- Molina Healthcare (Madison, WI)
- …the chief medical officer. * Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review and manages the ... and recommends corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * Attends… more
- McLaren Health Care (Port Huron, MI)
- …peer to peer reviews with payer/providers. 7. Actively participates in clinical case review /rounds with the interdisciplinary team regarding continued ... **Department:** Utilization Review **Daily Work Times:** 8:00am-4:30pm **Hours Per Pay...vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement… more
- Sanford Health (Rapid City, SD)
- …One year of leadership/management experience preferred. Experience in medical necessity review preferred. Currently holds an unencumbered registered nurse (RN) ... **Weekly Hours:** 40.00 **Department Details** Join our team as a Utilization Review and Case Management Manager and lead a high-impact, data-driven program that… more
- International Medical Group (Indianapolis, IN)
- …of the use of health care services, procedures, and facilities for utilization review and /or /evacuation/repatriation. Work as a liaison between the Insured, the ... outpatient management of assistance cases. + Knowledge of the Non-certification process and Appeals process including logs and time frames. + Participate in the on… more
- Catholic Health (Buffalo, NY)
- …and mentoring Utilization Review , Clinical Documentation Integrity and Clinical Denials and Appeals teams. They ensure the teams receive comprehensive ... care team and works in conjunction with the Utilization Review Manager and Manager Clinical Documentation Integrity....+ Bachelor of Science Nursing (BSN) degree + Registered Nurse with a current New York State license CERTIFICATION… more
- Crouse Hospital (Syracuse, NY)
- …department, including Utilization Management, Discharge Planning and Denials and Appeals functions. + Assessing workflow related to readmission prevention, length ... of stay and daily review of observation admissions. + Works with Business Office...Care Coordination Manager Requirements: + Licensed as a Registered Nurse in New York State + Bachelor's degree +… more
- Nuvance Health (Danbury, CT)
- …oversight for a team of utilization review staff, denials and appeals specialists, non- clinical support staff while partnering with local case management ... will be responsible for leading a team encompassing utilization review and denials/ appeals specialists and will need...nurse (RN) * Minimum of 5 years of clinical experience in an acute care setting * Minimum… more
- Omaha Children's Hospital (Omaha, NE)
- …opportunities for improvement. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians ... and obtains appropriate physician documentation while patients are in-house for clinical conditions and procedures to support the appropriate severity of illness,… more
- CaroMont Health (Gastonia, NC)
- …for promoting and monitoring safe, high-quality, cost-effective healthcare with the best clinical outcomes possible. Provide physician and nurse education to ... staff departments and committees. Assist with retrospective reviews and preparation of appeals as indicated. Facilitate peer review activities and integrate … more
- Hartford HealthCare (Farmington, CT)
- …Responsibilities:_** **Key Areas of Responsibility** *Denial Resolution* . Conduct a thorough review of medical records, coding and clinical documentation to ... . Prepare, document and submit appeals for DRG denials, ensuring appeals are well-supported with clinical evidence, coding guidelines, and regulatory… more