- Humana (Raleigh, NC)
- **Become a part of our caring community and help us put health first** The Appeals Nurse 2 resolves clinical complaints and appeals . The Appeals Nurse ... and independent determination of the appropriate courses of action. The Appeals Nurse 2 reviews documentation and interprets data obtained from clinical records… more
- UNC Health Care (Kinston, NC)
- …the Physician Advisors and subject matter experts for all audit and appeals work activities. Assists with documentation review to support the clinical documentation ... specialists and Patient Financial Services. Supports the Utilization Review Nurse team when necessary by applying established criteria to evaluate the… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with ... care. * Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed. *...Duties as assigned. Essential Qualifications * Current Licensed Practical Nurse (LPN) or Registered Nurse (RN) with… more
- CVS Health (Raleigh, NC)
- …accordance with contract. + Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) ... incoming correspondence and internal referrals. + Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management. Performs… more
- Sharecare (Raleigh, NC)
- …enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited to medical, ... 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status +...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …all Clinical Services (CS) functions (prior authorization, concurrent review, appeals , case management, disease management, population health) per defined Client ... all WC State Reporting and audits. Essential Qualifications + Currently licensed Registered Nurse (RN), Nurse Practitioner (NP), or Physician Assistant (PA) with… more