- MetroHealth (Cleveland, OH)
- …appropriate and necessary healthcare services are covered by insurance. Reviews clinical criteria to support patient care inquiries regarding the appropriateness of ... Current Registered Nurse License State of Ohio. Minimum of 5 years clinical experience. Knowledge and experience with medical necessity criteria for inpatient… more
- Centers Plan for Healthy Living (Margate, FL)
- RN - Grievance and Appeals Clinical Reviewer 5297 W Copans Rd, Margate, FL 33063, USA Req #461 Tuesday, November 5, 2024 Centers Plan for Healthy Living's ... plans they need for healthy living. JOB SUMMARY: The Grievance & Appeal Clinical Reviewer performs complex medical necessity reviewed on Initial Adverse… more
- Guthrie (Binghamton, NY)
- …for prior authorization/certification for reimbursement of patient care services. The Utilization Reviewer : * Secures authorization as appropriate * Documents ... Utilization Management (Days) Full Time Position Summary: The Utilization Management (UM) Reviewer , in collaboration with...to track and monitor the status for denials and appeals . c) Collects and aggregates clinical , financial,… more
- Prime Therapeutics (Washington, DC)
- …fuels our passion and drives every decision we make. **Job Posting Title** Physician Clinical Reviewer - GI- REMOTE **Job Description Summary** Key member of the ... utilization management team, and provides timely medical ...clinical determinations cannot be made by the Initial Clinical Reviewer . + Discusses determinations with requesting… more
- Evolent Health (Austin, TX)
- …for the mission. Stay for the culture. **What You'll Be Doing:** As a Cardiology, Physician Clinical Reviewer you will be a key member of the utilization ... when available, within the regulatory timeframe of the request. + Utilizes medical/ clinical review guidelines and parameters to assure consistency in the… more
- Evolent Health (Honolulu, HI)
- …of the request and provides clinical rationale for standard and expedited appeals . + Utilizes medical/ clinical review guidelines and parameters to assure ... the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer , you will be a key... and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National… more
- University of Michigan (Ann Arbor, MI)
- Utilization Rev Appeals Spec Apply Now **Job Summary** **Why Join Michigan Medicine's Hospital Billing Audits & Appeals (HBAA) Department?** The Audit and ... Registration, MiVisit Business services, clinics and ancillary departments. + Review patient medical records and utilize clinical ...RN + At least 2-5 years of experience in Utilization Management, Appeals Management or Case Management… more
- Blue Cross Blue Shield of Massachusetts (Boston, MA)
- …the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer also provides clinical leadership in other areas of BCBSMA. The ... healthcare? Bring your true colors to blue. The Physician Reviewer is responsible for evaluating clinical service...clinical practice in order to participate in panel appeals + Experience in Utilization Management in… more
- ManpowerGroup (Columbia, SC)
- …+ Ensure thorough documentation of each determination for utilization or claims review . + Review first-level appeals and provide accurate basis for ... of medical claims review processes, medical necessity guidelines, and utilization review practices. + Proficiency in medical terminology, coding procedures,… more
- ManpowerGroup (Columbia, SC)
- …" to join one of our Fortune 500 clients. **Job Summary** The Medical Review and Utilization Management Specialist is responsible for performing medical reviews ... **Title: Medical Reviewer ** **Location:** **4101 Percival Road Columbia SC 29229...appeals . This role involves documenting decisions based on clinical guidelines, providing support for medical claims reviews, and… more