- Fallon Health (Worcester, MA)
- …including state/federal regulatory agency and three to five years clinical experience in utilization review , appeals, or case management within a healthcare ... appeal to the Plan Medical Director, Center for Medicare/Medicaid Services, contracted reviewer , and the Plan contracted external review agency in accordance… more
- Molina Healthcare (Warren, MI)
- …of payment decisions. + Serves as a clinical resource for Utilization Management , Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals. ... SKILLS & ABILITIES:** + Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years… more
- Veterans Affairs, Veterans Health Administration (Biloxi, MS)
- …not limited to): Supervises QM Programs for the following - Accreditation, Utilization Management , Flow Control Center, Infection Control, Risk Management ... Summary The Registered Nurse - Assistant Chief of Quality Management...Review , VA Surgical Quality Improvement Program (VASQIP), Quality Management Specialists, & controlled Substance Inspections. Oversees Quality Council… more
- Alameda Health System (San Leandro, CA)
- Nurse , Care Management + San Leandro, CA + San...in Case Management in an acute setting or utilization review at a medical group or health plan. ... Management provides Care Coordination, Compliance, Transition Coordination, and Utilization Management . **DUTIES & ESSENTIAL JOB FUNCTIONS** NOTE:The… more
- Emory Healthcare/Emory University (Duluth, GA)
- … of medical necessity for all inpatients, concurrent stay documentation per utilization management plan, verification and correction of patient status, ... Monitoring of observation patients per hospital policy; + Maintains documentation of utilization review function per hospital policy and federal and state… more
- McLaren Health Care (Grand Blanc, MI)
- …Three years of recent case management , clinical documentation, or utilization review experience + Five years of clinical nurse experience in an acute ... insurance. 8. Educates health team colleagues about complex clinical appeals, utilization review , including role, responsibilities tools, and methodologies. 9.… more
- Elevance Health (Houston, TX)
- …members in different states; therefore, Multi-State Licensure will be required.** The **Medical Management Nurse ** is responsible for review of the most ... **Medical Management Nurse ** **Location: Virtual: This role...+ Medical Management experience is preferred, + Utilization Review experience is preferred. + Knowledge… more
- Elevance Health (Latham, NY)
- …members in different states; therefore, Multi-State Licensure will be required.** The **Medical Management Nurse ** is responsible for review of the most ... **Medical Management Nurse ** **Location: Virtual: This role...+ Medical Management experience is preferred, + Utilization Review experience is preferred. + Knowledge… more
- Northern Light Health (Bangor, ME)
- …health care delivery to achieve optimal quality and financial outcomes. * Provides ongoing utilization review of primary care patients. Review for over ... Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with the basic...responsible way. * Works to promote cost containment through utilization management * Collaborate effectively with physicians… more
- Ventura County (Ventura, CA)
- …candidate is an experienced Mental Health Nurse with a background in utilization review and discharge planning. They also have extensive years of experience ... evaluation, and review ; + Performs daily clinical reviews to support utilization and quality management , ensuring compliance with guidelines and standards… more