- Highmark Health (Tallahassee, FL)
- …Risk Compliance Analyst is responsible for monitoring and analyzing medical and utilization management activities to ensure compliance with internal policies, ... and guidance to internal departments. The Analyst conducts audits of Medical Directors, Utilization Management (UM) and Case Management (CM) processes and… more
- CVS Health (Tallahassee, FL)
- …outcomes. * Leverage extensive knowledge of health care delivery system, utilization management , reimbursement methods and treatment protocols for DSNP/MMP ... Behavioral Health, Pharmacy, Member Outreach, Care Management , National Quality Management , Utilization Management , Compliance, and other departments to… more
- CVS Health (Tallahassee, FL)
- …appropriate member care. . Attends and participates in case rounds, including utilization management rounds for behavioral health and physical health to ... and/or face to face assessing, planning, implementing, and coordinating all care management activities with members to evaluate the medical and behavioral health… more
- AdventHealth (Deland, FL)
- …+ BSN + Health-related Master's degree or MSN + Prior Care Management / Utilization Management experience ACM/CCM Certification This facility is ... The expertise and experiences you'll need to succeed: Minimum qualifications: + Associate's degree Nursing or RN Diploma degree + Registered Nurse (RN) + Two (2)… more
- Bluestone Physician Services (Orlando, FL)
- …with primary care teams to ensure high quality team-based care + Use utilization management tools to facilitate appropriate transitional care management ... their unique needs. Using an evidence-based approach focused on quality care management and data-driven medical decisions, Bluestone care teams collaborate to manage… more
- Molina Healthcare (St. Petersburg, FL)
- …only). **Preferred Experience** 3-5 years clinical practice with managed care, hospital nursing or utilization management experience. **Preferred License, ... Certification, Association** Active, unrestricted Utilization Management Certification (CPHM). **MULTI STATE / COMPACT LICENSURE required.** **Individual state… more
- Humana (Tallahassee, FL)
- …during Medicare and Medicaid LOB - Medicare Clinical Criteria Review (MCCR), Utilization Management Committee (UMC), Medical Coverage Policy Adoption (MCPA) + ... **Desired Qualifications** + Master's degree in health-or business-related field + Utilization management experience (Commercial and/or Medicare) + Proven… more
- Centers Plan for Healthy Living (Margate, FL)
- …Plan For Healthy Living is currently accepting applications for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer ... or support in their home to improve their quality of life. Utilization Management Clinical Reviewer will assess and process all authorization requests to… more
- HCA Healthcare (Fort Walton Beach, FL)
- …Case Management is preferred + BSN is preferred + Certification in Case Management , Nursing or Utilization Review is preferred HCA Florida Fort ... with physicians, patients, families, hospital staff, and outside agencies + Performs utilization management reviews and communicates information to third party… more
- Elevance Health (Miami, FL)
- …required.** The **Telephonic Nurse Case Manager II** is responsible for care management within the scope of licensure for members with complex and chronic care ... **Telephonic Nurse Case Manager II** **Location: This role enables...claims or service issues. + Assists with development of utilization /care management policies and procedures. **Minimum Requirements:**… more