• Utilization Review Clinician…

    Centene Corporation (Columbus, OH)
    …and substance abuse preferred. Knowledge of mental health and substance abuse utilization review process preferred. Experience working with providers and ... appropriateness in accordance with regulatory guidelines and criteria + Performs concurrent review of behavioral health (BH) inpatient to determine overall… more
    Centene Corporation (11/19/25)
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  • Care Review Clinician , PA (RN)

    Molina Healthcare (Akron, OH)
    …Experience** Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual ... plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS… more
    Molina Healthcare (10/26/25)
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  • Care Review Clinician (RN)

    Molina Healthcare (Akron, OH)
    **JOB DESCRIPTION** Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and ... 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 (10/25/25)
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  • Payment Integrity Clinician

    Highmark Health (Columbus, OH)
    …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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