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May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination.
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INTERVENTIONS - Monitor and evaluate short-term and long-term patient responses to interventions in collaboration with quality assurance and utilization review, maintaining interdependent follow-up as necessary.
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Attend certification inspections, utilization review and independent professional reviews as needed. Ensure all work is reviewed and cosigned by an agency Registered Nurse (to be scheduled by clinical supervisor) Administer TB tests.
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Performs prior authorization, precertification, and retrospective reviews and prepares decision letters as needed in support of the utilization review contract Assists management with training new Nurse Reviewers to include daily monitoring, mentoring, feedback and education.
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While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies.
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Monogram’s innovative, in-home approach utilizes a national nephrology practice powered by a suite of technology-enabled clinical services, including case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs across the healthcare continuum.
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Enhances the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness through the integration of functions of case management, utilization review and management, and discharge planning.
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2 years of experience in any combination of case management, home care and utilization review preferred. Patient Care Coordinator Buffalo General Medical Center Full Time Days Job Description Has the responsibility of collaborating with members of the interdisciplinary team to coordinate care, facilitate utilization and resource management and discharge planning functions, working to achieve optimal outcomes for the patient in the acute care setting.
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Plays a leadership role in utilization review committee which includes identification of opportunities for appropriate utilization of resources to avoid denials and resource management as it pertains to delivery of care.
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Conducts utilization review using nationally recognized medical necessity criteria and documents the review. Participates in infection control activities by screening, monitoring, and reporting individual cases and/or trends to the infection control nurse.
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Registered Nurse - Utilization Review TRS Healthcare is seeking a Registered Nurse who is licensed to work in TX, and has Utilization Review experience. 1 year of recent experience specializing in Utilization Review.
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Activities include concurrent clinical management, discharge planning, social work and utilization review. Qualifications Skills Behaviors : Motivations : Education Experience Required 2 years: Clinical experience Licenses & Certifications Required BLS Registered Nurse Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant.
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Experience in case management, utilization review, or discharge planning a plus. Follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with external review agencies.
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Summary We are seeking a talented individual for a Nurse Reviewer who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided.
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Quality support from a single point of contact REMOTE POSITION Utilization Review RN REQUIRED: Three years of acute care nursing experience. Knowledge of health insurance standard, utilization management, appeals, or claims processing.
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utilization review nurse jobs
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