- AmeriHealth Caritas (Newark, DE)
- **Responsibilities:** Under the direction of a supervisor, the Utilization Management Review Nurse evaluates medical necessity for inpatient and ... making determinations based on clinical criteria. Using professional judgment, the Utilization Management Review Nurse assesses the appropriateness of… more
- Humana (Dover, DE)
- …leader, with responsibility for evolving Humana's Utilization Management of medical review by physician or nurse , with a focus on our 5+ million Medicare ... members. The Director, Physician leadership will lead Medical Directors performing utilization management for Medicare inpatient and behavioral medicine case… more
- Sharecare (Dover, DE)
- …appropriate resource utilization and desired clinical outcomes. The Disease Management Nurse is also responsible during their interactions with participants ... learn more, visit www.sharecare.com . **Job Summary:** The Disease Management Nurse has the responsibility for supporting...and to take the pre and post tests to review competency during orientation. Yearly competency tests are required… more
- CVS Health (Dover, DE)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... or Specialty Pharmacy.** **Preferred Qualifications** + 1+ years' Case Management experience or discharge planning, nurse navigator...lower levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC… more
- CVS Health (Dover, DE)
- …Friday 8:00am - 5:00pm in time zone of residence **Preferred Qualifications** - Utilization Management review - Managed Care experience **Education** ... As a QM Nurse Consultant you will be responsible for the review and evaluation of clinical information and documentation. + Reviews documentation and interprets… more
- Fresenius Medical Center (Dover, DE)
- …auditing activities. + Accountable for completion of the Annual Standing Order Review and Internal Classification of Disease (ICD) coding. + Manages clinic ... financials including efficient utilization of supplies or equipment and regular profits and...of supplies or equipment and regular profits and loss review . + Responsible for all required network reporting and… more
- Highmark Health (Dover, DE)
- …Highmark Inc. **Job Description :** **JOB SUMMARY** This job implements effective utilization management strategies including: review of appropriateness of ... and offers interventions and/or alternatives. **ESSENTIAL RESPONSIBILITIES** + Implement care management review processes that are consistent with established… more
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