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The UMQM Nurse shall also participate in Utilization Management related activities with the Appeals and Grievance Department as well as the Compliance Department to assure that the quality compliance is being met for NCQA, state and federal regulatory requirements.
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From conducting any utilization management activities that require clinical information interpretation. Collection and data entry of structured clinical data (including diagnosis codes, procedures, procedure codes) and demographic information into the Novare Utilization management System DDR.
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Five years of experience in clinical setting analyzing data and performing reviews such as utilization management, quality assurance, charge capture, coding, billing and medical necessity to facilitate correct claims submission to federal and state payers required.
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RN, care management, case management, UAS, ambulatory care, community health, Home health, LTSS, MLTC, medicaid, utilization management. Understanding of the basic Utilizations Management aspects of the department.
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The Utilization Management Nurse 2 reviews the medical documentation, completes telephonic reviews with the Utilization Reviewer at the Acute Care Facilities to obtain sufficient clinical information.
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Is prepared to conduct PPS meetings maintaining MDS assessments per Medicare schedule and maintains PPS board for monitoring of Medicare days and RUGs utilization in the absence of the Care Management Coordinator.
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REQUIRES : Bachelor’s degree or foreign degree equivalent in Civil Engineering, Construction Management or related field and 1 year of experience as Project Engineer, Cost Estimator, Construction Advisor, or any related occupation working with large construction or engineering projects.
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Maintains a smooth, constant flow of patients from reception to operatories in a fast paced environment; is able to effectively coordinate with RDA Lead and/or Clinic Supervisor the activities of several operatories efficiently through proper utilization of time, resources, abilities and patient needs.
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The Field Reimbursement Manager will be responsible for the management of defined accounts in Urology and Oncology area, specifically supporting our client's product. The Reimbursement Manager will also work on patient level reimbursement issue resolution, and thus will need access to be knowledge of and have had experience with patient health information (PHI), navigating access issues, and working with payer and NCCN guidelines for product utilization.
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Payer Formularies and restrictive Utilization Management Criteria including: Prior Authorization Processes, Step Edits, Appeals, detailed Clinical Documentation, Peer to Peer reviews etc.
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Obtain all necessary construction permits for assigned projects, including dewatering, drainage, water and sewer, and other underground utilities, maintenance of traffic, right of way utilization, and fire line permits.
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Demonstrated level of proficiency with support technology (e.g., PC, tablet, & Customer Relationship Management (CRM) tools) The Field Reimbursement Manager will execute the collaborative territory strategic plan through partnership with internal and external stakeholders, including acting as an extension of patient support program and in other collaboration with other partners.
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Requires dedicated and focused customer facing support through the Reimbursement Management Team. The Field Reimbursement Manager is a critical front-line member of the Regeneron Commercial and Field Reimbursement Management team.
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The Utilization Management Quality Management (UMQM) Nurse position is meant to ensure the quality of the work of the individuals in the Prior Authorization Department. This position reports to the Director of Utilization Management.
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The Field Reimbursement Management reports to the District Manager of Field Market Access. Field Reimbursement Manager, Immunology Position Summary: The Field Access & Reimbursement environment for specialty biologics has proven to be highly challenging for HCPs and Patients.
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