- Humana (Atlanta, GA)
- …utilizing electronic medical record and documentation programs + Experience with Utilization Review and/or Prior Authorization, preferably within a managed ... + Knowledge of Medical Terminology and/or ICD-10 codes + Experience with Utilization Review and/or Prior Authorization, preferably within a managed care… more
- Molina Healthcare (Savannah, GA)
- …managed care experience in the specific programs supported by the plan such as utilization review , medical claims review , long-term services and supports ... medical officer on denial decisions. * Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. * Identifies… more
- CVS Health (Atlanta, GA)
- …we have an Integrated plan. Experience with managed care (Medicare and Medicaid) utilization review preferred. **Education** MD (Doctor of Medicine) or DO ... and consistent responses to members and providers related to precertification, concurrent review , and appeal request. The medical director is a work-at-home position… more
- Highmark Health (Atlanta, GA)
- …NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review , the incumbent participates as the physician member of the ... **JOB SUMMARY** This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most… more
- CenterWell (Atlanta, GA)
- …Director of Physician Strategy at Utilization Management. The Medical Director conducts Utilization review of the care received by members in an assigned ... this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all… more
- CenterWell (Atlanta, GA)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and ... the utilization of Performance Improvement principles. + Responsible for review of the appropriate number of Case Managers and clinical staff documentation… more
- Elevance Health (Atlanta, GA)
- …must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... appeal case reviews with attending physicians or other ordering providers to discuss review determinations. + Serves as a resource and consultant to other areas of… more
- Highmark Health (Atlanta, GA)
- …designs, competitive position, product development, network options, strategic partnerships, utilization review , local/national client demographics and dentist ... confidentiality agreements. Monitor financial performance of contracts by tracking utilization and competitive environment, including group specific performance guarantees.… more
- Elevance Health (Atlanta, GA)
- …must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... for medications with attending physicians or other ordering providers to discuss review determinations. + Will participate in a physician on-call weekend rotation… more
- Highmark Health (Atlanta, GA)
- …+ Participate in product specific Pharmacy and Therapeutics Committees and Drug Utilization Review (DUR) Committees as necessary or contractually required. + ... Participate in product specific government meetings as necessary. + Coordinate implementation of clinical programs and operational requirements as necessary. + Support product specific business retention and business development activities as necessary. +… more