- CareFirst (Baltimore, MD)
- …strategies to improve individual and team-based performance as needed. **Licenses/Certifications** : + RN - Registered Nurse - State Licensure And/or Compact ... medical facts and issues relating to appeals or claims payment. Acts as a liaison and collaborates with...or similar clinical experience OR 5 years experience in Medical Review , Utilization Management or Case Management… more
- Molina Healthcare (Ann Arbor, MI)
- …Microsoft Excel (edit/save spreadsheets, sort/filter) **Required License, Certification, Association** Licensed registered nurse ( RN ), Licensed practical ... internal policies, and contract requirements. This position completes a medical review to facilitate a referral to...corresponding medical records to determine accuracy of claims payments. + Review of applicable policies,… more
- Sedgwick (Raleigh, NC)
- …providers to support the claim request and documents decision rationale. + Completes medical review of all claims by reviewing medical documentation ... clinical evaluations on claims that require additional review based on medical condition, client requirement,... management of claims including comprehension of medical terminology and substantiating claim decisions. **ADDITIONAL… more
- Actalent (Atlanta, GA)
- …Service, Claims , Contracts and Benefits - Appeals, and Risk Management. Essential Skills + Registered Nurse ( RN ) with a valid license in GA or Compact. + ... Job Title: Utilization Review - FULLY REMOTE Job Description This role...REMOTE Job Description This role involves performing precertification and medical necessity reviews for designated referrals and targeted outpatient… 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
- CommonSpirit Health (Centennial, CO)
- …Education: BSN required Minimum Experience required: 4 years clinical experience as a Registered Nurse . 3 years with progressive experience in utilization ... flourish and leaders who care about your success. The RN Clinical Denials Appeals Specialist functions as a revenue...as indicated through research and coordination of completion of medical records and utilization review processes. Identifies… more
- Hartford HealthCare (Farmington, CT)
- …DRG denial management and appeals preferred. **Licensure, Certification, Registration** * Active Registered Nurse license from the State of Connecticut * ... Responsibilities:_** **Key Areas of Responsibility** *Denial Resolution* . Conduct a thorough review of medical records, coding and clinical documentation to… 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
- HCA Healthcare (Thornton, CO)
- …Position Requirements: + Current licensure in the State of Colorado as a Registered Nurse , or current active multistate Registered Nurse ... join an organization that invests in you as a(an) RN Case Manager? At HCA HealthONE Mountain Ridge, you...colleagues. The available plans and programs include: + Comprehensive medical coverage that covers many common services at no… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …assurance standards and MagnaCare policies and procedures. Essential Qualifications + Currently licensed Registered Nurse in the state of NY, or the ability to ... About The Role Brighton Health Plan Solutions (BHPS) provides Utilization Review / Medical and Case Management services for Workers' Compensation. The Workers'… more