid **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to… more
- Humana (Harrisburg, PA)
- …new systems (proficient to advanced) **Preferred Qualifications** + Experience with Utilization Review and/or Prior Authorization, preferably within a managed ... first** The UM Administration Coordinator contributes to administration of utilization management. The UM Administration Coordinator 2 performs varied activities… more
- Highmark Health (Pittsburgh, PA)
- …fraud, waste and abuse (FWA) programs and fraud awareness training, (d) participates on Medical Review Committee (MRC), including being a key liaison to external ... and civil law related to insurance fraud and advances in the post-payment utilization review process + Comprehensive knowledge of legal and investigative… more
- Humana (Harrisburg, PA)
- …role, you will be a key enterprise leader, with responsibility for evolving Humana's Utilization Management of medical review by physician or nurse, with ... our most vulnerable members. The Director, Physician leadership will lead Medical Directors performing utilization management for inpatient authorizations… 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 ... Director and other members of the healthcare team to provide appropriate medical management and resource utilization utilizing established/approved criteria. b)… more
- Humana (Harrisburg, PA)
- …and Managed Medicaid. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, ... to operationalize this knowledge in their daily work. The Medical Director's work includes computer-based review of...on size of region or line of business. The Medical Director conducts Utilization Management of the… more
- Humana (Harrisburg, PA)
- …group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, ... Medical Director, depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members in an… more
- Humana (Harrisburg, PA)
- …clinical group practice management + Utilization management experience in a medical management review organization, such as Medicare Advantage and managed ... management, provider relations, quality of care, audit, grievance and appeal and policy review . The Behavioral Health Medical Director will develop and present… more
- Highmark Health (Harrisburg, PA)
- …NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review , the incumbent participates as the physician member of the ... and improve the care of our members **ESSENTIAL RESPONSIBILITIES** + Conduct electronic review of escalated cases against medical policy criteria, which may… more