- Houston Methodist (Houston, TX)
- …Sr Utilization Review Specialist Nurse (URSN) position is a licensed registered nurse ( RN ) responsible for promoting the achievement of optimal ... Functions as a resource to department staff in communicating medical information required by external review entities,...in case management **LICENSES AND CERTIFICATIONS - REQUIRED** + RN - Registered Nurse -… more
- AdventHealth (Altamonte Springs, FL)
- …: Remote **The role you will contribute:** The role of the Utilization Management (UM) Registered Nurse ( RN ) is to use clinical expertise by analyzing ... resolutions of conflicts between status and authorization. Evaluates clinical review (s) and physician documentation for at-risk claims ;...carrier. **The expertise and experiences you'll need to succeed:** RN - Registered Nurse -… more
- Carnival Cruise Line (Miami, FL)
- …health team to assess fitness for duty per International Maritime Health guidelines. + **Crew Medical Claims Management** + Review crew cases of high risk ... return-to-work planning in compliance with regulations and employment obligations. + Support disability claims and benefits review for crew unable to return to… more
- DOCTORS HEALTHCARE PLANS, INC. (Coral Gables, FL)
- …improve clinical outcomes. + Collaborate with internal stakeholders including the Chief Medical Officer, Provider Relations, Claims , and IT to ensure seamless ... Coordinator RNs, Medical Management Coordinators. + Manages the daily concurrent review process through department staff, including review of daily hospital… more
- Commonwealth Care Alliance (Boston, MA)
- …Summary:** Working under the direction of the Sr. Director, TPA Management and Claims Compliance, Healthcare Medical Claims Coding Sr. Analyst will ... Medicare and Medicaid + 7+ years progressive experience in medical claims adjudication, clinical coding reviews for...adjudication, clinical coding reviews for claims , settlement, claims auditing and/or utilization review required +… more
- Trinity Health (Maywood, IL)
- …organizational, time management, typing and communication skills are necessary. + Current Registered Nurse License State of Illinois + Specialty certification in ... **Employment Type:** Full time **Shift:** Day Shift **Description:** Utilization Review - RN Reviewer- Regional Coverage for Loyola, Gottlieb and MacNeal… more
- Elevance Health (Mason, OH)
- …Capabilities and Experiences:** + **Operating room and/or auditing experience highly preferred.** + ** Medical claims review with prior health care fraud ... you will make an impact:** + Investigates potential fraud and over-utilization by performing medical reviews via prepayment claims review and post payment… more
- Centene Corporation (New York, NY)
- …license; and a NYS Driver's License or Identification card.** **Position Purpose:** The Utilization Review Nurse I provides first level clinical review for ... beneficiary and the Network Provider. + Provides first level RN review for all outpatient and ancillary...necessity using appropriate criteria, referring those requests that fail review to the medical director for second… more
- Centene Corporation (Jefferson City, MO)
- …Responsible for leading clinical coding compliance nurses and non-clinical team members through medical claim review . Ensure compliance with coding practices ... through a comprehensive review and analysis of medical claims...software systems in a managed care organization preferred. **Certifications:** RN - Registered Nurse or… more
- Texas Health Resources (Fort Worth, TX)
- …patient safety/risk exposures affecting the quality of care and outcomes. * Makes medical staff quality review referrals as appropriate. * Utilizes statistical ... Risk Manager RN - Quality Department _Bring your passion to...Actively engages in the Patient Safety Program developing effective medical error reduction strategies and tools. * Works in… more