- Evolent (Harrisburg, PA)
- …focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and procedures ... 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 by adhering to company… more
- Genesis Healthcare (Mechanicsburg, PA)
- …Clinical Operations Area Director in the timely completion of the annual merit review for therapy staff. 7. Assists Clinical Operations Area Director in the hiring ... 8. Participates in and coordinates the timely completion of the annual merit review for therapy staff. 9. Assumes responsibility for hiring therapy staff (in… more
- Highmark Health (Harrisburg, PA)
- …business relationships, the impact of Highmark's business decisions on Informatics, personnel utilization , and the use and planning of technology. The role involves ... units that may assist in the resolution of issues or problems. + Access, review , utilize, contribute content to and participate in the maintenance of the shared… more
- Highmark Health (Harrisburg, PA)
- …**Job Description :** **JOB SUMMARY** This job implements effective complimentary utilization and case management strategies for an assigned member panel. Provides ... to appropriate resources for additional support. + Implement care management review processes that are consistent with established industry, corporate, state, and… more
- Geisinger (Lewistown, PA)
- …occasionally cover weekends and call as part of a shared rotation. Don't worry, we'll review this in your interview. At least two (2) years of prior RN experience is ... services with the goal of optimizing the patient or member's health status. Manages utilization and practice metrics to further refine the delivery of care model to… more
- Highmark Health (Harrisburg, PA)
- …of the claim rejection and the proper action to complete the retrospective claim review with the goal of proper and timely payment to provider and member ... Payment Integrity strategies on a pre-payment and retrospective claims review basis. Review process includes a ...data to assure appropriate level of payment and resource utilization . It is also used to identify issues which… more
- Commonwealth of Pennsylvania (PA)
- …family-centered services. Your role will involve scheduling and facilitating case review meetings, coordinating specialized teams to meet specific needs of children ... and objectives by reviewing documentation such as strategic plans, service utilization and development reports, and financial reports; compiling findings to assess… more
- Penn Medicine (West Chester, PA)
- …and consultation. It also oversees service line VACs, supporting standardization, utilization , and new product assessments, while coordinating closely with supply ... + Meets regularly with hospital leadership and management to review product/equipment/supply issues and provide updates on resolution to known… more
- Humana (Harrisburg, PA)
- …health insurance, other healthcare providers, clinical group practice management. + Utilization management experience in a medical management review ... 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
- Humana (Harrisburg, PA)
- …Delivery Systems, health insurance, or clinical group practice management + Utilization management experience in a medical management review organization ... us put health first** The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical director work assignments… more