- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …appropriate. At the request of the Senior Medical Director of the Physician Review Unit (PRU), the reviewer also provides clinical leadership in other areas ... your true colors to blue. The Role The Physician Reviewer is responsible for evaluating pre & post-service clinical...as determined by plan benefit design, plan riders, and medical necessity criteria. In making coverage decisions regarding level… more
- Healthfirst (NY)
- **Duties/Responsibilities:** + The Medical Peer Reviewer will assess/ review requests for authorization, and claims payment, based on medical records and ... adjusted based on changing needs of the organization. **Weekday Requirements:** + The Medical reviewer requires 25 hours a week of coverage/5 days per week. +… more
- LA Care Health Plan (Los Angeles, CA)
- Physical Accessibility Review Survey Reviewer II Job Category: Clinical Department: Facility Site Review Location: Los Angeles, CA, US, 90017 Position Type: ... to achieve that purpose. Job Summary The Physical Accessibility Review Survey (PARS) Reviewer II is responsible...PARS assessments, FSR Survey up to 150 points, and Medical Record Review up to 30 charts.… more
- Blue Cross Blue Shield of Massachusetts (Boston, MA)
- …At the request of the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer also provides clinical leadership in other areas of ... your true colors to blue. The Role The Physician Reviewer is responsible for evaluating clinical service requests made...+ Perform additional tasks as assigned by the Associate Medical Director of the Physician Psychologist Review … more
- AmeriHealth Caritas (Washington, DC)
- …When necessary, cases are escalated to the Medical Director for further review . The reviewer independently applies medical and behavioral health ... document and assess patient cases + Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and… more
- Commonwealth of Pennsylvania (PA)
- Clinical Care Reviewer (County Care Management Manager) Fayette County MD/ID Print (https://www.governmentjobs.com/careers/pabureau/jobs/newprint/5168241) Apply ... Clinical Care Reviewer (County Care Management Manager) Fayette County MD/ID Salary...automated system and client records; reviewing and evaluating the medical appropriateness of psychiatric/behavioral health and substance abuse cases… more
- CVS Health (IL)
- …each and every day. Job Profile Summary The Utilization Management Physician Reviewer ensures timely and clinically sound coverage determinations for inpatient and ... are essential for success. Role Description: The Utilization Management Physician Reviewer -FT role is responsible for provisioning accurate and timely coverage… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …conduct billing compliance investigations as required, which may include audits designed to review the adequacy of medical record documentation to support claims ... Reporting to the Director of Billing Compliance, the Senior Billing Compliance Reviewer will be responsible for the identification and performance of Billing… more
- Zelis (St. Petersburg, FL)
- …maintain claim review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies and Dispute Rationales + Perform regulatory ... are. Position Overview At Zelis, the DRG Clinical Dispute Reviewer role is responsible for the resolution of facility...provider disputes. + Utilize the most up-to-date approved Zelis medical coding sources for claim review maintenance.… more
- State of Colorado (Denver, CO)
- Foster Home Certification Reviewer Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5195453) Apply Foster Home Certification Reviewer ... IHA-04842 01.12.2026 Department Colorado Department of Human Services Division Administrative Review Division Opening Date 01/14/2026 Closing Date 1/28/2026 11:59 PM… more