- Martin's Point Health Care (Portland, ME)
- …Point has been certified as a "Great Place to Work" since 2015. Position Summary The Utilization Review Nurse is responsible for ensuring the receipt of high ... reviews for retrospective authorization requests as well as claims disputes. The Utilization Review Nurse will use appropriate governmental policies as well… more
- Humana (Augusta, ME)
- …a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are...who will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The… more
- CenterWell (Augusta, ME)
- …actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that ... Prior clinical experience, managed care experience, DME, Florida Medicaid **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to… more
- CVS Health (ME)
- …Monday through Friday 8:30-5pm EST. No weekends or holidays. + 1+ years of utilization review / utilization management required. + 3+ years of behavioral ... we do it all with heart, each and every day. **Position Summary** Fully remote role. Monday-Friday 8:30-5pm EST. No weekends or holidays. Utilizes clinical skills to… more
- CVS Health (Augusta, ME)
- …with transferring patients to lower levels of care. + 1+ years' experience in Utilization Review . + CCM and/or other URAC recognized accreditation preferred. + ... community at a time. **Position Summary** **This is a remote work from home role anywhere in the US...is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that… more
- Highmark Health (Augusta, ME)
- …**Job Description :** **JOB SUMMARY** This job implements effective complimentary utilization and case management strategies for an assigned member panel. Provides ... to appropriate resources for additional support. + Implement care management review processes that are consistent with established industry, corporate, state, and… more
- Humana (Augusta, ME)
- …for review depending on case findings. Educates providers on utilization and medical management processes. Enters and maintains pertinent clinical information in ... of our caring community and help us put health first** The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following… more
- Evolent (Augusta, ME)
- …the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- CenterWell (Augusta, ME)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and ... delivery, and documentation requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking for performance … more
- CenterWell (Portland, ME)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and ... **Branch Location** : **Portland, ME** **This is not a remote or work-from-home position. This position requires you to...requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking… more