- Molina Healthcare (TX)
- …of health care services provided to plan members. * Supports plan utilization management program and accompanying action plan(s), which includes strategies to ensure ... most appropriate care at the most effective setting. *Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-… more
- Molina Healthcare (Fort Worth, TX)
- …modification of payment decisions. + Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/ appeals . + Provides ... (Team will work on set schedule) Looking for a RN with experience with appeals , claims review, and medical coding. **Job Summary** Provides support for medical claim… more
- Guardian Life (Plano, TX)
- …as needed (eg Specialty Referral Guidelines) with guidance from the Quality and Utilization Management Manager . + Demonstrate expertise in QMP processes and ... with applicable state regulations. You will ensure that claims, referrals, appeals , and grievances meet state specific regulations, timeframes, and definitions for… more
- Elevance Health (Grand Prairie, TX)
- …must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... medical director provides clinical expertise in all aspects of utilization review and case management. Provides input on the...Strategy. Unless specified as primarily virtual by the hiring manager , associates are required to work at an Elevance… more
- Sharecare (Austin, TX)
- …open enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited to ... 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or...Physical Therapy Assistant + Nursing Assistant + Medical Secretary/Clinic Manager + Radiology Technician + Home Health Aide +… more
- Molina Healthcare (Austin, TX)
- …oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs and chemical ... working closely with regional medical directors to standardize behavioral health utilization management policies and procedures to improve quality outcomes and… more
- Elevance Health (TX)
- …must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... not required for posting. + Works independently with oversight from immediate manager . + May be responsible for an entire clinical program and/or independently… more
- Houston Methodist (Sugar Land, TX)
- …care benefits + Supports and assists with concurrent insurance denials and appeals process, transmission of utilization reviews to insurance companies, ... the case management and social work department to facilitate efficient utilization of resources and discharge planning including referrals management, communication… more
- Elevance Health (Grand Prairie, TX)
- …program, including Prior Authorizations, Medication Therapy Management (MTM), Lock-in, and Drug Utilization Review (DUR) programs. **How you will make an impact:** + ... monographs, and formulary recommendations. + Develop strategies to drive formulary utilization and optimization. + Collaborate with account management teams to… more
- Elevance Health (TX)
- …must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... for posting. + Works independently with oversight from immediate manager . + May be responsible for an entire clinical...Strategy. Unless specified as primarily virtual by the hiring manager , associates are required to work at an Elevance… more