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Job Description
Job Description...
* Performs utilization management reviews in accordance with federal and state regulations
* Maintains compliance with regulatory changes affecting utilization management
* Perform UM reviews (prospective/concurrent/retrospective) for inpatient services according to the NCQA, URAC, CMA & DOH standards and client requirements and/or policies
...

We’re unique. You should be, too.
We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?
We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.
The Physician Revie...

JOB SUMMARY
The NY Workers' Compensation CSR / IME SCheduler is responsible for receipt of new cases and ensuring proper system drafting and setup. The CSR also is responsible for taking direction and facilitating the case assignment/scheduling process.
Dane Street's success relies on individual and team contributions every day. We care for our customers, each other and Dane Street. It is the r...

Overview
Empower AI is AI for government. Empower AI gives federal agency leaders the tools to elevate the potential of their workforce with a direct path for meaningful transformation. Headquartered in Reston, Va., Empower AI leverages three decades of experience solving complex challenges in Health, Defense, and Civilian missions. Our proven Empower AI Platform® provides a practical, sustain...

Company Overview
Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.
Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership ...

Current Employees:
If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this tip sheet.
The Clinical Documentation Integrity (CDI) Second Level Reviewer performs high-level, complex, secondary case reviews to faci...

Job Responsibilities
* Develop and administer inter-reviewer reliability methodology to ensure medical necessity determinations are consistent with CMS published guidelines corporate medical review criteria, and medical policy guidelines.
* Analyze, evaluate and apply clinical metrics that produce actionable information in support of medical management and quality improvement initiative...

Job Title
Clinical Services Specialist RN
Job Type
Full-Time
Category
Medical Services
Location
Work from Home FSM Based - Fort Smith, AR 72903 US (Primary)
Education
Associate Degree
Travel
0 - 10%
Job Description
SCOPE OF POSITION:
Responsible for analyzing patient records to determine legitimacy and necessity of medical services in compliance with government reimbursement policies. Review m...

JOB RESPONSIBILITIES
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Medical Review - Performs medical review activities pertaining to delegated pediatric services including medical review of complex, controversial, or experimental medical services.
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Quality - Assists Medical Director in improving quality and cost-effectiveness of care and service for members and provides medical expertise in the operation of approved quality i...

Company :
Highmark Inc.
Job Description :
JOB SUMMARY
This job provides front line staff guidance, ensures effective and efficient delivery of Pharmacy call center services. Serves as first line reviewer in monitoring and ensuring adherence to the health plan’s state and federal multiple drug benefit design offerings. The incumbent responds to physician and pharmacy network provider inq...