- CenterWell (Springfield, IL)
- …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
- Evolent (Springfield, IL)
- …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
- Health Care Service Corporation (Chicago, IL)
- …education/local resource information and encourage member (self) education functioning in a clinical care advisory role, the primary nurse case administrator ... all other entities involved in managing specialty care. The primary nurse case administrator performs care coordination; identifies alternate treatment programs;… more
- US Tech Solutions (Chicago, IL)
- …documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations. + Considers all documented system information ... additional information. + Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines. + Responsible for… more
- Humana (Springfield, IL)
- …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
- Highmark Health (Springfield, IL)
- …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
- Datavant (Springfield, IL)
- …recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully. Ideal candidate should be a Licensed ... Practical Nurse or Registered Nurse well versed in...denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines. **You will:** +… more
- Molina Healthcare (IL)
- JOB DESCRIPTION Job Summary 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...the Molina care model. * Adheres to utilization management ( UM ) policies and procedures. Required Qualifications * At least… more
- Molina Healthcare (Downers Grove, IL)
- …compliance with all state and federal regulations and guidelines. + Analyzes clinical service requests from members or providers against evidence based clinical ... and efficient manner. + Makes appropriate referrals to other clinical programs. + Collaborates with multidisciplinary teams to promote...teams to promote Molina Care Model + Adheres to UM policies and procedures. + Occasional travel to other… more