- Humana (Austin, TX)
- **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
- Molina Healthcare (Dallas, TX)
- …Medical Review Nurse provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory ... and Grievances department. We are seeking a Registered Nurse with previous Appeals experience. The candidate must have strong organizational skills, proficient… more
- Houston Methodist (Sugar Land, TX)
- …utilization review activities, and monitoring the clinical denial management and appeals process, as applicable, in collaboration with clinical team partners. This ... and determines the need for or feasibility of submitting appeals . + Facilitates communication with payors and external case...**LICENSES AND CERTIFICATIONS - REQUIRED** + RN - Registered Nurse - Texas State Licensure -- Compact Licensure -… more
- Elevance Health (Houston, TX)
- …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
- Select Medical (Dallas, TX)
- …+ Obtaining insurance approvals and authorizations, as well as facilitating appeals for patients + Demonstrates positive referrer satisfaction and account retention. ... state licensure or eligibility for state licensure as a Registered Nurse , Physical Therapist, Occupational Therapist, or Speech Language Pathologist required.… more
- CVS Health (Austin, TX)
- …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 (Austin, TX)
- …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
- Molina Healthcare (Fort Worth, TX)
- …medical necessity. * Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for 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
- Molina Healthcare (San Antonio, TX)
- 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 ... set schedule) Looking for a RN with experience with appeals , claims review, and medical coding. JOB DESCRIPTION Job...equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in… more
- Texas Health Resources (Bedford, TX)
- …financial data (eg, LOS data, avoidable days, adverse determinations, and denials/ appeals ) and makes recommendations to improve performance. Achieves and maintains ... of supervisory and leadership experience Required Licenses and Certifications RN - Registered Nurse Upon Hire Required Or LMSW - Licensed Master Social Worker Upon… more