- Evolent (Boston, MA)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of ... a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and… more
- Cognizant (Boston, MA)
- …to Friday - Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced level work related to clinical ... . Maintain working knowledge of applicable health insurers' internal claims, appeals , and retro-authorization as well as timely filing deadlines and processes.… more
- Fallon Health (Worcester, MA)
- …Facebook, Twitter and LinkedIn. **Brief summary of purpose:** The Fallon Health Appeals and Grievance process is an essential function to Fallon Health's compliance ... and member expectations. Under the direction of the Director, the Appeal Nurse represents, manages and oversees second level appeal cases (Office of Medicaid,… more
- Beth Israel Lahey Health (Cambridge, MA)
- …to the Director of Quality & Patient Safety, the Quality and Patient Safety nurse specialist plays a role in reviewing publicly reported quality data by leading the ... processes to reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review clinical charts, interpret data, and… more
- Commonwealth Care Alliance (Boston, MA)
- …intensive care management and care delivery. Within the CIC Program, the Registered Nurse (RN) serves as an integral member of an interdisciplinary team for medical ... needs of the defined panel of members, the Registered Nurse will engage in regular assessments, visits at regularly...as approved + Supports escalation of member grievances and appeals + Supports the procurement of network providers and… more
- Beth Israel Lahey Health (Boston, MA)
- …participates in the resolution of retrospective reimbursement issues, including appeals , third-party payer certification, and denied cases. 6. Monitors ... as required and directed. **Qualifications:** _Required_ + Licensure as a Registered Nurse (RN), Massachusetts + Three years of recent clinical or utilization… more
- Beth Israel Lahey Health (Plymouth, MA)
- …team to assess and improve the denial management, documentation, and appeals process. + Collaborates with UR Manager and/or physician advisor regarding ... cases that do not meet established guidelines for admission or continued stay. + Acts as a liaison between physicians and payers, coordinating peer-to-peer phone calls. + Collects and compiles data as required. _It is understood that this is a summary of key… more
- Beth Israel Lahey Health (Plymouth, MA)
- …team to assess and improve the denial management, documentation, and appeals process. + Collaborates with UR Manager and/or physician advisor regarding ... cases that do not meet established guidelines for admission or continued stay. + Acts as a liaison between physicians and payers, coordinating peer-to-peer phone calls. + Collects and compiles data as required. _It is understood that this is a summary of key… more
- Beth Israel Lahey Health (Newburyport, MA)
- …mailing, in collaboration with other hospital departments. Organizes the follow-up appeals documentation post-audit and coordinates the submission of the Physician ... variety of sources (eg Auditors, CMS, BCBS, Permedion, DPH, Nurse Audit, HCHP, DPH, Disability, Workman's Comp, EHR, attorneys,...final review, and submission to Permedion and EHR for appeals on behalf of Case Management. Works closely with… more
- Dana-Farber Cancer Institute (Brookline, MA)
- …Authorization Specialist will bring clinical expertise to the prior authorization and appeals processes and serve as a liaison and patient advocate between Dana ... estimates for waivers. + Root causes claim denials, reprocesses, and submits claim appeals . + Creates drug cost estimates for both on-label and off-label waivers and… more