- Evolent (Trenton, NJ)
- …provides clinical rationale for standard and expedited appeals. . Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD ... review process to reflect appropriate utilization and compliance with...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Evolent (Trenton, NJ)
- …available, within the regulatory timeframe of the request. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance… more
- Evolent (Trenton, NJ)
- …available, within the regulatory timeframe of the request. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance… more
- WTW (Fort Lee, NJ)
- …leading direct-to-consumer insurance services business, specializing in the distribution of Medicare Advantage, Medicare Supplement and Life & Supplemental ... that partner-run campaigns meet TRANZACT's quality and compliance standards. + Regularly review and audit partner activities for adherence to guidelines. **6. Daily… more
- RWJBarnabas Health (Oceanport, NJ)
- …coding and DRG assignment for inpatient encounters for other payers (not Medicare /Managed Medicare ). This requires critical thinking and a skill set ... a team with other Quality Officers to ensure SMART review goals are met for all RWJBarnabas facilities. +...accuracy and completeness. Communicates the need for Case Management review to the RWJBarnabas facilities when appropriate. + Reviews… more
- CVS Health (Trenton, NJ)
- …from home. **Position Summary** + Responsible for performing second level quality inter-rater review audits of medical records coded by internal team, as well as ... ICD codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of...years recent and related experience in medical record documentation review , diagnosis coding, and/or auditing. + CPC (Certified Professional… more
- CVS Health (Florham Park, NJ)
- …Manufacturer Rebates you will perform a critical role in the analysis of Medicare and Commercial formularies to determine client eligibility for rebates with respect ... by manufacturers and clients. + Adhering to quality control process in review of formulary rebate eligibility and contributing to enhancing our quality control… more
- Evolent (Trenton, NJ)
- …Field Medical Directors. **What You Will Be Doing:** + Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval ... documentation in order to approve services that meet clinical review criteria. + Conducts ongoing activities which monitor established...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Evolent (Trenton, NJ)
- …Field Medical Directors. **What You Will Be Doing:** + Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval ... documentation in order to approve services that meet clinical review criteria. + Conducts ongoing activities which monitor established...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Nestle (Bridgewater, NJ)
- …market dynamics, including reimbursement models and payer landscapes (Medicaid, Medicare , and private insurance). By negotiating and executing distributor programs, ... understanding of healthcare trends, Healthcare Reform, Reimbursement, and Payer Sources ( Medicare , Medicaid, Private Insurance) + Experience with Med B Billing in… more