- US Tech Solutions (May, OK)
- …clinical policy, regulatory and accreditation guidelines. . Responsible for the review and evaluation of clinical information and documentation. . Reviews ... . 1+ years of inpatient hospital experience . Registered Nurse in state of residence . Must have prior...knowledge. . MUST HAVE UM experience, inpatient utilization management review . . MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT… 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, ... responsible for review of documentation to ensure medical necessity and appropriate...quality of care issues. + Assists with Complex Claim review including DRG Validation, Itemized Bill Review ,… more
- UCLA Health (Los Angeles, CA)
- Description The Quality Management Nurse is responsible for conducting comprehensive facility site reviews (FSRs) to ensure compliance with healthcare standards and ... inspections of clinical areas, patient care practices, and administrative processes + Review medical records of services in preparation for health plan and/or… more
- Sanford Health (Rapid City, SD)
- …Functions within the scope and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules in state of practice and licensure. The ... of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Incumbent must obtain and subsequently maintain required… more
- Beth Israel Lahey Health (Burlington, MA)
- …necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue integrity, these specialized case managers ... necessity of the hospital care. Using the concepts of utilization review , clinical documentation improvement and revenue integrity, these specialized case managers… more
- New York State Civil Service (Syracuse, NY)
- NY HELP No Agency Attorney General, Office of the Title Legal Nurse : Investigate Medicaid Fraud/Patient Abuse (6401) Occupational Category Legal Salary Grade NS ... Fraud Control Unit (MFCU) is seeking an experienced Registered Nurse to serve as a Medical Analyst in its...needed, please include a cover page to provide the reviewer with any relevant context or background information.* Reference… more
- New York State Civil Service (Albany, NY)
- NY HELP No Agency Attorney General, Office of the Title Legal Nurse : Investigate Medicaid Fraud/Patient Abuse (6399) Occupational Category Legal Salary Grade NS ... Fraud Control Unit (MFCU) is seeking an experienced Registered Nurse to serve as a Medical Analyst in its...needed, please include a cover page to provide the reviewer with any relevant context or background information.* Reference… more
- Centene Corporation (Jefferson City, MO)
- …discuss member care being delivered + Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in ... determinations or provide recommendations based on requested services and concurrent review findings + Assists with providing education to providers on utilization… more
- Albany Medical Center (Albany, NY)
- …documents findings based on Departmental standards.* While performing utilization review identifies areas for clinical documentation improvement and contacts ... Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies.* Facilitates removal of delays and documents… more
- Beth Israel Lahey Health (Plymouth, MA)
- …using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal clinical denials related to the care provided to ... the hospitalized patient. + Conducts concurrent reviews to determine the continued need for acute care setting, appropriateness and timeliness of treatments/procedures and to optimize the potential for reimbursement. + Collaborates with the multidisciplinary… more