- Molina Healthcare (Tampa, FL)
- …1-3 years Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and ... outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously denied cases… more
- CVS Health (Tallahassee, FL)
- …frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management ... community + Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department ...must have an active and unrestricted Compact Licensed Practical Nurse (LPN) License in state of residence + 3+… more
- Elevance Health (Miami, FL)
- **Telephonic Nurse Case Manager II** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training ... in different states; therefore, Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager II** is responsible for care management within the… more
- Molina Healthcare (Miami, FL)
- …experience, including hospital acute care/medical experience (STRONGLY DESIRED)** + **Registered Nurse with Claims and CIC coding experience (STRONGLY DESIRED)** ... **_For this position we are seeking a (RN) Registered Nurse who must be licensed for the state of...Payment Integrity strategies through both pre-payment and post payment claims reviews, aligning with industry and corporate standards as… more
- Molina Healthcare (FL)
- …the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the ... and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource… more
- CVS Health (Tallahassee, FL)
- …frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management ... functioning in the community. - Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and… more
- HCA Healthcare (Trinity, FL)
- …Healthcare Quality) OR CHCQM (Diplomate in American Board of Quality Assurance and Utilization Review Physicians) _Individuals without CPHQ or ABQUARP will be ... members on analysis of risk assessment, historical and concurrent occurrence and claims data and national trends. .You will ensure responsibility for organizational… more
- HCA Healthcare (Sun City Center, FL)
- …Healthcare Quality) OR CHCQM (Diplomate in American Board of Quality Assurance and Utilization Review Physicians) _Individuals without CPHQ or ABQUARP will be ... members on analysis of risk assessment, historical and concurrent occurrence and claims data and national trends. . You will ensure responsibility for organizational… more