- Evolent (Harrisburg, PA)
- …Reviewers. **What You Will Be Doing:** + Serve as the specialty match reviewer in Cardiology cases, that do not initially meet the applicable medical necessity ... the regulatory timeframe of the request. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Evolent (Harrisburg, PA)
- …or required. **What You Will Be Doing:** + Serve as the Physician match reviewer in Imaging cases, that do not initially meet the applicable medical necessity ... rationale for standard and expedited appeals. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Guthrie (Sayre, PA)
- …Care Coordination including, but not limited to Case Management, Utilization Review (UR), Utilization Management (UM), and Medical Social Work. Provides leadership ... five (5) years. Knowledge and ability to demonstrate understanding of Medicare /Medicaid regulations, Medicare Advantage UM rules/regulations, and Commercial… more
- Intermountain Health (Harrisburg, PA)
- …Billing, Follow-Up, Collections) required + Knowledge of Medicaid and Medicare billing regulations required **Physical Requirements** + Operate computers and ... other office equipment requiring the ability to move fingers and hands. + Remain sitting or standing for long periods of time to perform work on a computer, telephone, or other equipment. + May require lifting and transporting objects and office supplies,… more
- Humana (Harrisburg, PA)
- …group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or ... and other sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements, and will...daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, … more
- Elevance Health (Harrisburg, PA)
- … of complex exception requests and CMS change requests. + Perform supervisory review of workload involving complex areas of Medicare part A reimbursement ... Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare...experienced associates as assigned. + Prepare and perform supervisory review of cost report desk reviews and audits. +… more
- Humana (Harrisburg, PA)
- …help us put health first** The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing home health, SNF, DME, dual Medicare ... of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. All work occurs with a… more
- Humana (Harrisburg, PA)
- …help us put health first** The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing home health, SNF, DME, dual Medicare ... of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. All work occurs with a… more
- Humana (Harrisburg, PA)
- …group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or ... internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to… more
- Humana (Harrisburg, PA)
- …and other vendors. + Document all calls and requests. + Search for Medicare and Medicaid Guidelines. + Process all incoming fax/emails request for services the ... and/or ICD-10 codes. + Member service + Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization. **Additional… more