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Case Appeals Nurse Jobs

Case Management - Nurse, Consultant
By Blue Shield of California At , Long Beach $109,120 - $163,680 a year
Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
Assumes supervisor day to day responsibilities in manager’s absence and under the direction of the manager
A minimum of 3+ year experience in inpatient, outpatient or managed care environment required
Health insurance/managed care experience desired.
Requires at least 7 years of prior experience in nursing, healthcare or related field
Transitions of care experience desired
Case Management - Nurse, Senior
By Blue Shield of California At , Rancho Cordova, 95670 $85,360 - $128,040 a year
Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)
Requires at least 5 years of prior experience in nursing, healthcare or related field
Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions.
Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable.
Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes
Nurse Case Coordinator Jobs
By NYU Langone At , New York, 10016 $88,979 - $126,399 a year
Care Coordination and Case Management for WTC responders
Assess active members for case-management service needs as clinically indicated
Develops Intensive case management Plan of Care and necessary follow-ups
Coordination with case management for post-discharge outreach
Address the unique health care needs of individual members and improve member satisfaction with the Program
Review of authorizations for medical necessity (prior authorization/prospective reviews and retrospective authorizations) as related to member’s WTC certified condition(s)
Appeals Nurse Consultant Jobs
By CVS Health At , Hartford $58,760 - $125,840 a year

Must have active and unrestricted RN licensure in state of residence

California RN license preferred (not required)

Case Management - Nurse, Senior
By Blue Shield of California At , $85,360 - $128,040 a year
Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
Provides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD).
A minimum of 1 year experience in inpatient, outpatient or managed care environment required
Health insurance/managed care experience desired.
Requires at least 5 years of prior experience in nursing, healthcare or related field
Transitions of care experience desired
Nurse Case Mgr Jobs
By Sentara Healthcare At , Norfolk, 23502
Keywords: nursing, discharge planning, managed care, case management, RN, nurse, health plan, health care, Indeed, Monster
Nursing experience 3 years required
Sentara Health Plans is currently seeking a full-time, Nurse Case Manager
Associates or Bachelor’s Degree in Nursing
Registered Nurse License (RN) - Virginia
Registered Nurse License (RN) - Compact/Multi-State License
Rn Appeals Nurse (Hybrid)
By VillageCare At New York, NY, United States

Appeals Nurse (Hybrid) VillageCareMAX 112 Charles Street, New York, NY 10014 VillageCare is looking for a self-motivated and passionate RN for our Appeals Nurse position. While supporting the ...

Sr Nurse Case Analyst (Remote)
By CSX At ,
Knowledge of FRA Conductor and Engineer certification requirements
Review medical qualification of new hires, job transfers and certification examinations
Miscellaneous activities and responsibilities as assigned by manager
Knowledge of FRA drug testing requirements
Knowledge of Commercial Driver's License (CDL) medical requirements
3 or more years of work experience in the medical field
Nurse Appeals (Contract) Jobs
By Elevance Health At , Los Angeles
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
Sr Nurse Case Analyst (Remote)
By CSX At United States
Knowledge of FRA Conductor and Engineer certification requirements
Review medical qualification of new hires, job transfers and certification examinations
Miscellaneous activities and responsibilities as assigned by manager
Knowledge of FRA drug testing requirements
Knowledge of Commercial Driver's License (CDL) medical requirements
3 or more years of work experience in the medical field
Nurse Case Mgr Ii
By Elevance Health At Phoenix, AZ, United States
Preferred Skills, Capabilities, And Experiences
Monitors and evaluates the effectiveness of the care management plan and modifies, as necessary.
Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
Assists with the development of utilization/care management policies and procedures.
Certification as a Case Manager is preferred.
Prior managed care experience is strongly preferred.
Nurse Appeals Jobs
By Elevance Health At Florida, United States
Job Family: Medical and Clinical
National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint
Resolving member clinical grievances (complaints).
Conducts investigations and reviews of member grievances and potential quality of care issues.
Reviews medical records for potential quality of care issues.
Extrapolates and summarizes medical information for medical director.
Nurse Appeals Jobs
By Elevance Health At United States
Job Family: Medical and Clinical
National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint
Resolving member clinical grievances (complaints).
Conducts investigations and reviews of member grievances and potential quality of care issues.
Reviews medical records for potential quality of care issues.
Extrapolates and summarizes medical information for medical director.
Appeals Case Manager Ii
By Guardian Life At United States
Utilize effective claim management skills to plan, implement and execute the investigation of disputed claims; ensure timely and compliant appeal resolution.
Demonstrated ability to manage multiple tasks in accordance with regulatory requirements.
A minimum of 5 years of Group Disability and/or Life claims experience.
A minimum of 3 years of experience handling appeals or complex claims (preferred).
Bachelor’s Degree (preferred) or equivalent professional experience.
A client focus with excellent verbal and written communication skills.
Appeals Nurse Jobs
By Netsmart At United States
At least 3 years of case management, concurrent review or utilization management experience
Prepare professional, effective clinical appeals in response to managed care, governmental, or RAC denials for hospital clients.
At least 5 years of clinical experience in acute care setting
Participate in telephonic Administrative Law Judge Hearings and present oral arguments for reversing Medicare denials.
Bachelor of Science degree in Nursing
Proficiency in medical record review
Case Manager Nurse Jobs
By Clinical Management Consultants At Redondo Beach, CA, United States

A nearly 450 bed medical center in southern LA County is seeking a Nurse Case Manager. The RN Case Manager will enjoy the supportive environment at this hospital that is part of a regional healthcare ...

Appeals Nurse Jobs
By Mindlance At Ohio, United States
Experience with Utilization Review/Management--2 yrs
Utilization review nurse, appeal review nurse and direct patient care experience.
Share resume at : [email protected]
Behavior and accountability and ability to pivot when new priorities come up
Describe the performance expectations/metrics for this individual and their team:
What previous job titles or background work will in this role?
Nurse Appeals Jobs
By Elevance Health At Ashburn, VA, United States
Preferred Capabilities, Skills And Experiences
Location: Remote – OH, VA, NY, FL
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Nurse Appeals Jobs
By Elevance Health At Columbus, OH, United States
Preferred Capabilities, Skills And Experiences
Location: Remote – OH, VA, NY, FL
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Nurse Appeals Jobs
By Elevance Health At Richmond, VA, United States
Preferred Capabilities, Skills And Experiences
Location: Remote – OH, VA, NY, FL
Job Family: Medical and Clinical
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.