- Elevance Health (Grand Prairie, TX)
- …Finder and follows up with provider on referrals given. + Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care. + ... ** Utilization Management Representative II** **Virtual:** This role enables...impact:** + Managing incoming calls or incoming post services claims work. + Determines contract and benefit eligibility; provides… more
- Elevance Health (Grand Prairie, TX)
- …prior authorization, and post service requests. + Refers cases requiring clinical review to a Nurse reviewer. + Responsible for the identification ... ** Utilization Management Representative I** **Location:** This role enables...responsible for coordinating cases for precertification and prior authorization review . **How will you make an impact:** + Managing… more
- Molina Healthcare (San Antonio, TX)
- …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 (Austin, TX)
- …frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management ... compliance driven timelines. - Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and… more
- Elevance Health (Grand Prairie, TX)
- **Telephonic Nurse Case Manager II** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...as applicable. + Assists in problem solving with providers, claims or service issues. + Assists with development of… more
- Elevance Health (Houston, TX)
- **Telephonic Nurse Case Manager Senior** **Location:** This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager Senior** is responsible for care management...as applicable. + Assists in problem solving with providers, claims or service issues. + Assists with development of… more
- Molina Healthcare (TX)
- …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 (Austin, TX)
- …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
- Humana (Austin, TX)
- …involvement in day-to-day UM activities and discussions with UM leaders. 20% 2. Review and monitor Contract Change Orders and evaluate impact on Utilization ... **Use your skills to make an impact** **Required Qualifications** + **Registered Nurse (RN)** **with current, unrestricted licensure** + BSN or degree in related… more