- UPMC (Pittsburgh, PA)
- The Regional Medical Director, CC/DP and Utilization Review , provides clinical and management leadership across multiple hospitals within the region. This role ... managed care organizations, providers, and payers to address benefit coverage, utilization review , and quality assurance. + Promote adherence to URAC standards,… more
- Centene Corporation (Harrisburg, PA)
- …and substance abuse preferred. Knowledge of mental health and substance abuse utilization review process preferred. Experience working with providers and ... shifts, or 5-8HR shifts. **Position Purpose:** Performs a clinical review and assesses care related to mental health and...Analyzes BH member data to improve quality and appropriate utilization of services + Provides education to providers members… more
- Penn Medicine (Philadelphia, PA)
- …or Equivalent Experience: + Bachelor of Arts or Science (Required) + Utilization Review experience (Required) + Bachelor's Degree in Nursing required.2+ ... quality data collection and risk management referral. Responsibilities: + Utilization management activities: monitor appropriate use of internal resources,… more
- Baylor Scott & White Health (Harrisburg, PA)
- …Note: Benefits may vary based on position type and/or level **Job Summary** As the Utilization Review RN you will review patient cases for medical necessity ... and the provider's care coordination departments. Your expertise is needed to review medical necessity. Working with the team, you'll verify medical records reflect… more
- St. Luke's University Health Network (Sellersville, PA)
- …we serve, regardless of a patient's ability to pay for health care. The Utilization Review (UR) Assistant manages and obtains all funding for inpatient clients ... at the St. Luke's Penn Foundation Inpatient Recovery Center. JOB DUTIES AND RESPONSIBILITIES: + Manages the day-to-day insurance and funding reviews for all inpatient clients. + Performs continued stay and discharge reviews when needed. + Performs… more
- Wellpath (Lemoyne, PA)
- …The Medical Director of Utilization Management leads and oversees utilization review , case management, quality improvement, and related policy and ... efforts to ensure quality patient care and the appropriate utilization of medical services. The Medical Director of ...utilization of medical services. The Medical Director of Utilization Management serves as a key liaison with external… more
- CVS Health (Harrisburg, PA)
- …in ER, Med/Surg, and/or Critical care setting + Managed Care experience + Utilization review experience + Experience working with MS office applications such ... heart, each and every day. **Position Summary** This is a fulltime remote Utilization Management Nurse Consultant opportunity. Utilization management is a 24/7… more
- AmeriHealth Caritas (Philadelphia, PA)
- …provides organizational leadership in the operational areas of care management, utilization review , appeals, quality improvement and related policy and ... practice initiatives in collaboration with the Corporate Medical Director(s), Utilization Management and the Vice President, Medical Affairs. ;The following… more
- Highmark Health (Pittsburgh, PA)
- …and civil law related to insurance fraud and advances in the post-payment utilization review process + Comprehensive knowledge of legal and investigative ... execution of the strategic plan of the Financial Investigations & Provider Review (FIPR) organization. The strategic plan focuses on the detection and investigation… more
- Prime Healthcare (Bristol, PA)
- …and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting. Able to work independently and ... institution in a Health and Human Services field is highly preferred. 2. Utilization Review /Case Management experience is highly preferred. 3. 1+ year of… more