• Behavioral Health Physician Advisor…

    Carle Health (Champaign, IL)
    …Advisor is responsible for conducting clinical case reviews referred by the Utilization Management Team, the Case Management Team, the Clinical Denial Management ... participate in discussions with payer physicians to ensure efficient and appropriate utilization of hospital services for their assigned patient population. + The… more
    Carle Health (12/20/25)
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  • Field Medical Director, Interventional Cardiology…

    Evolent (Phoenix, AZ)
    utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality ... for the culture. **What You'll Be Doing:** Job Description **Cardiovascular Utilization Management Reviewer (Interventional Cardiologist)** Are you ready to make a… more
    Evolent (12/18/25)
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  • Oncology Prior Authorization Case Manager, Non-RN…

    University of Miami (Miami, FL)
    …SCCC Business Operations has an exciting opportunity for a full time Utilization Review Case Manager to work to work remote . The incumbent conducts initial, ... concurrent and retrospective chart reviews for clinical utilization and authorization. The Utilization Review Case Manager coordinates with the healthcare… more
    University of Miami (12/20/25)
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  • RN Clinical Appeals Nurse Remote

    Molina Healthcare (Kearney, NE)
    …candidate with a RN licensure, Diagnosis-Related Group (DRG) experience, 2 years of Utilization Review and/or Medical Claims Review experience. Knowledge in ... a plus. Work hours: Monday - Friday 8:00am- 5:00pm Remote position **Essential Job Duties** * Performs clinical/medical reviews...the specific programs supported by the plan such as utilization review , medical claims review ,… more
    Molina Healthcare (01/02/26)
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  • Temporary to Hire Prior Authorization RN - Hybrid…

    Fallon Health (Worcester, MA)
    …of purpose:** The PA Nurse uses a multidisciplinary approach to review service requests (prior-authorizations), focusing on selected complex medical and psychosocial ... functional, and psychosocial information from the medical records on site, through remote electronic access, telephonically or by fax in a collaborative effort with… more
    Fallon Health (12/14/25)
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  • Medical Director - Medicaid ( remote )

    Humana (Washington, DC)
    …health insurance, other healthcare providers, clinical group practice management. + Utilization management experience in a medical management review ... this knowledge in their daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, review of all… more
    Humana (01/01/26)
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  • Regulatory Compliance Administrator Hybrid/…

    University of Utah (Salt Lake City, UT)
    …( CPC , ACS , CCS -P/H, RHIA , or RHIT ). Preferences Knowledge of utilization review and quality assurance procedures as well as experience with InterQual or ... or religious beliefs that object to vaccinations. **Preferences** 1. Knowledge of utilization review and quality assurance procedures, as well as experience… more
    University of Utah (12/23/25)
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  • Licensed Physician Reviewer - Ortho…

    ChenMed (Miami, FL)
    …experience in Hospital medicine preferred + At least one (1) year of utilization review experience preferred **PAY RANGE:** $198,797 - $283,995 Salary **EMPLOYEE ... our team. The Physician Reviewer is the primary physician reviewer for Utilization Management/Clinical Appropriateness review cases in our organization. Other… more
    ChenMed (10/16/25)
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  • Underwriting & Financial Analyst, Employee…

    World Insurance Associates, LLC. (Miami, FL)
    review analysis + Renewal rate and funding initial projections/modeling + Claims utilization review + Rate and contribution modeling + Benchmarking studies + ... self-funded arrangements. You'll prepare financial deliverables, model renewals, evaluate utilization trends, and support client decision-making with data-driven insights.… more
    World Insurance Associates, LLC. (12/07/25)
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  • Regulatory Compliance Manager - Hybrid/…

    University of Utah (Salt Lake City, UT)
    …demonstrated human relations and effective communication skills also required. Knowledge of utilization review and quality assurance procedures is preferred. An ... demonstrated human relations and effective communication skills also required. Knowledge of utilization review and quality assurance procedures is preferred. An… more
    University of Utah (11/15/25)
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