- UPMC (Pittsburgh, PA)
- …to identify total amount of optimization and missed opportunities. Meet with coding management as scheduled to review progress, discuss problems, and initiate ... remote! In this role, the DRG Specialist II will review clinical documentation within the medical record to ensure...the medical record to ensure that all patient resource utilization , diagnostic complications and co-morbidities have been coded in… more
- UPMC (Pittsburgh, PA)
- …and sequenced according to coding and compliance guidelines. + Meet with coding management as scheduled to review progress, discuss problems, and initiate new ... role requires three years of coding experience. In this role, you will review clinical documentation within the medical record to ensure that all patient resource… more
- WellSpan Health (York, PA)
- …with team members to identify root cause and countermeasures.* Holds In Episode Management meetings on a regularly scheduled basis with individual staff to ensure ... safe quality care, progress towards goals, and proper utilization of services. * Provides after-hours and on-call staff support as well as visits and consultation on… more
- Amergis (Pittsburgh, PA)
- …and referrals for psychosocial needs + Participates in Quality Assurance and Utilization Review activities, as directed + Empowers patients in decision-making ... regarding accessibility of services + Follows State/County mandated guidelines for the nurse case management programs + Participates in outreach activities to… more
- Penn State Health (Hershey, PA)
- …information with dyad leaders. + Coach and mentor end users and requestors. + Review clinical trends as well as CQVA trends. + Maintain best practice for CQVA ... program. + Expert in change management . + Lead and support change initiatives while prioritizing...Strategically expands the CQVA framework to support effective implementation, utilization , and continuous improvement. + Maintain and grow the… more
- Penn Medicine (Lancaster, PA)
- …of Nursing. + Bachelor's degree in Nursing BSN . + Knowledge of utilization review or managed care. + Care management experience in a managed care setting. ... Coordinates care across the continuum inpatient outpatient community to assure appropriate utilization of clinical and community resources. + Oversees and guides the… more
- Humana (Harrisburg, PA)
- …identified gaps. They will work closely with established functions inside utilization management (Medical Director, clinician decision making teams, quality ... identify appropriate actions when controls indicate process gaps. + Review appeal overturns and provider complaints about coverage policies...capacity ie Committees, projects. + 3 or more years' Utilization Management Experience + 2 + years… more
- Highmark Health (Pittsburgh, PA)
- …with operational areas regarding issues related to supported technology. Manage utilization review , translation of foreign claims, coordination of benefits ... the enhanced Nurse Licensure Compact (eNLC). + Nationally recognized Case Management Certification within 5 years of start date. + Critical thinking and problem… more
- St. Luke's University Health Network (Allentown, PA)
- …for admission and/or referral to appropriate level of care. + May assist in the utilization management of psychiatric cases in the absence of the utilization ... appropriate to the age of the patient treated. + Performs admission review on all inpatients. Attends daily patient rounds and shares professional knowledge,… more
- Guthrie (Sayre, PA)
- …and autonomy in nursing practice. Preferred experience with PCMH process, care management / utilization review , and payer knowledge. Fast paced ambulatory ... Coordinator has the responsibility and accountability for coordinating the medical management of patients, using an outcomes‐based approach. In collaboration with… more