- CenterWell (Raleigh, NC)
- …our caring community and help us put health first** The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical ... **Required Qualifications** + Must be a licensed Registered Compact Nurse license (RN) with no disciplinary action and ability...Lung or Critical Care Nursing experience required + Prior clinical experience preferably in an acute care, skilled or… more
- Humana (Raleigh, NC)
- …community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills to support the coordination, ... from medical records sent from Behavioral Health Facilities to obtain sufficient clinical information. The Utilization Management Behavioral Health Nurse 2 work… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily ... in a quality-focused, production-driven environment. The position reports directly to the Clinical Appeal Manager. Note: This job description is not intended to be… more
- Brighton Health Plan Solutions, LLC (NC)
- …in a UM team within managed care setting. * 3+ years' experience in clinical nurse setting preferred. * TPA Experience preferred. Powered by JazzHR ... provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with… more
- Humana (Raleigh, NC)
- …a part of our caring community and help us put health first** The Telephonic Nurse Case Manager will be a member of the In-Home Case Management Team, providing a ... beneficiary's capacity for self- care, to cost-effectively achieve desired clinical outcomes and to enhance quality of medical care....and to enhance quality of medical care. The **Telephonic Nurse Case Manager** will collect and document data to… more
- Highmark Health (Raleigh, NC)
- …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
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- About The Role The Manager, Utilization Management ( UM ) will manage the Utilization Management team consisting of Clinicians and Non- Clinical support staff. The ... ideal candidate will have a strong clinical background within a managed care setting including a...and alignment with regulatory requirements. + Facilitate training for UM team members including Nurses and Coordinators on systems,… more
- Datavant (Raleigh, NC)
- …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
- Elevance Health (Winston Salem, NC)
- …outpatient precertification, prior authorization, and post service requests. + Refers cases requiring clinical review to a Nurse reviewer. + Responsible for the ... identification and data entry of referral requests into the UM system in accordance with the plan certificate. + Responds to telephone and written inquiries from… more