- Commonwealth Care Alliance (Boston, MA)
- …Work collaboratively with internal departments-including Clinical Operations, Contracting, Network Management , Utilization Management , and Business ... Knowledge, Skills, Abilities & Language (nice to have):** + Familiarity with care management and utilization management systems and workflows for populations… more
- Martin's Point Health Care (Portland, ME)
- …Martin's Point Health Plan members. + Assists in the construction of the annual Utilization Management , Care Management , and Disease Management Program ... (eg NCQA, CMS, TRICARE) + Participates in medical policy review and policy development. + Works with Informatics, Network...of process improvement tools + Experience in Health Plan utilization management + Experience in Medicare Advantage… more
- Molina Healthcare (Green Bay, WI)
- …learn new programs. Preferred Qualifications * Experience with utilization /quality program management . * Managed care experience. * Peer review experience. * ... health oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs… more
- UPMC (Pittsburgh, PA)
- …requests in accordance with quality, timeliness, and efficiency standards. + Critically review pharmacy utilization management requests for approval/denial ... skills to adequately research drugs and disease states pertaining to complex utilization management reviews or other ancillary responsibilities. + Utilize a… more
- CareFirst (Baltimore, MD)
- …+ Provide deep subject matter expertise in all areas of Utilization Management (UM), including pre-service, concurrent review , and inpatient management , ... 5 years experience in business development, operational technology support, Utilization Management (UM) operations, Clinical Product Configuration, Health… more
- HCA Healthcare (Tallahassee, FL)
- …is acceptable for position if current and compliant** + **Certification in Case Management , Nursing, or Utilization Review , preferred** + **Three years ... and assess observation patients for appropriateness in observation status + Performs utilization management reviews and communicates information to third party… more
- Sharp HealthCare (San Diego, CA)
- …new provider requests, and processes requests in a timely manner.Works closely with utilization management and contracting teams to ensure network gaps are ... delegated medical groups. **Required Qualifications** + Bachelor's Degree in Healthcare Management , Business, Communications, or related field of study. + 5 Years… more
- Centene Corporation (Baton Rouge, LA)
- …findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and ... preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. **Applicants must have a compact… more
- Corewell Health (Grand Rapids, MI)
- …of the guiding principles will be demonstrated through applications of evidence-based utilization review process and application of sound clinical judgement. The ... peer to peer clinical discussions, and participation in denials management which include review of previous clinical...management + Provide clinical oversight to nurse case management and utilization management . +… more
- Rochester Regional Health (Rochester, NY)
- …in the Care Management Data base to support the clinical review process. + Concurrently monitors resources utilization , performing continued stay reviews ... efficient utilization of resources. Carries out activities related to utilization management , discharge planning, care coordination and referral to other… more