- Molina Healthcare (OH)
- …appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct...denied cases in which a formal appeals request has been made or upon request by… more
- CVS Health (Columbus, OH)
- …8:00am-5:00pm in time zone of residence Monday - Friday. **Position Summary** The Appeals Nurse Consultant position is responsible for processing the medical ... necessity of Medicare appeals for participating providers. Primary duties may include, but...+ Managed Care experience. + Utilization Management experience. + Appeals experience. + Pre Certification experience. + Pre Authorization… more
- Evolent (Columbus, OH)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Evolent Appeals Nurse 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… more
- Evolent (Columbus, OH)
- …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
- Molina Healthcare (Cincinnati, OH)
- …resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/ Appeals . + Provides training and support to clinical peers. + ... Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol. **JOB QUALIFICATIONS** Graduate from an Accredited School of Nursing **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:** + Minimum 3 years… more
- Molina Healthcare (Cincinnati, OH)
- …responsibilities will include specialized medical necessity reviews and/or appeals and supporting market performance. Performance activities include physician ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- Elevance Health (Columbus, OH)
- …will make an impact:** + Perform physician-level case review, following initial nurse review, of Medical Oncology regimens and supportive care. + Perform ... physician-level case review, following initial nurse review, of chemotherapy regimens. + Determine medical necessity...a subject matter expert. + Perform first level provider appeals as designated by the client for adverse determinations.… more
- Molina Healthcare (Dayton, OH)
- …medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse ... and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends… more
- Sharecare (Columbus, OH)
- …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
- Trinity Health (Columbus, OH)
- …RHIA, RHIT, CCS, CPC/COC or other coding credentials and/or Licensed Vocational Nurse / Licensed Practical Nurse licensure is required. CHC (Healthcare Compliance ... accordingly. Epic experience desired. 9. Experience and knowledge of working on appeals for insurance denials and identifying root cause. 10. Knowledge of Hospital… more