- CenterWell (Atlanta, GA)
- …our caring community and help us put health first** The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical ... **Required Qualifications** + Must be a licensed Registered Compact Nurse license (RN) with no disciplinary action and ability...Lung or Critical Care Nursing experience required + Prior clinical experience preferably in an acute care, skilled or… more
- Molina Healthcare (Savannah, GA)
- **JOB DESCRIPTION** **Job Summary** The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals requests ... regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and… more
- Molina Healthcare (Columbus, GA)
- …**Job Summary** The RN Care Review Clinician provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...intensive care unit, or in a telemetry type setting. UM medical review experience highly preferred. Work Hours: Monday… more
- Evolent (Atlanta, GA)
- …with clinical decision-making criteria sets (ie Milliman, InterQual) + UM Experience + Strong interpersonal, oral and written communication skills. + Possess ... for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are… more
- Humana (Atlanta, GA)
- …us put health first** Full-Time, Remote Telephonic opportunity The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation… more
- Humana (Atlanta, GA)
- …a part of our caring community and help us put health first** The Telephonic Nurse Case Manager will be a member of the In-Home Case Management Team, providing a ... beneficiary's capacity for self- care, to cost-effectively achieve desired clinical outcomes and to enhance quality of medical care....and to enhance quality of medical care. The **Telephonic Nurse Case Manager** will collect and document data to… more
- CVS Health (Atlanta, GA)
- …heart, each and every day. **Position Summary** CVS Aetna is seeking a dedicated **Appeals Nurse Consultant** to join our remote team. In this role, you will play a ... critical role in ensuring fair and accurate resolution of clinical appeals by applying sound clinical judgment...clinician support as required. + This position may support UM (includes expedited), MPO, Coding, or Behavioral Health appeals.… more
- Highmark Health (Atlanta, GA)
- …experience, or provider operations and/or health insurance experience + 1 year in a clinical setting **Preferred** + 5 years in UM /CM/QA/Managed Care + 1 year ... over a specified panel of members that range in health status/severity and clinical needs; and assesses health management needs of the assigned member panel and… more
- Molina Healthcare (Atlanta, GA)
- …national, state, and local laws and regulatory requirements affecting the medical and clinical staff. + Marketplace UM reviews + MD licenses required for ... appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership… more
- Molina Healthcare (Columbus, GA)
- …**Job Summary** The Care Review Clinician (RN) provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...a candidate with a RN licensure that has previous UM and Inpatient Hospital experience. Candidates with MCO experience… more
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