6 clinical reviewer utilization management jobs found

POSITION SUMMARY AND RESPONSIBILITIES Performs utilization management activities including prior authorization review, concurrent review, retrospective review, and appeal review activities utilizing approved medical necessity criteria, organizational policies, contractual requirements, and regulatory guidelines. Evaluates clinical information to determine medical necessity, appropriateness of care, level of care, and benefit coverage within delegated authority. Collaborates with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes, appropriate utilization of healthcare resources, and regulatory compliance. Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements. EDUCATION/EXPERIENCE Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN) preferred. Minimum two (2) years of clinical nursing, utilization...

POSITION SUMMARY AND RESPONSIBILITIES Performs utilization management activities including prior authorization review, concurrent review, retrospective review, and appeal review activities utilizing approved medical necessity criteria, organizational policies, contractual requirements, and regulatory guidelines. Evaluates clinical information to determine medical necessity, appropriateness of care, level of care, and benefit coverage within delegated authority. Collaborates with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes, appropriate utilization of healthcare resources, and regulatory compliance. Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements. EDUCATION/EXPERIENCE Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN) preferred. Minimum two (2) years of clinical nursing, utilization...

POSITION SUMMARY AND RESPONSIBILITIES Performs utilization management activities including prior authorization review, concurrent review, retrospective review, and appeal review activities utilizing approved medical necessity criteria, organizational policies, contractual requirements, and regulatory guidelines. Evaluates clinical information to determine medical necessity, appropriateness of care, level of care, and benefit coverage within delegated authority. Collaborates with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes, appropriate utilization of healthcare resources, and regulatory compliance. Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements. EDUCATION/EXPERIENCE Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN) preferred. Minimum two (2) years of clinical nursing, utilization...

POSITION SUMMARY AND RESPONSIBILITIES Performs utilization management activities including prior authorization review, concurrent review, retrospective review, and appeal review activities utilizing approved medical necessity criteria, organizational policies, contractual requirements, and regulatory guidelines. Evaluates clinical information to determine medical necessity, appropriateness of care, level of care, and benefit coverage within delegated authority. Collaborates with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes, appropriate utilization of healthcare resources, and regulatory compliance. Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements. EDUCATION/EXPERIENCE Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN) preferred. Minimum two (2) years of clinical nursing, utilization...

POSITION SUMMARY AND RESPONSIBILITIES Performs utilization management activities including prior authorization review, concurrent review, retrospective review, and appeal review activities utilizing approved medical necessity criteria, organizational policies, contractual requirements, and regulatory guidelines. Evaluates clinical information to determine medical necessity, appropriateness of care, level of care, and benefit coverage within delegated authority. Collaborates with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes, appropriate utilization of healthcare resources, and regulatory compliance. Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements. EDUCATION/EXPERIENCE Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN) preferred. Minimum two (2) years of clinical nursing, utilization...

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. Contributes to the Hospital’s mission by supporting proper classification and a safe plan of care. This professional licensed position will have an impact on finance and growth by classifying patients’ status appropriately and supporting the workflow and care plan to ensure the delivery of high quality, safe patient care while maintaining an expected length of stay within budget. This role is critical to the denial management, utilization review, and discharge planning process and will support the evolution towards a system approach in this realm. This role functions in a high integrity manner and as a case management and utilization expert, collaborating interdepartmentally to educate and improve processes to appropriate classify patient status, which ultimately improves reimbursement. The Utilization Management Specialist will impact the patient experience and...