- MTC (Bryan, TX)
- …disorders. 2. Performs complex technical assistance work; implements quality assurance utilization review procedures; and responds to inquiries regarding ... technical program and administrative rules, regulations, policies, and procedures. 3. Assists in monitoring, reviewing, interpreting, and evaluating quality of services; assists in compiling and analyzing data and preparing reports; and makes recommendations… more
- Baylor Scott & White Health (Rockwall, TX)
- …+ Calculates accurate patient financial responsibility. + Communicates promptly with Utilization Review . Collaborates effectively with the physician and facility ... staff. Ensures financial clearance of the patient's account before any service during the hospital stay. + Interprets complex payer coverage information, including network participation status, limited plan coverage, and inactive benefits. + Documents systems… more
- CVS Health (Austin, TX)
- …consistent responses to members and providers. Leads all aspects of utilization review /quality assurance, directing case management Provides clinical expertise ... and business direction in support of medical management programs through participation in clinical team activities. Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs… more
- Catholic Health Initiatives (Houston, TX)
- …when required, obtaining pre‐certification reference number, approved length of stay, and utilization review company contact person and telephone number. 13. ... Notify hospital Case Managers on all in‐house patients regarding insurance plan changes/COB order, out of network plans, and Medicare supplemental plans that require pre‐certification. 14. Contact physician's on scheduled patients, to notify them of… more
- Cognizant (Austin, TX)
- …guidelines and regulations. * Experience in the analysis and processing of claims, utilization review /quality assurance procedures. * Must be able to work with ... minimal supervision. * Creative thinker with good skills a problem resolution specifically related to healthcare claim adjudication. * Possess ability to work at a computer for extended periods. * Can work closely with other departments **Required Education… more
- HCA Healthcare (Dallas, TX)
- …and other parties as appropriate regarding behavioral services** + **Performs utilization review as assigned** + **Participates in developing department ... goals/objectives and clinical programming** + **Reviews, coaches and assists with training of new staff/interns as assigned within approved practice and program guidelines.** + **Demonstrates knowledge and role in hospital codes** + **Follows all hospital and… more
- Sedgwick (Irving, TX)
- …physician filings and decisions on appropriate treatments recommended by utilization review .** Maintains professional client relationships** **ADDITIONAL ... FUNCTIONS and RESPONSIBILITIES** **Performs other duties as assigned.** **Supports the organization's quality program(s).** **Travels as required.** **QUALIFICATION** **Education & Licensing** **Bachelor's degree from an accredited college or university… more
- Erickson Living (Dallas, TX)
- …of MDS processes, including but not limited to MDS, RAPs, Care Planning, and Utilization Review . + Experience documenting in an Electronic Medical Record (EMR) ... preferred. + Successful completion of AANAC MDS Coordinator Certification. Please note that specific state regulations and requirements may be applicable. These regulations take precedence over the requirements outlined in the job description. Highland Springs… more
- CVS Health (Fort Worth, TX)
- …stability, and administration. + Audits appropriateness of therapy through prospective drug utilization review . + Checks the completion and accuracy of all ... new and refill labels and orders. + Guides pharmacy compliance with all applicable government regulations. + Advises senior management of ongoing issues and drives the development of action plans for issue resolution. + Guides junior colleagues through… more
- CVS Health (Austin, TX)
- …and providers. As a Medical Director you will focus primarily on overseeing utilization review / quality assurance and be responsible for predetermination ... reviews and reviews of claim determinations. This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed. The Medical Director will provide… more