• Medical Director, Commercial Line of Business

    Excellus BlueCross BlueShield (Rochester, NY)
    …recommendations and/or decisions on Utilization or Case Management activities. Utilization review activities include: reviews of requests for broad range of medical ... clinical reviews with attending physicians or other providers to discuss review determinations with providers and external physicians. + Conduct clinical appeal… more
    Excellus BlueCross BlueShield (07/01/25)
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  • Healthcare Quality Management Analyst - Remote

    NTT DATA North America (Woonsocket, RI)
    …meet regulatory compliance requirements with a key focus on Utilization Review (UR) /Utilization Management (UM). Data gathering requires navigation through multiple ... regulatory compliance requirements with a key focus on Utilization Review (UR) /Utilization Management (UM). . Data gathering requires...as required **Minimum Job Qualifications:** . 1 year of HEDIS or UM related experience. . 1 year of… more
    NTT DATA North America (07/30/25)
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  • Practical Nurse

    Defense Health Agency (Fort Irwin, CA)
    …( HEDIS ) metrics, procedure preparation, wellness screening paperwork, etc. Review patient appointments, 24-78 hours prior to scheduled appointment and identifies ... record. Prepares assigned rooms for clinic schedule. Attends clinic huddle to review scheduled patients with Primary Care Manager to coordinate delivery of care.… more
    Defense Health Agency (07/10/25)
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  • Nurse Practitioner / Physician Assistant

    CenterWell (Las Vegas, NV)
    …with administrative coverage including but not limited to prescription refills, document review , and review of imaging and laboratory results. + Follows ... by Clinical Leadership. + Meets regularly with Associate Medical Director to review job performance. + Participates in potential growth opportunities for new or… more
    CenterWell (08/02/25)
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  • Care Management Supervisor (Hybrid)

    CareFirst (Baltimore, MD)
    …Utilizes MCG to act as a resource for the nurses to conduct concurrent review for medical necessity and appropriate level of care for Commercial and Government lines ... + Oversees associates conducting care coordination activities including concurrent review utilizing MCG. Collaborates with CareFirst medical directors and… more
    CareFirst (07/09/25)
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  • Clinical Pharmacist - Primary Care

    Matrix Providers (Kittery, ME)
    …the Home Port Team to monitor Healthcare Effectiveness Data and Information Set ( HEDIS ) measures and intervene in patients with chronic disease states with scheduled ... Hypertension, Lipid, and Pain management. Emergent/Urgent Care and Admission Consults: + Review any Emergent/Urgent care and admission consults to monitor trends, … more
    Matrix Providers (07/02/25)
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  • Senior Client Coding Project Manager

    Datavant (Providence, RI)
    …+ Previous Medicare Advantage Risk Adjustment, CDI, Medicaid, Commercial RA, and HEDIS experience. + Familiarity with HIPAA patient privacy requirements. + Excellent ... protected status. To learn more about our commitment, please review our EEO Commitment Statement here (https://www.datavant.com/eeo-commitment-statement) . Know Your… more
    Datavant (06/28/25)
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  • Epic Sr. Analyst - Quality and Population Health

    University of Miami (Miami, FL)
    …staff position using the Career worklet, please review this tip sheet (https://my.it.miami.edu/wda/erpsec/tipsheets/ER\_eRecruiting\_ApplyforaJob.pdf) . The ... members, including participating in weekly project team meetings. + Review the status of projects and issues on an...you will: + Build and maintain Clinician's workflow and HEDIS quality measure for Medicare Advantage programs + Build… more
    University of Miami (05/31/25)
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  • PRN - Virtual Physician Collaborator (Remote)

    CenterWell (Bismarck, ND)
    …physician for nurse practitioners or physician assistants, including completing regular chart review and coordinating monthly meetings. . Be available to act as a ... . Meet with clinic leaders about quality of care, review of outcome data, policy, procedure, and records issues....Knowledge of Medicare guidelines and coverage . Knowledge of HEDIS quality indicators . Experience working in value-based care… more
    CenterWell (08/02/25)
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  • Revenue Cycle Manager

    Robert Half Finance & Accounting (Shrewsbury, MA)
    …and enforce performance standards, KPIs, and SLAs related to vendor performance. * Review and escalate vendor issues that impact cash flow or compliance. * Ongoing ... * Analyze claims data and suggest/implement procedures to maximize UDS/ HEDIS and incentive revenue collections (ie, ICD-10 and CPT...and grant reporting projects as needed. * Perform the review of contracted rates vs. reimbursements. * Creates and… more
    Robert Half Finance & Accounting (07/30/25)
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