• Utilization Management…

    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
    Humana (11/12/25)
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  • Medical Review Nurse (RN)

    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
    Molina Healthcare (09/06/25)
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  • Senior Denials Mgmt Specialist

    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 (10/29/25)
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  • Senior Director Case Management

    Houston Methodist (Houston, 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
    Houston Methodist (10/16/25)
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  • Medical Director (NV)

    Molina Healthcare (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
    Molina Healthcare (10/31/25)
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  • Medical Director (AZ)

    Molina Healthcare (Fort Worth, TX)
    … and effective resource management . + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...analysts to produce tools to report, monitor and improve Utilization Management . + Actively participates in regulatory,… more
    Molina Healthcare (10/17/25)
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  • RN Care Review Clinician Remote

    Molina Healthcare (Houston, TX)
    …to provide quality and cost-effective member care. The candidate must have Medicare Appeals and/or Utilization Management knowledge. Work hours are ... to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. **Required...equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in… more
    Molina Healthcare (11/09/25)
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  • Care Review Clinician (RN)

    Molina Healthcare (Austin, TX)
    …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is...set schedule) Looking for a RN with experience with appeals , claims review, and medical coding. JOB DESCRIPTION Job… more
    Molina Healthcare (11/01/25)
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