- Molina Healthcare (Warren, MI)
- …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
- Humana (Lansing, MI)
- …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
- Molina Healthcare (Ann Arbor, MI)
- …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
- Elevance Health (Dearborn, MI)
- …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
- CVS Health (Warren, MI)
- …And we do it all with heart, each and every day. **Case Manager Registered Nurse ** WFH Flexible This role will be 25-50%% travel within **Wayne or Macomb Countie** ... all case management activities with members to evaluate the medical needs of the member to facilitate the member's...member's overall wellness. + Uses clinical tools and information/data review to conduct an evaluation of member's needs and… more
- CVS Health (Coldwater, MI)
- …and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness. **Position ... to enhance a member's overall wellness. + Uses clinical tools and information/data review to conduct an evaluation of member's needs and benefits. + Applies clinical… more
- McLaren Health Care (Flint, MI)
- …for utilization management functions. This includes but is not limited to review and authorization of services, utilization of medical policy, utilization ... of high risk, and under and overuse of services. Collaborates with Medical Director and senior management on complex cases and special projects. **Equal… more
- McLaren Health Care (Flint, MI)
- …This includes but is not limited to the following: participates in the medical management of members in assigned product lines, including case specific and disease ... of high risk, and under and overuse of services. Collaborates with Medical Director and senior management on complex cases and special projects. **Equal… more
- Sedgwick (Lansing, MI)
- …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
- Trinity Health (Livonia, MI)
- …processes and audits, and clinical billing. Strong understanding of various medical claim formats. Knowledge of clinical documentation improvement processes ... Private payer regulations. Performs coding functions, including CPT, ICD-10 assignment, documentation review and claim denial review Responsible for proofing… more
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