• Care Review Clinician (RN)

    Molina Healthcare (WI)
    …or emergency room. Preferred Experience Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of ... JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically… more
    Molina Healthcare (12/13/25)
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  • Payment Integrity Clinician

    Highmark Health (Madison, WI)
    …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
    Highmark Health (11/14/25)
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  • Care Review Clinician (RN)

    Molina Healthcare (WI)
    …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
    Molina Healthcare (11/23/25)
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  • Care Review Clinician (RN)…

    Molina Healthcare (Madison, WI)
    …JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically ... with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At least 2… more
    Molina Healthcare (11/14/25)
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  • Plan Performance Medical Director

    Elevance Health (Waukesha, WI)
    …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 ... required by law. The **Plan Performance Medical Director** serves as a lead clinician and oversees the administration of medical services for the individual ACA… more
    Elevance Health (12/31/25)
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  • Georgia Medicaid Clinical Account Manager - Remote

    Prime Therapeutics (Madison, WI)
    …Medicaid Clinical Account Manager - Remote **Job Description** Innovative business clinician accountable for building and maintaining customer relationships as well ... fashion. + Demonstrates the value of pharmacy solutions (unit cost, utilization management & patient care enhancement). + Identifies opportunities for additional… more
    Prime Therapeutics (12/18/25)
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