- Evolent (Augusta, ME)
- …coordinating with UM staff to ensure timely and accurate communication of clinical decisions. Responsible for completion of UM projects and participation in ... with the Director of UM to ensure client satisfaction. Perform all peer clinical review activities while located in a state or territory of the United States.… more
- Humana (Augusta, ME)
- …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
- Martin's Point Health Care (Portland, ME)
- …as a "Great Place to Work" since 2015. Position Summary The Utilization Review Nurse works as is responsible for ensuring the receipt of high quality, cost efficient ... retrospective authorization requests as well as claims disputes. The Utilization Review Nurse will use appropriate governmental policies as well as specified … more
- Highmark Health (Augusta, ME)
- …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 (Augusta, ME)
- …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
- Sharecare (Augusta, ME)
- …available 3rd parties for care management and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and ... hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management ( UM ) status, including but not limited to medical, dental, and vision… more