- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …Working knowledge of NCQA UM accreditation requirements, Massachusetts, and Rhode Island utilization review regulations + Knowledge of compliance and QI ... utilization management regulatory and accreditation standards, such as NCQA, Massachusetts utilization review regulations, Rhode Island utilization … more
- Humana (Sacramento, CA)
- …group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, ... to operationalize this knowledge in their daily work. The Medical Director's work includes computer-based review of...on size of region or line of business. The Medical Director conducts Utilization Management of the… more
- Humana (Harrisburg, PA)
- …group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, ... to operationalize this knowledge in their daily work. The Medical Director's work includes computer-based review of...on size of region or line of business. The Medical Director conducts Utilization Management of the… more
- Humana (Bismarck, ND)
- …group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, ... Medical Director, depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members in an… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …Health and Medical Management clinical staff, including Care Management, Utilization Management, and the Physician Review Unit.The Operational Support ... a variety of different tasks supporting clinical operations including the Physician Review Unit, Case Management and Utilization Management. Some of the… more
- LifePoint Health (Rutherfordton, NC)
- …all staff in UR standards and LOS topics. Insures effective Utilization Review Process.1. Performs admission and concurrent medical record review .2. ... execution, adaptation and outcome of care management as prescribed in the initial Utilization Review Plan with regard to resources, appropriateness of care and… more
- New York State Civil Service (Albany, NY)
- …improvement, focus on prioritization and areas to be addressed through collaborative review and utilization of available data.* Serve as physician advisor ... OPWDD's Medical Director of the Naloxone program.* Conduct ongoing review of OPWDD agency-wide policies and procedures.* Participate on various committees,… more
- Humana (Concord, NH)
- …clinical group practice management + Utilization management experience in a medical management review organization, such as Medicare Advantage and managed ... management, provider relations, quality of care, audit, grievance and appeal and policy review . The Behavioral Health Medical Director will develop and present… more
- Highmark Health (St. Paul, MN)
- …NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review , the incumbent participates as the physician member of the ... and improve the care of our members **ESSENTIAL RESPONSIBILITIES** + Conduct electronic review of escalated cases against medical policy criteria, which may… more
- CVS Health (Tallahassee, FL)
- …care of patients with severe, complex, and/or treatment resistant illnesses through peer review and educational interventions. * Work with medical director teams ... focusing on inpatient care management, clinical coverage review , member appeals clinical review , medical claim review , and provider appeals clinical … more