- AmeriHealth Caritas (Dover, DE)
- …Under the direction of a supervisor, the Clinical Care Reviewer - Utilization Management evaluates medical necessity for inpatient and outpatient services, ... in a fast-paced environment. ;The Clinical Care Reviewer - Utilization Management will also be counted upon...document and assess patient cases. + Strong understanding of utilization review processes, including medical necessity criteria,… more
- Evolent (Dover, DE)
- …As a Clinical Reviewer, Nurse , you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference ... Clinical Reviewers are supported by Field Medical Directors (MDs) in the utilization management determination process. + Reviews charts and analyzes clinical… more
- Evolent (Dover, DE)
- …appeals. **What You Bring:** + 1-3 years' experience in clinical Appeals Review or Utilization Management Review as an LPN or LVN is required. + Must ... the culture. **What You'll Be Doing:** The Evolent Appeals Nurse team offers candidates the opportunity to make a...appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and… 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 ... in **Oncology** **.** **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)
- …Founded in 1993, AHH is URAC accredited in Case Management , Disease Management and Utilization Management . AHH delivers flexible medical management ... using a keyboard. **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
- Sharecare (Dover, DE)
- …total healthcare management and ensure cost effective, appropriate resource utilization and quality outcomes. The Clinical Registered Nurse is also ... the participants and their Primary Care Provider according to the disease management program intervention guidelines. A Clinical Registered Nurse is supervised… more
- Lincoln Financial (Dover, DE)
- …Care, Orthopedics, Coronary Care, , Trauma , Disability, Workman's comp or case management or Utilization review **Application Deadline** **What's it like ... Role at a Glance** We are excited to bring on a highly motivated Nurse Disability Consultant to our clinical organization. This position will be responsible for… more
- Evolent (Dover, DE)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and ... work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators...Be Doing:** + Practices and maintains the principles of utilization management and appeals management … more
- Highmark Health (Dover, DE)
- …triaging members to appropriate resources for additional support. + Implement care management review processes that are consistent with established industry, ... Nursing **EXPERIENCE** **Required** + 7 years in any combination of clinical, case/ utilization management and/or disease/condition management experience, or… more
- Fresenius Medical Center (Dover, DE)
- …and acts as the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member eligibility. Facilitate timely ... workup of patients for access management , dialysis services, patient education, hospitalizations, and kidney transplantation as appropriate, and ensures coordination… more