- CenterWell (Atlanta, GA)
- …actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that ... RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to work… more
- Elevance Health (Columbus, GA)
- …of our customer expectations and responses. + Responsibilities exclude conducting any utilization or medical management review activities which require the ... you will make an impact:** + Utilizes guidelines and review tools to conduct extensive research and analyze the...summarize and route to nursing and/or medical staff for review . + The grievance and appeal work is subject… more
- Emory Healthcare/Emory University (Atlanta, GA)
- …Contracting and Value Analysis teams 11. Work with clinical specialty committees to review utilization and product standardization GPO Rostering & Compliance 1. ... contract performance and spend reports by category, supplier, or contract 5. Review and verify GPO analyses; develop recommendations 6. Confirm GPO contract details… more
- Molina Healthcare (Macon, GA)
- …team supporting non-clinical healthcare services activities for care management, care review , utilization management, transitions of care, behavioral health, ... within Molina's clinical/healthcare services function, which may include care review , care management, and/or correspondence processing, etc. * Researches and… more
- Elevance Health (Atlanta, GA)
- …policies, and CMS Coverage Determinations, as applicable. + Perform physician-level case review of utilization requests for procedures and interventions listed ... decisions. + Brings to their supervisors attention, any case review decisions that require Medical Director review ...case review decisions that require Medical Director review or policy interpretation. + Determine medical necessity of… more
- Stantec (Savannah, GA)
- …and maintain confidence of C-suite client executives - Monitor profitability & fee utilization against contract value - Review the design for adherence to ... the project - Monitor all client communication and correspondence - Review and approve all client invoices - Review...- Review and approve all client invoices - Review and approve project invoices and payment requests such… more
- Molina Healthcare (Atlanta, GA)
- JOB DESCRIPTION **Job Summary** The RN Care Review Clinician provides support for clinical member services review assessment processes. Responsible for verifying ... cost-effective member care. The candidate must have Medicare Appeals and/or Utilization Management knowledge. Work hours are Monday-Friday 8:00am- 5:00pm PST. This… more
- Datavant (Atlanta, GA)
- …healthcare. The purpose of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for medical ... author appeal letter Identification of referrals to the medical director for review + Select appropriate preferred and contracted providers + Provide proper… more
- CVS Health (Atlanta, GA)
- …to improve our company's discount position and strategic cost and utilization initiatives and is essential to managing conflicting priorities and multiple ... projects. As part of the Medical Expense Review (MER) team, you will prepare for monthly presentations,...our patients. You will also: * Analyze and research utilization and unit cost medical costs drivers * Turn… more
- Molina Healthcare (Columbus, GA)
- …on set schedule) Looking for a RN with experience with appeals, claims review , and medical coding. JOB DESCRIPTION Job SummaryProvides support for clinical member ... services review assessment processes. Responsible for verifying that services are...to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications *… more