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Elevance Health
Overview
Conduct clinical case reviews to determine the medical necessity of therapy services and lead peer-to-peer calls with providers. Document findings and ensure decisions comply with company medical policies and regulatory standards.
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Compensation
Salary not listed
Posted
4 days ago
Ochsner Health
The RN Clinical Surgical Reviewer is responsible for managing the STS database, ensuring accurate data collection and submission for surgical patients. This role involves collaboration with various departments to identify clinical quality improvement opportunities.
AmeriCare
The Quality Reviewer RN ensures the accuracy, completeness, and integrity of documentation completed by the COC. The primary focus is ensuring OASIS assessments comply with CMS Regulatory Requirements and Guidance Manual conventions.
Bienvivir All-Inclusive Senior Health
Responsible for scanning, auditing, and organizing medical records within the EMR system to ensure accuracy and regulatory compliance. Manages medical record requests for hospitalizations and visitors while coordinating with external facilities and nursing homes.
$13 - $20 / HOUR
Gainwell Technologies LLC
The Nurse Reviewer will perform clinical reviews to assess the appropriateness of care based on medical record documentation. This includes documenting findings, determining approvals, and assisting in training new Nurse Reviewers.
$65,000 - $75,000 / YEAR
Liberty Healthcare Corporation
The role involves reviewing Medicaid HCBS waiver providers through onsite visits and critical incident management. The specialist is responsible for evaluating person-centered care practices and writing comprehensive summary reports.
$55,990 / YEAR
5 days ago
Palm Medical Centers
The role involves reviewing medical referrals to determine medical necessity and ensure compliance with CMS guidelines. It requires collaborating with healthcare providers and documenting findings to facilitate coordinated patient care.
Blue Cross Blue Shield of Massachusetts
The role involves conducting pre-certification, concurrent, and retrospective reviews to ensure medically necessary services are authorized at the appropriate level of care. The reviewer collaborates with a multidisciplinary team to develop cost-effective care plans and monitor clinical quality concerns.
$39 - $48 / HOUR
6 days ago
The Cigna Group
Perform clinical case reviews for molecular and genetic testing requests to authorize coverage based on established protocols. Serve as an expert advisor for physicians and laboratories regarding the appropriate use of current and emerging genetic tests.
$73,200 - $122,000 / YEAR
9 days ago
The DRG Nurse Reviewer Appeals and Hearings coordinates and performs all appeal-related duties, including analyzing and responding to provider appeals and preparing case files for hearings. The role also involves participating in hearings and assisting in training new reviewers.
$90,000 - $99,000 / YEAR
Prime Therapeutics
This role involves providing timely medical review for service requests that do not initially meet medical necessity guidelines, often interacting with requesting physicians and providers. Responsibilities include discussing determinations, providing clinical rationale for appeals, and ensuring documentation accuracy according to established guidelines.
$91 - $154 / HOUR
10 days ago
This role involves providing timely medical review for service requests that do not initially meet medical necessity guidelines, requiring interaction with physicians and providers to discuss determinations and provide clinical rationale for appeals. The reviewer also assists in maintaining consistency by utilizing clinical review guidelines and participating in training and research activities related to utilization management.
This role involves providing timely medical review for service requests that do not initially meet medical necessity guidelines, often interacting with physicians and management staff. Responsibilities include discussing determinations with requesting providers and providing clinical rationale for standard and expedited appeals.
The Physician Clinical Reviewer provides timely medical review of service requests that do not meet initial medical necessity guidelines, routinely interacting with physicians and staff. Responsibilities include discussing determinations with requesting providers, providing clinical rationale for appeals, and ensuring consistency using medical review guidelines.
The Physician Clinical Reviewer conducts timely medical reviews of service requests that do not meet initial necessity guidelines. They also provide clinical rationale for appeals and act as a resource for the utilization management team.
This role involves providing timely medical review for service requests that do not initially meet medical necessity guidelines, requiring routine interaction with physicians and management staff. Responsibilities include discussing determinations with requesting providers within regulatory timeframes and providing clinical rationale for standard and expedited appeals.
The Physician Clinical Reviewer provides timely medical review of service requests that do not initially meet medical necessity guidelines, interacting with providers and staff as needed. Responsibilities include reviewing complex cases, discussing determinations with requesting physicians, providing clinical rationale for appeals, and ensuring compliance with various guidelines and policies.
HealthFirst
The Medical Peer Reviewer consults on medical necessity within utilization management, ensuring adherence to internal and external regulations by assessing authorization requests and claims payments based on medical records. This role involves rendering determinations within regulatory timeframes, maintaining productivity standards, and collaborating across various medical and management departments.
$122,907 - $188,020 / YEAR
11 days ago
Acentra Health, LLC
Review medical records against regulatory standards and criteria to determine the medical necessity and appropriateness of care. Coordinate with physician consultants for denials and ensure all documentation aligns with NCQA, URAC, and CMS benchmarks.
