- Evolent (Columbus, OH)
- …to Standard processing, documenting accordingly. + Works closely with the appeals -dedicated Clinical Reviewers to ensure timely adjudication of processed ... for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a...be able to exercise independent and sound judgment in clinical decision making. - **Preferred** + Able to navigate… more
- Humana (Columbus, OH)
- …our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, ... action. Humana is seeking a Part C Grievance & Appeals (G&A) Nurse who will assist in...no disciplinary action + 3 or more years of clinical experience preferably in an acute care, skilled or… more
- Molina Healthcare (Cleveland, OH)
- …a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/ appeals . + Provides training and support to clinical peers. + ... JOB DESCRIPTION **Job Summary** Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal… more
- Prime Therapeutics (Columbus, OH)
- …and enters data of these cases in web-based application and spreadsheets. + Supports clinical services such as the appeals program. + Participates in meetings ... work visa or residency sponsorship **Additional Qualifications** + Registered Nurse (RN). + 5 years of post-degree clinical... Nurse (RN). + 5 years of post-degree clinical experience. + Experience in managed care, specialty drugs,… more
- Molina Healthcare (Cleveland, OH)
- …medical necessity. * Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for investigation of adverse ... and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical … more
- Molina Healthcare (OH)
- For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is a Remote position, home office with internet connectivity of high ... (Team will work on set schedule) Looking for a RN with experience with appeals , claims review, and medical coding. JOB DESCRIPTION Job SummaryProvides support for … more
- Molina Healthcare (OH)
- …**Job Summary** The RN Care Review Clinician provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through… more