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Qualified candidates will have prior LTSS or Medicare Inpatient Utilization Management experience within a Managed Care setting, LTSS, MLTC MAP, will have a NYS Registered Nurse License, familiar with MCG/Milliman/Interqual Guidlines and a desire to join a great team.
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Perform daily utilization management functions at designated Recovery Works/Pinnacle location(s) and take appropriate action when necessary. Minimum of five years’ experience in the mental health and substance abuse field required; experience with all target populations and direct experience performing benefits and/or utilization management in a managed care setting preferred.
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Job DescriptionAcentra is currently looking for a Utilization Management Appeals Nurse - LPN/RN to join our growing team. Job Summary:Our Utilization Management Appeals Nurse - LPN/RN will help orchestrate the seamless resolution of appeals in line with health regulations.
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The role requires a broad knowledge and focus on Utilization Management and Denials principles such as performance improvement, healthcare finance (including contractual arrangements, utilization/quality metrics, and evidence of enhancing revenue cycle), regulatory standards, utilization management, industry benchmarks, demonstrated regulatory requirement experience and medical necessity criteria.
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The Executive Director, Regulatory and Enterprise Risk Management works with legal and regulatory risk analysis and claims/litigation activities, self-insurance, and excess insurance programs, as well as other related legal and regulatory issues related to the UHealth clinical enterprise.
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Serves as a liaison with headquarters, TRICARE regional offices, MTF staff and professional organizations concerning Utilization Management practices. Must maintain a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing; the Case Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); CAMH; (AAAHC); Health Services Inspection (HSI); and other applicable DoD and Service specific guidance and policies.
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Experience in Case Management, Utilization Management, or discharge planning, This RN case manager/reviewer will be making sure that the care provided to a member will be provided in compliance with the health organization's regulatory and contractual requirements.
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Develops corporate policies, procedures, and specifications for vegetation management programs to ensure uniform practices and regulatory compliance. Provides presentations on utility vegetation management.
$107,254 - $139,431 a yearFull-timeExpandApply NowActive JobUpdated 6 days ago - UpvoteDownvoteShare Job
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By continuously reviewing and auditing participant treatment files, the Utilization Management Nurse will ensure that participants receive necessary procedures, effective treatment through collaboration with external hospital and skilled nursing facilities teams reducing the opportunity for readmission.
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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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Performs utilization management activities in accordance with accreditation standards and regulatory guidelines described in legacy Tufts Health Plan or Harvard Pilgrim Health Care UM Policy and Procedure Manual.
$271,866 - $351,826 a yearFull-timeExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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Technical expertise should include Windows 10/11, MS Office 365, Active Directory, SCCM, Intune, utilization of GPO's. Technical expertise should include Windows 10/11, MS Office 365, Active Directory, SCCM, Intune, utilization.
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Utilization management experience. Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
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Acentra is currently looking for a Utilization Management Appeals Nurse - LPN/RN to join our growing team. Our Utilization Management Appeals Nurse - LPN/RN will help orchestrate the seamless resolution of appeals in line with health regulations.
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The Interim Concurrent Review Nurse conducts telephonic concurrent review of inpatient activities and is responsible for ensuring that member care is provided at the appropriate level, for the requisite length of time.
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regulatory utilization management jobs Company: Metroplus Health Plan
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