8 clinical reviewer utilization management jobs found

POSITION SUMMARY/RESPONSIBILITIES Assists Community First Health Plan (CFHP) members regain optimum health or improved functional capacity by ensuring that members have access to all of the health care services they need in the most efficient and effective manner possible. Responsibilities include but are not limited to overseeing the allocation of resources, cost and quality of health care for members; coordinating care between the primary care physician, community resources, family and member; coordinating care across the health care continuum while monitoring and managing benefit utilization; and, collaborating with multi-disciplinary health care team members in identifying the educational and discharge needs of members. EDUCATION/EXPERIENCE Registered Nurse (RN) is required. Bachelor of Science in Nursing (BSN) or Master's degree is preferred. Minimum three (3) years nursing, acute care, quality management or managed care experience is required. Basic knowledge of...

POSITION SUMMARY/RESPONSIBILITIES Assists Community First Health Plan (CFHP) members regain optimum health or improved functional capacity by ensuring that members have access to all of the health care services they need in the most efficient and effective manner possible. Responsibilities include but are not limited to overseeing the allocation of resources, cost and quality of health care for members; coordinating care between the primary care physician, community resources, family and member; coordinating care across the health care continuum while monitoring and managing benefit utilization; and, collaborating with multi-disciplinary health care team members in identifying the educational and discharge needs of members. EDUCATION/EXPERIENCE Registered Nurse (RN) is required. Bachelor of Science in Nursing (BSN) or Master's degree is preferred. Minimum three (3) years nursing, acute care, quality management or managed care experience is required. Basic knowledge of...

POSITION SUMMARY/RESPONSIBILITIES Assists Community First Health Plan (CFHP) members regain optimum health or improved functional capacity by ensuring that members have access to all of the health care services they need in the most efficient and effective manner possible. Responsibilities include but are not limited to overseeing the allocation of resources, cost and quality of health care for members; coordinating care between the primary care physician, community resources, family and member; coordinating care across the health care continuum while monitoring and managing benefit utilization; and, collaborating with multi-disciplinary health care team members in identifying the educational and discharge needs of members. EDUCATION/EXPERIENCE Registered Nurse (RN) is required. Bachelor of Science in Nursing (BSN) or Master's degree is preferred. Minimum three (3) years nursing, acute care, quality management or managed care experience is required. Basic knowledge of...

POSITION SUMMARY/RESPONSIBILITIES Assists Community First Health Plan (CFHP) members regain optimum health or improved functional capacity by ensuring that members have access to all of the health care services they need in the most efficient and effective manner possible. Responsibilities include but are not limited to overseeing the allocation of resources, cost and quality of health care for members; coordinating care between the primary care physician, community resources, family and member; coordinating care across the health care continuum while monitoring and managing benefit utilization; and, collaborating with multi-disciplinary health care team members in identifying the educational and discharge needs of members. EDUCATION/EXPERIENCE Registered Nurse (RN) is required. Bachelor of Science in Nursing (BSN) or Master's degree is preferred. Minimum three (3) years nursing, acute care, quality management or managed care experience is required. Basic knowledge of...

POSITION SUMMARY/RESPONSIBILITIES Assists Community First Health Plan (CFHP) members regain optimum health or improved functional capacity by ensuring that members have access to all of the health care services they need in the most efficient and effective manner possible. Responsibilities include but are not limited to overseeing the allocation of resources, cost and quality of health care for members; coordinating care between the primary care physician, community resources, family and member; coordinating care across the health care continuum while monitoring and managing benefit utilization; and, collaborating with multi-disciplinary health care team members in identifying the educational and discharge needs of members. EDUCATION/EXPERIENCE Registered Nurse (RN) is required. Bachelor of Science in Nursing (BSN) or Master's degree is preferred. Minimum three (3) years nursing, acute care, quality management or managed care experience is required. Basic knowledge of...

Job Summary:  Completes initial review for medical necessity for all admissions in assigned area(s), applying established criteria within 24 hours of admission. Assesses patient status, whether outpatient, observation, or inpatient and determines appropriateness of status and level of care based on criteria (Ex: Interqual). Communicates with physicians to ensure status and medical necessity are accurately determined. Refers to physician advisor and /or second level reviewer when necessary. Documents initial review, communications, and referrals in permanent medical record. For all observation patients in assigned areas, daily reviews of medical necessity will be performed and documented in medical review, including daily status update while patient is in observation status. Ongoing continued stay reviews are done for assigned areas. Concurrent reviews are to be documented in patient medical record and shared with managed care organizations when requested. Assesses for best...

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...

Job Summary :  The Clinical Appeals Specialist is responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted, the Clinical Appeals Nursing Specialist will write sound, compelling factual arguments in order to recoup revenue.    This position also facilitates collaboration between the Utilization Review Specialist's, Medical Staff, Physician Advisor, Nursing staff, Commercial Payers, VA, Managed Medicare Organizations, Medicare, and Medicaid (Center for Medicare/Medicaid Services) to ensure correct admission status as dictated by medical necessity criteria for correct reimbursement for level of care provided and to ensure that any denial is thoroughly reviewed and that an appeal letter, if warranted, is well written and submitted in a timely manner.   In addition, the following are essential duties and responsibilities of the Nurse Reviewer:...