- State of Massachusetts (Boston, MA)
- …delivery of health care services through networks of providers, or that employ utilization review systems to evaluate the medical necessity and appropriateness ... applications for licensure. Review is of carriers' operations, including utilization review , quality assurance, contracts with pharmacies and prescription… more
- The Cigna Group (Bloomfield, CT)
- …in CMS' Preclusion List** **Preferred Skill Sets:** + Experience in medical management, utilization review and case management in a managed care setting. + ... Cigna. **Summary description of position** : A Medical Principal performs medical review and case management activities. The physician provides clinical insight to… more
- Ascension Health (Racine, WI)
- …areas of responsibility, to include but not limited to; + Quality and Safety + Utilization Review + Peer Review and Credentialing + Growth and Strategic ... of services, policies, processes, and programs, including medical practice review , governance, credentialing, privileging, peer review , medical information… more
- Ascension Health (Appleton, WI)
- …areas of responsibility, to include but not limited to; + Quality and Safety + Utilization Review + Peer Review and Credentialing + Growth and Strategic ... of services, policies, processes, and programs, including medical practice review , governance, credentialing, privileging, peer review , medical information… more
- Amergis (Baltimore, MD)
- …and referrals for psychosocial needs + Participates in Quality Assurance and Utilization Review activities, as directed + Empowers patients in decision-making ... continuum of care activities for assigned patients and ensuring optimum utilization of resources, service delivery, and compliance with medical regime. Essential… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- About The Role MagnaCare provides Utilization Review / Case Management/ Medical Management/Claims Review services to its clients. Care Coordinators facilitate ... care management and utilization review by performing data collection & data entry, and effectively communicating with Nurse Case Reviewers/Managers, employers… more
- Elevance Health (Seven Fields, PA)
- …must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US ... ensuring clinical integrity of broad and significant clinical programs. May perform clinical review . **How you will make an impact:** + May provide clinical guidance… more
- HCA Healthcare (El Paso, TX)
- …and retrospective review of patient medical records for purposes of utilization review , compliance with requirements of external review agencies ... Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review /quality assurance, use of InterQual(R) or other… more
- World Insurance Associates, LLC. (Miami, FL)
- … review analysis + Renewal rate and funding initial projections/modeling + Claims utilization review + Rate and contribution modeling + Benchmarking studies + ... self-funded arrangements. You'll prepare financial deliverables, model renewals, evaluate utilization trends, and support client decision-making with data-driven insights.… more
- Highmark Health (Tallahassee, FL)
- …NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review , the incumbent participates as the physician member of the ... **JOB SUMMARY** This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most… more