- Molina Healthcare (Miami, FL)
- …ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) ... modification of payment decisions. + Serves as a clinical resource for utilization management , CMOs, physicians and member/provider inquiries/appeals. + Provides… more
- Humana (Tallahassee, FL)
- …. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial ... daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, ...with prior experience participating in teams focusing on quality management , utilization management , case … more
- Molina Healthcare (FL)
- …(ICU) or emergency room. Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG ... with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At… more
- Community Based Care of Brevard, Inc. (Brevard, FL)
- …Position Summary: This position is responsible for the clinical coordination, utilization management , and authorization of initial and ongoing services ... alternative funding sources whenever possible. The position facilitates Team Review Meetings and the utilization review...the most efficient and effective use of agency resources. Utilization Management - Essential Function: Ensure that… more
- Evolent (Tallahassee, FL)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and ... work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators...Be Doing:** + Practices and maintains the principles of utilization management and appeals management … more
- HCA Healthcare (Sanford, FL)
- …in Case Management is preferred + BSN is preferred + Certification in Case Management , Nursing or Utilization Review is preferred HCA Florida Lake Monroe ... with physicians, patients, families, hospital staff, and outside agencies + Performs utilization management reviews and communicates information to third party… more
- Ascension Health (Jacksonville, FL)
- …of recent work experience in a hospital setting, preferably with some Physician Advisory/ Utilization Management work experience. If you are ready to join a ... of care and length of stay determination. + Assist and manage the denial management process. + Review and offer suggestions related to resources and service… more
- Evolent (Tallahassee, FL)
- …the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care across the… more
- HCA Healthcare (Sun City Center, FL)
- …Healthcare Quality) OR CHCQM (Diploma in American Board of Quality Assurance and Utilization Review Physicians). _Individuals without CPHQ or_ CHCQM _will be ... of experience in a healthcare environment + Previous experience in accreditation, quality, utilization management , or risk management required. + Knowledge… 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