! Job Summary Responsible for receiving, processing and documenting referral or prior authorization requests from the clinical... areas. Provides customer service and support for the clinical areas and patients for referrals and prior authorizations...
as compliance and turnaround time of grievances and appeals Education/Experience: Bachelor's degree in Nursing or related... clinical field or equivalent experience. Master's’ degree preferred. 10+ years of healthcare operations experience, including...
coordinating with the Director of UR, VP of Clinical Operations, Division President, and treatment teams. Acting as a liaison... between clinical teams and other departments, this position is responsible for ensuring that documentation and utilization review...
responsibilities include: Analyze and resolve complaints/appeals: Gather and organize key information, ensuring a thorough review... medical records using clinical guidelines to determine medical appropriateness, investigating member history, clinical...
for: a) Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review b) Preparing... potential of clinical disputes/denials or those eligible for clinical review. Demonstrates proficiency in use of medical...
requests for medications, collaborating with primary care and specialty providers to gather necessary clinical documentation... guidelines. Follow-up and Appeals: Monitor the progress of prior authorization requests and drug program applications, managing...
’ concerns requiring clinical interpretation to the appropriate provider (MD, RPh, RN, NP, PA). 8. Resolves patients’ payer..., clinical, non-clinical) operating in a “hands on” environment. The majority of time is spent in the delivery of support...
discovering clinical innovations and enhancing access to the most up-to-date facilities, equipment, technologies, and research.... Utilization Review Coordinator Cayuga Health System seeks a motivated and experienced individual to join the Clinical Resource...
management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members... and those involved with members’ care including clinical nurses and treating physicians. Your Work In this role...
(UM) and care management (CM) activities demonstrating clinical judgement and independent analysis, collaborating with members... and those involved with members’ care including clinical nurses and treating physicians. Your Work In this role, you will: Research...
) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members...’ care including clinical nurses and treating physicians. The Triage Registered Nurse Case Manager will report to the FEP...
management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating... with members and those involved with members’ care including clinical nurses and treating physicians. The Regional Registered Nurse...
Your Role The Case Management team performs and case management (CM) activities demonstrating clinical judgment... and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating MDs...
, such as Medicare and FEP. Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance. Clinical..., Disease Management, Appeals and Grievance and Quality Departments, as necessary. Identifies potential over-payments: - CISD...
Minimum Qualifications Current and valid Pennsylvania Registered Nurse License Minimum two (2) years clinical... (MDR), Recommendation for Improvement (RFI) As needed, represent OLTL at hearings and appeals related to reportable...
compliance with customer expectations and lead clinical quality initiatives. Review clinical information for appeals to determine... Performance Improvement Projects (PIPS) Review clinical information for appeals to determine medical necessity Prepare...
support for the Clinical Resource Management Department by serving as a liaison with external agencies and third party payers.... The Utilization Management Specialist will apply approved clinical appropriateness criteria, InterQual™ Acute Care...
support for the Clinical Resource Management Department by serving as a liaison with external agencies and third party payers.... The Utilization Management Specialist will apply approved clinical appropriateness criteria, InterQual™ Acute Care...
clinical judgment and independent analysis, collaborating with members and those involved with members care including clinical... Management (DM) and Appeals and Grievance department (AGD) Recognize the clients right to self-determination as it relates...
! CNA's provide care to our residents under the direction of the RN or LPN on duty. CNA's perform appropriate charting... and regulatory standards. Timely report any changes in resident condition to the RN/LPN on duty. Perform and chart Activities...
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