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Assist in the development and implementation of utilization management programs including but not limited to: prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling medical policy review and development, member facing outreach initiativesDevelop and implement physician, pharmacy, account, and member educational initiatives that promote the Organization's Formularies, utilization management programs, and disease management initiatives.
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This position assists with the evaluation of risk, development of risk control strategies, review and negotiation of indemnification and insurance issues for all projects, and the annual corporate insurance renewal.
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The ROSA Zone Program Development Director builds successful programs by aligning with key stakeholders including surgeons, staff , executives and local implant teams to drive system utilization with the ROSA Robotic Knee Platform.
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2 years Case Management / Utilization Review in a hospital, post-acute or insurance/third party payer setting. Working knowledge of CMS guidelines and regulations governing discharge planning and utilization management.
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Reviews medical files and provides recommendations for utilization review, chart reviews, medical necessity, appropriateness of care and return to work, short and long-term disability, Family and Medical Leave Act (FMLA), Group health and workers’ compensation claims.
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Provide review and challenge on forecasting assumptions, projection results, and utilization of RLAP and RLEN methodologies and frameworks to estimate liquidity needs. If you are a person with a disability and need a reasonable accommodation to use our search tools and/or apply for a career opportunity review Accessibility at Citi.
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Duties: Coordinates utilization review s of managed care contracts using established guidelines and processes. Communicates w with physicians, discharge planners and others to process referrals, authorization for services, and capture data related to utilization.
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Attend certification inspections, utilization review and independent professional reviews as needed. Review monthly the medication record of each resident for potential adverse reactions, allergies, interactions, contraindications, rationality, and laboratory test modifications; advises the physician of any medication errors and indicated changes.
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Troubleshoot utilization review and medical necessity related issues utilizing AMM or other UR vendor's website information, and route claims for review accordingly. The Associate Claims Adjuster (Medical) - Remote is responsible for the review, investigation, decision making, and processing of production claim types, and all related claim functions and activities.
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Five (5) years of experience in an acute care setting requiredTwo (2) years of experience in case management/utilization review/quality improvement leadership position required. Develops and implements strategies to improve workflows and processes/procedures to enhance the utilization review program.
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Collect data and produce enrollment, claims, utilization reports from COGNOS, Tableau, Facets, and other databases/reporting tools. Evaluate risk using demographics, claims experience, predictive modeling, high-cost claimant review, and other criteria.
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Accurately a document review findings and provides clinical information to 3 rd party payers. Coordinates and ensures delivery of care; collects utilization management and quality assessment data; regularly interacts with physicians to clarify plans of care; and reviews patients for high-risk criteria for discharge planning needs.
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Minimum of 5 years medical advisory experience in occupational health, worker compensation, disability, health case management, or utilization review. Ensure quality standards for case management are met; implement Reed Group’s continuous quality improvement process whenever efficiencies or quality standards are not met.
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The Department of Care Management at SUNY Downstate Health Sciences University is seeking a full-time Utilization Review Nurse. Prior hospital and/or community-based Care Management and Utilization Review experience.
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Develops and implements tools (e.g., surveys, tracking tools) to gather data and track status of current/graduated client for utilization review, quality assurance and evaluation of overall effectiveness of the program.
$109,900 - $146,500 a yearExpandApply NowActive JobUpdated Today
utilization review jobs in New York, NY
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