- Highmark Health (Austin, TX)
- …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
- Oracle (Austin, TX)
- …stays. + Knowledge of third-party payor rules and regulations. + 2-3 years of Utilization Review experience in a healthcare setting preferred; 1-2 years of ... college and AHIMA Certified RHIT credentials preferred + Certification in Utilization Review , case management, and healthcare quality preferred… more
- Highmark Health (Austin, TX)
- …NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review , the incumbent participates as the physician member of the ... **JOB SUMMARY** This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most… more
- HCA Healthcare (El Paso, TX)
- …and retrospective review of patient medical records for purposes of utilization review , compliance with requirements of external review agencies ... Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review /quality assurance, use of InterQual(R) or other… more
- CenterWell (Austin, TX)
- …Director of Physician Strategy at Utilization Management. The Medical Director conducts Utilization review of the care received by members in an assigned ... this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all… more
- Elevance Health (Houston, TX)
- …or case management experience and requires a minimum of 2 years clinical, utilization review , or managed care experience; or any combination of education ... experience is preferred. + Medical Management experience is preferred, + Utilization Review experience is preferred. + Knowledge of the medical management… more
- Humana (Austin, TX)
- …health insurance, other healthcare providers, clinical group practice management. + Utilization management experience in a medical management review ... this knowledge in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex clinical scenarios, review of all… more
- Insight Global (Amarillo, TX)
- …accordance with member benefits and coverage criteria within defined turn-around times. Review of prior authorization requests in accordance with member benefits and ... coverage criteria within defined turn-around times. Review prior authorizations and determine opportunities for interventions. Coordinate appeals. Provide clinical… more
- Humana (Austin, TX)
- …Delivery Systems, health insurance, or clinical group practice management + Utilization management experience in a medical management review organization ... us put health first** The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical director work assignments… more
- Oracle (Austin, TX)
- …are achieved, maintenances are performed with minimal risk, manage capacity utilization , address local maintenance requirements, and support technical projects. The ... responsibilities include change management, incident & event support, space utilization , efficiency upgrades, and general engineering support. Directors are expected… more