• Senior Medical Director Appeals, National Physical…

    Centene Corporation (Jefferson City, MO)
    …review Medicare UM and appeals, Clinical review quality oversight and management . + Utilization Management experience and knowledge of quality ... team of medical directors and supervise MD's responsible for utilization management and appeals functions to ensure...with key stakeholders for IRE challenges + Perform medical review activities pertaining to utilization review… more
    Centene Corporation (01/06/26)
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  • Case Manager II - Transition Planning - Sharp…

    Sharp HealthCare (San Diego, CA)
    …nursing experience or case management experience. + 3 Years case management , utilization review , care coordination experience. + California Registered ... position requires the ability to combine clinical/quality considerations with regulatory/financial/ utilization review demands to assure patients are receiving… more
    Sharp HealthCare (12/18/25)
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  • Case Manager, RN - Case Management - Per…

    University of Southern California (Los Angeles, CA)
    …multi-task. Preferred Qualifications: + Pref Bachelor's Degree Nursing + Pref 1 year Case management or utilization review experience within the last three ... populations. The RN case manager role integrates the functions of utilization management , quality management , discharge planning assessment, and coordination… more
    University of Southern California (01/07/26)
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  • Medical Director (CT)

    Molina Healthcare (AZ)
    …learn new programs. Preferred Qualifications * Experience with utilization /quality program management . * Managed care experience. * Peer review experience. * ... of health care services provided to plan members. * Supports plan utilization management program and accompanying action plan(s), which includes strategies… more
    Molina Healthcare (12/24/25)
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  • Remote Behavioral Medical Director

    Centene Corporation (Olympia, WA)
    …+ American Board certified in Child or Addiction Psychiatry, preferred + Utilization Management experience and knowledge of quality accreditation standards. + ... functions for the business unit. + Provides medical leadership of all for utilization management , cost containment, and medical quality improvement activities. +… more
    Centene Corporation (01/07/26)
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  • Medical Director

    Centene Corporation (New York, NY)
    …York + Board certified in Internal Medicine or Family Medicine preferred + Utilization Management experience and knowledge of quality accreditation standards. + ... functions for the business unit. + Provides medical leadership of all for utilization management , cost containment, and medical quality improvement activities. +… more
    Centene Corporation (01/06/26)
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  • Medical Management Specialist I

    Elevance Health (Tampa, FL)
    …Prepares reports and documents all actions. + Responsibilities exclude conducting any utilization management review activities which require interpretation ... appropriate area to refer or assign case ( utilization management , case management , QI, Med Review ). Provides information regarding network providers… more
    Elevance Health (12/24/25)
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  • Medical Director, Medical Management

    Highmark Health (Tallahassee, FL)
    …:** **JOB SUMMARY** This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and ... and DOL regulations at all times. In addition to utilization review , the incumbent participates as the...member of the multidisciplinary team for case and disease management . They will advise the multidisciplinary team on cases,… more
    Highmark Health (11/21/25)
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  • Senior Director, Resource Management…

    BeOne Medicines (San Mateo, CA)
    …Resource Management will lead the end-to-end global budget & resource management / utilization within GCO including the development of the Annual Operating ... team on resource-related decisions, including prioritization, hiring, and FSP vendor utilization . + Lead cross-functional resource review forums to optimize… more
    BeOne Medicines (12/31/25)
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  • Compliance Consultant

    Blue Cross Blue Shield of Massachusetts (Hingham, MA)
    …true colors to blue. The Role:The Compliance Program Consultant will focus on utilization management compliance and audit readiness activities such as evaluating ... Medical Management 's (HMM) and delegate's compliance with the applicable NCQA utilization management standards and state and federal regulations. The Team:… more
    Blue Cross Blue Shield of Massachusetts (12/17/25)
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