- Northwell Health (Melville, NY)
- …plus specialized certifications as needed. Preferred Skills 3-5 years experience in Utilization Review , Case Management, and Clinical Appeals . 3-5 years of ... stay. Ensures compliance with current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately… more
- Fallon Health (Worcester, MA)
- …related work experience including state/federal regulatory agency and three to five years clinical experience in utilization review , appeals , or case ... of clinical criteria and medical necessity determinations. The Appeal Nurse is responsible for ensuring compliance with all applicable state and federal… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …Appeals regulatory guidelines including URAC, NCQA, and ERISA + Proficiency in Clinical Appeals , Utilization Review , and Grievance processes including ... to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible...throughout employment + Minimum of 5 years' experience in Clinical Appeals and Grievances within a managed… more
- Minnesota Visiting Nurse Agency (Minneapolis, MN)
- …may require up to*Every Other Weekend*coverage/. *_SPECIFIC RESPONSIBILITIES:_* The Utilization Review (UR) Registered Nurse is responsible for evaluating the ... Minnesota. Some positions may require specialized certifications(s). **Title:** *Staff Nurse - Utilization Review (Float)* **Location:** *MN-Minneapolis-Downtown… more
- Molina Healthcare (Warren, MI)
- …set schedule) Looking for a RN with experience with appeals , claims review , and medical coding. **Job Summary** Utilizing clinical knowledge and experience, ... identified by the Payment Integrity analytical team; requires decision making pertinent to clinical experience + Documents clinical review summaries, bill… more
- University of Utah Health (Salt Lake City, UT)
- …stay review . + Communication to third-party payers for initial and concurrent clinical review . + Reviews patient chart to ensure patient continues to meet ... expected LOS, expected cost, or over/under-utilization of resources. + Performs verbal/fax clinical review with payer as determined by nursing judgment and/or… more
- Beth Israel Lahey Health (Boston, MA)
- …a Registered Nurse (RN), Massachusetts + Three years of recent clinical or utilization management experience _Preferred:_ + Bachelor's degree in nursing or ... Position Summary: In conjunction with the admitting/attending physician, the Utilization Review RN assists in determining the appropriate admission status based on… more
- Stanford Health Care (Palo Alto, CA)
- …role in the Revenue Cycle Denials Management Department by managing and resolving clinical appeals related to government audits and denials. This position ... likelihood of a successful appeal. + Proofreading and Editing: Review and edit appeals for clarity and...regulations, payor policies, and industry best practices related to clinical appeals and denials management. Evaluate internal… more
- BlueCross BlueShield of Tennessee (Chattanooga, TN)
- …review , special review requests, and UM pre\-certifications and appeals , utilizing medical appropriateness criteria, clinical judgement, and contractual ... **Join our team as a Clinical Review Manager\!** We are seeking...for other internal positions\. **Job Qualifications** _License_ + Registered Nurse \(RN\) with active license in the state of… more
- Beth Israel Lahey Health (Plymouth, MA)
- …data to establish the appropriate level of care using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal ... team to assess and improve the denial management, documentation, and appeals process. + Collaborates with UR Manager and/or physician advisor regarding… more