- AmeriHealth Caritas (Newtown Square, PA)
- Role Overview Under the direction of a supervisor, the Utilization Management Reviewer evaluates medical necessity for inpatient and outpatient services, ... and making determinations based on clinical criteria. Using professional judgment, the Utilization Management Reviewer assesses the appropriateness of… more
- AmeriHealth Caritas (Newtown Square, PA)
- ; Role Overview Under the direction of a supervisor, the Clinical Care Reviewer - Utilization Management evaluates medical necessity for inpatient and ... cases are escalated to the Medical Director for further review . The reviewer independently applies medical and...case management of all transplant members. Conduct utilization management reviews for all transplant services… more
- AmeriHealth Caritas (Newtown Square, PA)
- …with providers and appropriate others to facilitate and coordinate the Utilization Management process(es) activities. Utilize technology and resources (systems, ... Service Coordinators to collect all information necessary to perform a thorough needs review . It is at the Reviewer 's discretion to request additional… more
- RxBenefits (Philadelphia, PA)
- …channel management , B/G classifications, specialty designations, rebate eligibility, utilization trend, Utilization Management (UM) implications, ... structure, new prospect member size, marketing agreements, broker commissions, and drug utilization . Be the SME on dozens of medical vendor/PBM contracts including … more
- Humana (Harrisburg, PA)
- … management Utilization management experience in a medical management review organization such as Medicare Advantage, managed Medicaid, or Commercial ... The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The...with prior experience participating in teams focusing on quality management , utilization management , or similar… more
- Highmark Health (Harrisburg, PA)
- …internal clinical and value-based evaluation committees that drive formulary and utilization management functions. Participate in product specific Pharmacy and ... value of implemented initiatives. Lead product based pharmacy trend management discussions with internal partners including senior executives. Support...Therapeutics Committees and Drug Utilization Review (DUR) Committees as necessary or… more
- Carnegie Mellon University (Pittsburgh, PA)
- …Provide analytical support and financial insight for audits, facilities projects, space utilization , grants management , and special projects. Coordinate with the ... Coordinate with grant and contract accounting, including pre-award budget review , post-award expense tracking, effort reporting, and closeout. Coordinate with… more
- Geisinger (Dickson City, PA)
- …all Revenue Management teams and departments including Practice Consultants, Utilization Management and Care Management , Providers, Geisinger ... in and out surgeries and outpatient clinical departments. Follows Revenue Management policies and procedures regarding financial matters and payment arrangements.… more
- CBRE (Harrisburg, PA)
- …adhere to company standards. Act as a key point of contact for utilization management and coordination with outside procurement solutions. Lead by example ... consulting, real estate services, instrumentation repair and maintenance, full asset management , and more-covering the entire spectrum of life sciences facilities.… more
- Oracle (Harrisburg, PA)
- …an accredited college and AHIMA Certified RHIT credentials preferred Certification in Utilization Review , case management , and healthcare quality preferred ... inpatient stays. Knowledge of third-party payor rules and regulations. 2-3 years of Utilization Review experience in a healthcare setting preferred; 1-2 years of… more
