- CenterWell (Raleigh, NC)
- …Clinical Pharmacist develops, maintains, and/or operationalizes strategies related to utilization management edits and/or clinical coverage policies for pharmacy and ... clinical reviews, policy development and recommend drug coverage and potential drug utilization tools to mitigate Humana's cost and trend while improving our… more
- Evolent (Raleigh, NC)
- … utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality ... Rehab you will be a key member of the utilization management team. We can offer you a meaningful...rationale for standard and expedited appeals. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the… more
- Evolent (Raleigh, NC)
- … utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality ... Oncology, you will be a key member of the utilization management team. We can offer you a meaningful...rationale for standard and expedited appeals. . Utilizes medical/clinical review guidelines and parameters to assure consistency in the… more
- CenterWell (Raleigh, NC)
- …consistent and standardized program workflows, dyad communication/partnership, and quarterly business review of acute care and post-acute care utilization . + ... and coordinating care to reduce acute and post-acute care utilization . The Divisional Director role is a hybrid with...senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager,… more
- Evolent (Raleigh, NC)
- …adjudication of processed appeals. **What You Bring:** + 1-3 years' experience in clinical Appeals Review or Utilization Management Review as an LPN or LVN ... appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and client policies...set up the appeal, physicians and other clinicians who review the appeal, the claims department to review… more
- Evolent (Raleigh, NC)
- …Job Description As a Clinical Reviewer, Nurse, you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in ... You Will Be Doing:** + Functions in a clinical review capacity to evaluate all cases, which do not...are supported by Field Medical Directors (MDs) in the utilization management determination process. + Reviews charts and analyzes… more
- Evolent (Raleigh, NC)
- …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
- UNC Health Care (Hendersonville, NC)
- …care and cost effectiveness through the integrating and functions of care management, utilization review and discharge planning. The Care Manager must be highly ... based on approved criteria and standards per the Hospital Utilization Review Plan. Directs delivery of notifications...years of recent clinical experience in an acute care setting/ home health/or long-term care. + Basic Life Support (BLS)… more
- Humana (Raleigh, NC)
- …with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health ... health insurance, other healthcare providers, clinical group practice management. + Utilization management experience in a medical management review … more
- Humana (Raleigh, NC)
- …with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health ... health insurance, other healthcare providers, clinical group practice management. + Utilization management experience in a medical management review … more