patient appeals. Prepare case presentations, as directed, for Medical Grievance Review Claims and Utilization Review Committee.../but not limited to; pre, post, and focused audits, clinical component of appeals, policy preparation and review, creation of Desk Top...
patient appeals. Prepare case presentations, as directed, for Medical Grievance Review Claims and Utilization Review Committee.../but not limited to; pre, post, and focused audits, clinical component of appeals, policy preparation and review, creation of Desk Top...
and Utilization Review. Qualifications: Registered Nurse required Bachelor’s Degree in Nursing required Director of Case... appeals processes and works collaboratively with vendors to ensure the effectiveness and timeliness of appeals Analyzes...
) Utilization Management Experience (EX. Concurrent Review, Prior Authorization, Medical Audits, Appeals or Delegation) Experience... include: nurse education, care coordination and general assistance with managing day to day functional needs; assisting...
) Operations Medical reimbursement and policy Care management (utilization management, case management, PA, appeals... and medical necessity of healthcare services provided to Plan members Conducts retrospective reviews of claims and appeals...
for Utilization Review to maximize LOS efficiency. Coordinate and monitor compliance with 60% rule. Responsible for monitoring patient... chart review of medical record and updates IRF-PAI as necessary. Collaboration with IRF physicians to ensure accuracy...
services Participates in and facilitates patient/family education and communication Utilization Review Identifies need... documentation of non-commercial utilization review function per hospital policy and federal and state requirements Utilizing...
Job Summary The Utilization Management Nurse is responsible for the appeal process for the inpatient adult population... a bachelor's degree in healthcare related field and two years of Case Management, Utilization Management or Utilization Review...
Job Summary The Utilization Management Nurse is responsible for the appeal process for the inpatient adult population...'s degree in healthcare related field and two years of Case Management, Utilization Management or Utilization Review work...
for discharge Conducts utilization review in a timely manner and communicates with third party payers in a timely and accurate... Utilization review, Discharge planning and / or Case management Is cooperative in interactions, treating customers...
for discharge Conducts utilization review in a timely manner and communicates with third party payers in a timely and accurate... Utilization review, Discharge planning and / or Case management Is cooperative in interactions, treating customers...
, Social Work, Discharge Planning, Denials and Appeals Management, Utilization Review, Quality and Peer Review. The Director... direction and leadership in the oversight and management for Care Management, Social Work, Discharge Planning, Utilization...
and provides information to the department head as indicated. * Utilization review and utilization management The RN CM... areas. This position requires the ability to combine clinical/quality considerations with regulatory/financial/utilization...
the Medicare workflows related to denial review and appeals management, including the preparation of documents... collaboratively with Plan departments and will be responsible for review and interpretation of current medical policies...
Nurse License in good standing Current BLS certification by the American Heart Association ACM certification preferred... to use verbal, non-verbal and written communication skills which reflect nursing standards. Knowledge of current utilization...
with Utilization and Care Management Departments to assist in the review process for initial organizational determinations. Liaison... responsible for management and end to end processing of clinical appeals, grievances and quality of care concerns that conforms...
Nurse License in good standing Current BLS certification by the American Heart Association ACM certification preferred... to use verbal, non-verbal and written communication skills which reflect nursing standards. Knowledge of current utilization...
or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review... of medical claims and utilization practices. 80% May provide any of the following in support of medical claims review...
improvement activities relevant to identified opportunities. · Actively collaborates with utilization review team to facilitate... and facilitating efficient throughput, ensuring appropriate utilization of resources, identifying needs, and establishing safe...
will review all referrals prior to admission Admission Nurse , will be our liaison between Crestview and Grady hospital, work... and experience with Appeals/Denials process. Broad clinical background in acute and long term care with knowledge of payer mix...