- Humana (Austin, TX)
- **Become a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the ... communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work...action. Humana is seeking a Part C Grievance & Appeals (G&A) Nurse who will assist in… more
- Evolent (Austin, TX)
- …and accomplishments. **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to ... and as an RN - **Required** + Minimum of 5 years in Utilization Management , health care Appeals , compliance and/or grievances/complaints in a quality… more
- CVS Health (TX)
- …**Position Summary** Administers review and resolution of clinical complaints and appeals . Interprets data obtained from clinical records to apply appropriate ... Monday to Friday from 8:00am to 5:00pm CST - 1+ years of Utilization Review experience required **Preferred Qualifications** - Managed Care experience preferred -… more
- Houston Methodist (Katy, TX)
- …Utilization Review department to ensure efficient, high-quality, and compliant utilization management practices across the organization. This position ensures ... Master's degree in nursing preferred **EXPERIENCE** + Five years' experience in inpatient case management , social work or utilization management or in the… more
- Houston Methodist (Katy, TX)
- …is responsible for strategic, administrative, and operational leadership for the Utilization Management (UM) department across the Houston Methodist system. ... + Leverages technology platforms, predictive analytics, and real-time dashboards to enhance utilization management processes. Works with IT and analytics teams… more
- Molina Healthcare (TX)
- …decisions. + Serves as a clinical resource for utilization management , CMOs, physicians and member/provider inquiries/ appeals . + Provides training and ... ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS)… more
- Prime Therapeutics (Austin, TX)
- …of post-degree clinical experience. + Experience in managed care, specialty drugs, care management and utilization review. + Meets Credentialing criteria. + At ... the future of pharmacy with us. **Job Posting Title** Infusion Referral Nurse Sr- REMOTE **Job Description** Under supervision, is responsible for performing… more
- Houston Methodist (Sugar Land, TX)
- …performing utilization review activities, and monitoring the clinical denial management and appeals process, as applicable, in collaboration with clinical ... team partners. This position uses sound clinical judgement in the Utilization Management process and knowledge of regulatory requirements to make appropriate… more
- Houston Methodist (Katy, TX)
- …improvements as needed. + Collaborates with HMCPA on care transition and utilization management initiatives. + Provides strategic vision and execution for ... for providing executive leadership and strategic oversight for all hospital-based Case Management Directors and the Central Utilization Review Director across… more
- Molina Healthcare (Dallas, TX)
- …of health care services provided to plan members. * Supports plan utilization management program and accompanying action plan(s), which includes strategies ... the most appropriate care at the most effective setting. *Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and… more