- Guthrie (Binghamton, NY)
- Summary The Registered Nurse ( RN ) Utilization Management (UM) in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices, and ... of patient status. 1. Collaborate and set standards with registered nurse ( RN ) case managers...Health System process improvement. + Denials Adjudication 1. Facilitate review of rejected medical claims … more
- Elevance Health (Chicago, IL)
- …and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to payment. Researches new healthcare-related questions ... **Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon...Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Clinical Fraud Investigator II** is responsible… more
- LA Care Health Plan (Los Angeles, CA)
- …case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, ... requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse ( RN ) - Active, current and unrestricted… more
- McLaren Health Care (Flint, MI)
- We are looking for a Case Manager, RN to join us in leading our organization forward. McLaren Integrated HMO Group (MIG) is a fully owned subsidiary of McLaren ... This includes but is not limited to the following: participates in the medical management of members in assigned product lines, including case specific and disease… more
- CVS Health (Trenton, NJ)
- …applicant's home). Standard working hours Monday - Friday 8-5 pm **ICM Case Manager RN ** **WFH Flexible** **Position Summary:** Help us elevate our patient care to a ... all case management activities with members to evaluate the medical needs of the member to facilitate the member's...member's overall wellness. * Uses clinical tools and information/data review to conduct an evaluation of member's needs and… more
- McLaren Health Care (Indianapolis, IN)
- We are looking for a Case Manager, RN , to join us in leading our organization forward. McLaren Integrated HMO Group (MIG) is a fully owned subsidiary of McLaren ... This includes but is not limited to the following: participates in the medical management of members in assigned product lines, including case specific and disease… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …with Provider Relations, explaining processes for accessing Health Plan to perform medical review , obtains case or disease management support, or otherwise ... regulatory and accreditation entities. Refers appropriate cases to the Medical Director for review . Refer to and...Mandates. + May be responsible for pricing, coding, researching claims to ensure accurate application of contract benefits and… more
- Nuvance Health (Danbury, CT)
- …percentage of charge reimbursement payers. * If concurrent inpatient case does not meet medical necessity review criteria during the first level review , ... REQUIRED* * *Hybrid/Remote* * *Summary:* The purpose of the Denial Prevention Nurse is to ensure that all patient admissions are appropriately status within… more
- AdventHealth (Riverview, FL)
- …business or healthcare related field 3 years clinical experience in healthcare related field Registered Nurse ( RN ) This facility is an equal opportunity ... be caring for:** AdventHealth Riverview AdventHealth is expanding our medical expertise, innovation, and state-of-the-art technology to southern Hillsborough County… more
- Blue KC (Workman, MN)
- …of URAC and NCQA(R) guidelines and state and federal regulations. + Valid and active Registered nurse ( RN ) in Missouri and Kansas. + Case Management ... and post-transplant claims . Sets up transplant pre-pay review for each individual claim . Reviews transplant...management and clinical transplant experience + Valid and active Registered nurse ( RN ) licensure in… more