- Zelis (St. Petersburg, FL)
- …role with production and quality metric goals. What you'll do: + Review provider disputes for DRG Coding and Clinical Validation (MS and APR) ... and maintain claim review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies and Dispute Rationales + Perform… more
- ChenMed (Miami, FL)
- …to join our team. The Physician Reviewer is the primary physician reviewer for Utilization Management/ Clinical Appropriateness review cases in our ... for our patients. The position will also participate in Process and Quality improvement in our developing area of Delegated Utilization Management. **ESSENTIAL JOB… more
- Blue Cross Blue Shield of Massachusetts (Boston, MA)
- …the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer also provides clinical leadership in other areas of BCBSMA. The ... your true colors to blue. The Role The Physician Reviewer is responsible for evaluating clinical service...anticipatory case management for members whose cases come for review , in partnership with case managers + Participate in… more
- Evolent (Lansing, MI)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- AmeriHealth Caritas (Washington, DC)
- …determinations based on clinical criteria. Using professional judgment, the Clinical Care Reviewer assesses the appropriateness of services, identifies care ... When necessary, cases are escalated to the Medical Director for further review . The reviewer independently applies medical and behavioral health guidelines… more
- Ochsner Health (Slidell, LA)
- …surgeries in the hospital. Works closely with Departments to identify opportunities for clinical quality improvement and other special projects as may be ... assumes responsibility for managing all facets of the National Surgical Quality Improvement Program (NSQIP) database which is a nationally validated, risk-adjusted,… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …gather clinical information to support the plan of care. + Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality ... use of the member's benefit to provide the best quality care. The TeamThe RN Utilization Management Reviewer...with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service. +… more
- Centene Corporation (Indianapolis, IN)
- …additional state licenses as needed. **Join Centene's mission-driven team as a Remote Psychologist Reviewer specializing in Applied Behavior Analysis (ABA) with ... the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified,… more
- Bristol Myers Squibb (Summit, NJ)
- …investigation experience. **Duties and Responsibilities:** + Supports all activities for the Quality Operations Investigations group. + Review and approve Site ... + Review and approve Supplemental actions. + Review and approve Impact assessments or Product Quality...also be limited for the capability centers. Employees in remote -by-design or lab-based roles may be eligible for summer… more
- Zelis (FL)
- …found and justifying the revised choices of new codes and DRG, based on the clinical evidence obtained during the review + Document all aspect of audits ... interests that shape who you are. Position Overview The Inpatient DRG Reviewer will be primarily responsible for conducting post-service, pre-payment and post pay… more
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