- Ventura County (Ventura, CA)
- …matters of VCHCP medical policy with the Health Care Agency Director and Insurance Administrator, Utilization Management staff and Quality Assurance Staff. ... Medical Director , Ventura County Health Care...care + Experience and current knowledge of Quality Assurance, Utilization Review and Peer Review … more
- Brighton Health Plan Solutions, LLC (NC)
- …changing environment- flexibility in assignment. * Proficient in Utilization Review process including benefit interpretation, contract language, medical and ... its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in...required turnaround times. * Prepares and presents cases to Medical Director (MD) for medical … more
- Sharp HealthCare (San Diego, CA)
- …the position, and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp ... + 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons...utilization /cost and quality outcomes. + Participates in policy review , performs analysis and makes recommendations for updating current… more
- AmeriHealth Caritas (Washington, DC)
- …compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review . The reviewer independently applies ... document and assess patient cases. + Strong understanding of utilization review processes, including medical necessity criteria, care coordination,… more
- St. Luke's Health System (Boise, ID)
- …of colleagues, St. Luke's is truly a great place to work. The ** Director of Clinical Review Management** provides strategic and operational leadership across ... multiple settings and operating units to lead the organization's utilization management function in support of SLHS mission, vision, and strategic objectives. **What… more
- Saint Francis Health System (Tulsa, OK)
- …participates in the Patient Care Committee for patient care reviews, and in Utilization Review Staff Committee, providing data and contributing to improvement of ... administrative and clinical support to the hospital and treatment team throughout the review of patients, their placement in various levels of care and their receipt… more
- Cognizant (Carson City, NV)
- …payment. . Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in ... the Health Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a valued member… more
- Elevance Health (Overland Park, KS)
- …The medical director provides clinical expertise in all aspects of utilization review and case management. Provides input on the clinical relevance to ... day clinical responsibilities means that the medical director is directly involved in Utilization Management...state or territory of the United States when conducting utilization review or an appeals consideration and… more
- CVS Health (Albany, NY)
- … medical necessity guidelines to service requests. Works closely with leadership and Medical Director on member requests. This role is responsible to ensure ... unrestricted New York state licensure + 1+ year of Utilization review experience + 1+ year of...our competitive wages, our great benefits include: + **Affordable medical plan options,** a **401(k) plan** (including matching company… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …II (in addition to Level I Qualifications) + Minimum 2-3 years of experience in medical management, utilization review and case management. + Knowledge of ... you, we encourage you to apply! Job Description: The Medical Director participates in the broad array...decisions on Utilization or Case Management activities. Utilization review activities include: reviews of requests… more
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