- CVS Health (Tallahassee, FL)
- …state of residence. + 3+ years of Nursing experience. Preferred Qualifications + Prior authorization utilization management /review experience preferred ... and external constituents in the coordination and administration of the utilization /benefit management function. Required Qualifications + Registered Nurse in… more
- Molina Healthcare (Orlando, FL)
- …standing Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG ... benefits and eligibility for requested treatments and/or procedures. + Conducts prior authorization reviews to determine financial responsibility for Molina… more
- Evolent (Tallahassee, FL)
- …the mission. Stay for the culture. **What You'll Be Doing:** The **Coordinator, Intake Utilization Management ** at Evolent will serve as a point of contact for ... processing prior authorization requests in accordance with departmental...client contractual agreements. **Collaboration Opportunities** : The Coordinator, Intake Utilization Management reports directly to the Manager,… more
- AdventHealth (Orlando, FL)
- …ROLLINS STREET, Orlando, 32803 **The role you'll contribute:** The role of the Utilization Management (UM) Registered Nurse (RN) is to use clinical expertise ... including concurrent payer communications to resolve status disputes. The Utilization Management Nurse is accountable for a...payor authorization processes as required, ensuring proper authorization has been secured prior to or… more
- Centene Corporation (Tallahassee, FL)
- …services to ensure level of care and services are medically appropriate + Performs prior authorization reviews related to mental health and substance abuse to ... 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, national organization offering competitive… more
- Centene Corporation (Tallahassee, FL)
- …(BH) and/or autism spectrum disorder needs and clinical standards + Performs prior authorization /appeal reviews related to BH to determine medical ... 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, national organization offering competitive… more
- Molina Healthcare (FL)
- … of the state health plan's Healthcare Services (clinical operations) teams including Utilization Management ( prior - authorization , inpatient review) and ... Active, unrestricted State Registered Nursing (RN) license in good standing. + Utilization Management Certification (CPHM) Certified Professional in Health Care… more
- DOCTORS HEALTHCARE PLANS, INC. (Coral Gables, FL)
- …safety programs, and medical/pharmacy cost savings + Make recommendations on utilization management edits such as Prior Authorization , Step Therapy and ... Part D Drug Formulary and administration of the Drug Utilization Management Program. This includes weekly new...+ Perform medical necessity reviews for formulary exceptions and prior authorizations according to the Medicare Part D defined… more
- Molina Healthcare (Jacksonville, FL)
- …include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and ... **JOB DESCRIPTION** **Job Summary** Molina Pharmacy Services/ Management staff work to ensure that Molina members...+ Performs initial receipt and review of non-formulary or prior authorization requests against plan approved criteria.… more
- Evolent (Tallahassee, FL)
- …teams and stakeholders. + Familiarity with healthcare claims, reimbursement methodologies, and cost/ utilization KPIs, including prior authorization data and ... insights to internal and external stakeholders. + Experience with value-based care, utilization management , or regulatory reporting (eg, HEDIS, NCQA, Milliman).… more