- Molina Healthcare (GA)
- …for appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical /medical ... with internet connectivity of high speed required **Job Summary** Clinical Appeals is responsible for making appropriate...more of the following: + Active and unrestricted Certified Clinical Coder + Certified Medical Audit Specialist … more
- TEKsystems (Annapolis, MD)
- The Clinical Denials Appeals Specialist ...management, denials, or billing + Must be a Registered Nurse or Licensed Nurse Practitioner Knowledge & ... clinical denials, determine appropriate next steps, and lead appeals efforts by analyzing medical necessity, addressing authorization issues, and resolving… more
- St. Luke's University Health Network (Allentown, PA)
- …serve, regardless of a patient's ability to pay for health care. The RN Clinical Review Appeals Specialist retrospectively reviews patient medical records, ... DUTIES AND RESPONSIBILITIES: + Conduct retrospective medical record reviews for clinical validation of diagnosis and procedure code assignment and MS-DRG/APR-DRG… more
- CareFirst (Baltimore, MD)
- **Resp & Qualifications** **PURPOSE:** The Appeals Specialist I is responsible for the initial analysis of appeals and/or grievance correspondence, and ... stakeholders, without breaching confidentiality of medical information. + Assists Supervisor and Appeals Specialist II and III with unit projects and other… more
- City and County of San Francisco (San Francisco, CA)
- …and assists with designing and implementing plans for meeting such needs. The Clinical Nurse Specialist performs other related duties as assigned/required. ... by the California Board of Registered Nursing; AND + Clinical Nurse Specialist Certificate: Possession...may be appealed under Civil Service Rule 110.4. Such appeals must be submitted in writing to the Department… more
- City and County of San Francisco (San Francisco, CA)
- … Nurse (RN) license issued by the California Board of Registered Nursing; AND + Clinical Nurse Specialist Certificate: Possession of a valid Clinical ... general medical and nursing direction, you will perform pediatric clinical nursing duties in hospitals, clinics, and community health...may be appealed under Civil Service Rule 110.4. Such appeals must be submitted in writing to the Department… more
- CenterWell (Columbia, SC)
- …caring community and help us put health first** The **Denials Management Specialist ** is responsible to respond to, monitor and analyze all governmental requests, ... to, managing and monitoring all payer requests for additional documentation (ADR), appeals and denials. Works with branch staff to gather required information and… more
- Beth Israel Lahey Health (Cambridge, MA)
- …to the Director of Quality & Patient Safety, the Quality and Patient Safety nurse specialist plays a role in reviewing publicly reported quality data by ... reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review...prepare various reports to state and federal regulators, insurance appeals , internal correspondence, and clinical summaries for… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …dynamic environment, the Clinical Authorization Specialist will bring clinical expertise to the prior authorization and appeals processes and serve ... plans. Reporting to the Prior Authorization Supervisor , the Clinical Authorization Specialist is responsible for managing...+ Root causes claim denials, reprocesses, and submits claim appeals . + Creates drug cost estimates for both on-label… more
- Community Health Systems (Franklin, TN)
- **Job Summary** The Clinical Utilization Review Specialist is responsible for evaluating the necessity, appropriateness, and efficiency of hospital services to ... collaborates with healthcare providers to facilitate efficient patient care. The Clinical Utilization Review Specialist monitors adherence to hospital… more
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