- St. Luke's University Health Network (Allentown, PA)
- …ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, claims data and coding of all ... Works inside with adequate lighting, comfortable temperature and ventilation. EDUCATION: Registered Nurse required, BSN preferred. Current license required. .… more
- Actalent (Boston, MA)
- Clinical Review Clinician Job Description As a Clinical Review Clinician specializing in appeals , you will be responsible for preparing case reviews for ... Medical Directors by thoroughly researching appeals , reviewing...the basis for each appeal. You will ensure timely review , processing, and response to appeals in… more
- Centene Corporation (Sacramento, CA)
- …PST Hours.** + **Position Purpose:** Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine ... for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering… more
- Centene Corporation (Raleigh, NC)
- …State Licensure required or + LVN - Licensed Vocational Nurse required or + RN - Registered Nurse - State Licensure and/or Compact State Licensure ... Purpose:** Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical...analyzing the basis for the appeal + Ensures timely review , processing, and response to appeal in accordance with… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …most appropriate decision within regulatory timeframes.The TeamAs an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will serve ... Key Responsibilities: + Review provider and member appeals utilizing sound clinical judgement, medical policy,...with medical necessity determinations. Key Qualifications: + Registered Nurse with an active unrestricted professional… more
- Centene Corporation (Salem, OR)
- …requirements. **(PST preferred).** + Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of ... **Position Purpose:** Act as the liaison for all statewide appeals , fair hearings, review organizations, and other...NCQA standards. + Maintain files and logs for all appeals + Coordinate with Medical Director(s) to… more
- R1 RCM (Boise, ID)
- …conduct a comprehensive review of clinical denials and formulate appeals based on clinical documentation, evidence-based medical necessity criteria, ... identify targeted areas for additional support and engagement. **Required Skills:** + Active Registered Nurse license For this US-based position, the base pay… more
- Geisinger (Danville, PA)
- …Experience Minimum of 3 years-Nursing (Required) Certification(s) and License(s) Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania OUR PURPOSE ... of PA. + At least three (3) years of RN work experience is required, and experience in Case...a plus. Managed care payor experience in either Utilization Review , Case Management or Appeals is preferred.… more
- Nuvance Health (Danbury, CT)
- …in nursing, health administration, or a related field preferred * Current licensure as a registered nurse ( RN ) * Minimum of 5 years of clinical experience ... leadership and operational oversight for a team of utilization review staff, denials and appeals specialists, non-clinical...medical necessity outreach, and feedback to the utilization review team on denial outcomes. * *Discharge Planning &… more
- St. Mary's Healthcare (Amsterdam, NY)
- …of nursing required. Licensure / Certification / Registration: Required Credential(s): * Registered Nurse credentialed from the New York Board of Nursing. ... and audit requests and coordinates attempts to overturn denials by drafting appeals , negotiating with payers, or following up with payer utilization review… more
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