- Healthfirst (NY)
- …out of home placement, and/or community-based services and may be called upon to do Utilization Review for those services + Develops care plans that align with ... + Applies care management principles by advocating, informing, and educating beneficiaries...principles by advocating, informing, and educating beneficiaries on services, self- management techniques, and health benefits related to the continuum… more
- Highmark Health (Pittsburgh, PA)
- …in planning/marketing strategy to ensure referral sources. + Participates in peer utilization and/or review and assists in coordination of related quality ... clients as assigned to assess urgency of client need and recommend appropriate management . Provides on call coverage to caseload and for staff coverage to assess… more
- Sharp HealthCare (San Diego, CA)
- …visits and responds to accrediting and regulatory agency feedback. + Supports pre-admission review , utilization management , and concurrent and retrospective ... + Participates in risk management reviews. + Assists in pharmacy utilization management , catastrophic case review , outreach programs, HEDIS reporting,… more
- Amergis (Orange, CA)
- …also be qualifying. Preferred Qualifications: + Utilization management reviewer experience. + Managed care experience. + Behavioral health clinical ... to help support a health insurance agency! The Medical Case Manager (BHI Utilization Management ) will be responsible for reviewing and processing requests for… more
- Ventura County (Ventura, CA)
- …medical policy with the Health Care Agency Director and Insurance Administrator, Utilization Management staff and Quality Assurance Staff. + Participates, as ... surgical procedures, referrals, tests, medication approvals requiring authorization.) + Develops utilization management standards and guidelines for approval by… more
- Molina Healthcare (Albuquerque, NM)
- **JOB DESCRIPTION** Opportunity for experienced Utilization Review RN (preferred) or LPN with a compact license who resides in New Mexico or Texas. This team ... 3-5 years clinical practice with managed care, hospital nursing or utilization management experience. **Preferred License, Certification, Association** Active,… more
- UPMC (Media, PA)
- …care delivered to Community Care members. This includes significant responsibility for quality management and utilization management and for assuring the ... MCOs. + Reviews the medical aspects of cost and utilization reports generated by Medical Management Information...the UPMC Health Plan. + Acts as a physician reviewer for cases referred by care management … more
- Highmark Health (Buffalo, NY)
- …OVERVIEW: * Receive, review and make determinations regarding physician reviewer assignments for medical management decisions. Cases requiring physician ... agencies' standards including the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Committee (URAC), Pennsylvania Department of… more
- The Cigna Group (Bloomfield, CT)
- …not be included in CMS' Preclusion List** **Preferred Skill Sets:** + Experience in medical management , utilization review and case management in a ... description of position** : A Medical Principal performs medical review and case management activities. The physician...will serve as a clinical educator and consultant to utilization management , case management , network,… more
- Molina Healthcare (Sparks, NV)
- …Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG ... guidelines. **Preferred License, Certification, Association** Active, unrestricted Utilization Management Certification (CPHM). NEVADA State Specific… more