- Evolent (Harrisburg, PA)
- …Doing:** As a Field Medical Director, Oncology, you will be a key member of the utilization management team. We can offer you a meaningful way to make a ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
- Humana (Harrisburg, PA)
- …. + 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
- UPMC (Pittsburgh, PA)
- …of health insurance experience preferred. + 1 year of experience in clinical, utilization management , home care, discharge planning, and/or case management ... clinical and social history, current medications, geriatric syndromes, healthcare resource utilization , and case management interventions. Updates the plan of… more
- Highmark Health (Harrisburg, PA)
- …triaging members to appropriate resources for additional support. + Implement care management review processes that are consistent with established industry, ... Nursing **EXPERIENCE** **Required** + 7 years in any combination of clinical, case/ utilization management and/or disease/condition management experience, or… more
- Evolent (Harrisburg, PA)
- …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
- Geisinger (Lewistown, PA)
- …and efficiency results for assigned population. + Works to appropriately apply benefits and utilization management serving as a resource to the patient or member ... as part of a shared rotation. Don't worry, we'll review this in your interview. At least two (2)...have prior RN experience in a hospital setting. Case Management experience is preferred and not required. The successful… more
- Evolent (Harrisburg, PA)
- …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
- The Cigna Group (Philadelphia, PA)
- …management functions, including case management (CM), utilization management (UM), and escalated case review . Ensures policies, procedures, and ... operating within health plan environments, including fluency in medical management functions such as utilization management (UM), case management (CM),… more
- UPMC (Pittsburgh, PA)
- …the CMA's collaborations, practical comprehension and hands-on experience in clinical care/ utilization management will result by collecting and assisting with ... + Assist clinical team with scheduling transportation, scheduling appointments, and tracking utilization . + Refer members to appropriate case management , health … more
- Humana (Harrisburg, PA)
- …. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial ... their 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