- ChenMed (Philadelphia, PA)
- …assess and record patients' progress and adjust and plan accordingly + Understanding utilization review and how to leverage with inpatient staff for possible ... through external providers and healthcare systems. The Acute Care Nurse is an important member of the Complex Care...required + A minimum of one (1) year of utilization review and/or case management, home health,… more
- Guthrie (Sayre, PA)
- …years of experience in an acute care setting with strong care management, utilization review , and payer knowledge. A Case Management certification or obtaining ... levels of care. The Acute Case Manager also performs Utilization Management throughout the continuum of care in collaboration...in addition to a degree in Nursing. A registered nurse with five (5) years relevant experience willing to… more
- CenterWell (Lancaster, PA)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and ... requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking...of Nursing. + Current state license as a Registered Nurse . + Proof of current CPR. + Valid driver's… more
- UPMC (Pittsburgh, PA)
- …prescribing and utilization to identify potential clinical care issues; prepayment review of claims, and prepayment review of unlisted codes. Claims analysis ... services related to clinical guidelines, coding requirements, regulatory requirements, and resource utilization . This role also acts as a SME for the department in… more
- Highmark Health (Monroeville, PA)
- …Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory ... the organization in a community setting. **GENERAL OVERVIEW:** Registered nurse who is proficient in the coordination of care...as an educational resource to all AHN staff regarding utilization review practice and governmental commercial payer… more
- Highmark Health (Jefferson Hills, PA)
- …including but not limited to: appropriateness of care, documentation requirements, utilization review principles and criteria, insurance benefits and ... outcomes, engages patients/caregivers in their healthcare, and supports effective resource utilization . Serves as key team members in the management of readmissions,… more
- UPMC (Pittsburgh, PA)
- Are you an experienced nurse with NICU experience? Do you want to make a difference in the lives of families in the community? UPMC Health Plan is looking for you! ... promotes healthy lifestyles, closes gaps in care, and reduces unnecessary ER utilization and hospital readmissions. Coordinate and modify the care plan with member,… more
- YesCare Corp (Philadelphia, PA)
- …Engage in all quality improvement initiatives, including sentinel event reviews. + ** Utilization Review :** Participate actively in utilization review ... justifications for non-formulary medication requests when necessary. + **Resource Utilization :** Resolve patient care issues using in-house resources before… more
- UPMC (Harrisburg, PA)
- **UPMC Harrisburg is hiring a Full-Time Physician Assistant or Certified Registered Nurse Practitioner (ACNP) to help support the Cardiac Surgery dept. The ideal ... on inpatient care and critical interventions * Procedural Skill Utilization : Central and arterial line cannulation, ventilator management, airway management,… 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