• Medical Claim Review…

    Molina Healthcare (Lexington, KY)
    …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... schedule) Looking for a RN with experience with appeals, claims review , and medical coding....clinical/ medical reviews of retrospective medical claim reviews, medical claims and… more
    Molina Healthcare (09/06/25)
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  • Clinical Review Nurse I

    Elevance Health (Louisville, KY)
    …Medicaid Services to transform federal health programs. The **Clinical Review Nurse ** is responsible for reviewing and making medical determinations as to ... **Clinical Review Nurse I** **Location:** This role...**Clinical Review Nurse I** **Location:** This role enables associates to...and reasonableness of the items supplied in a valid claim through the use of medical policy… more
    Elevance Health (09/11/25)
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  • Case Manager, Registered Nurse - Fully…

    CVS Health (Frankfort, KY)
    …within time zone of residence.** American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, ... Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.… more
    CVS Health (09/02/25)
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  • UM Behavioral Health Nurse

    Humana (Frankfort, KY)
    …action. + Complete medical record reviews + Assess discharge plans + Review and extract information from claims + Complete documentation for Quality Reviews ... the appropriate courses of action. The Utilization Management Behavioral Health Nurse 2 completes medical record reviews from medical records sent from… more
    Humana (09/09/25)
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  • Clinical Appeals Nurse (RN)

    Molina Healthcare (Bowling Green, KY)
    …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... the likelihood of a formal appeal being submitted. + Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge,… more
    Molina Healthcare (08/15/25)
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  • Clinical Fraud Investigator II - Registered…

    Elevance Health (Louisville, KY)
    …and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to payment. Researches new healthcare-related questions ... **Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU**...Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Clinical Fraud Investigator II** is responsible… more
    Elevance Health (09/11/25)
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  • Telephonic Nurse Case Manager II

    Elevance Health (Louisville, KY)
    **Telephonic Nurse Case Manager II** **Sign On Bonus: $3000** **Location** : This role enables associates to work virtually full-time, with the exception of required ... different states; therefore Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager II** is responsible for performing care management within… more
    Elevance Health (09/11/25)
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  • Sr VP Medical Director (Hourly)

    Sedgwick (Frankfort, KY)
    …review process including making a recommendation of specialty for the Independent Medical Review process. + Developing and delivering training materials and ... Best Workplaces in Financial Services & Insurance Sr VP Medical Director (Hourly) The ideal candidate would work 8-20...the following: + Conducting reviews on cases where the nurse is seeking treatment plan clarification, claim … more
    Sedgwick (08/22/25)
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  • Medical Director (Marketplace)

    Molina Healthcare (Lexington, KY)
    …retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as ... Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial… more
    Molina Healthcare (08/28/25)
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  • Clinical Audit and Appeals Consultant

    Intermountain Health (Frankfort, KY)
    …and appeal activity to stakeholders throughout the denial process up to and including medical review boards and in the court of law. **Essential Functions** + ... a registered nurse required. + Experience in Microsoft office, electronic medical record systems and electronic databases + Demonstrates in depth knowledge of… more
    Intermountain Health (09/08/25)
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