FULL_TIME

FEED

OTHER

Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources.

TriWest Healthcare Alliance

Utilization Clinical Reviewer

equestftpin

Utilization Management Clinical Reviewer

UNKNOWN

4- 6 years previous relevant experience in clinical documentation, or CDI second level review or inpatient coding quality review and/or DRG validation with a strong understanding of disease processes, clinical indications and treatments; provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according the rules of Medicare, Medicaid, and commercial payors as well as a solid understanding of hospital acquired conditions (HAC’s), patient safety indicators (PSI’s) and mortality models. Duties: Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and queries the provider using concurrent query process following ACDIS/AHIMA Guidelines for Compliant Query Writing.

Guidehouse

Second Level Reviewer-Clinical Documentation Integrity

4- 6 years previous relevant experience in clinical documentation, or CDI second level review or inpatient coding quality review and/or DRG validation with a strong understanding of disease processes, clinical indications and treatments; provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according the rules of Medicare, Medicaid, and commercial payors as well as a solid understanding of hospital acquired conditions (HAC's), patient safety indicators (PSI's) and mortality models. Duties: Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and queries the provider using concurrent query process following ACDIS/AHIMA Guidelines for Compliant Query Writing.

YEAR

Guidehouse Inc

Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews; refrains from using case studies, cohorts, and the like to make decisions due to their limited sample sizes. Performs other duties as assigned, including identifying and responding to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits.

Dane Street, LLC

Physician Reviewer - (Ophthalmology, Otolaryngology, OB/GYN)

ea_via_bold

Physician Reviewer - (Ophthalmology, Otolaryngology, Ob/Gyn)

Additional responsibilities include consenting, conducting subject visits, specimen collection/processing/shipping, IP management, data entry, query resolution, participant payment processing, research billing review, subject and study documentation, assessing logistics for study implementation, ensuring compliance with study protocols and regulatory requirements, and supporting data analysis. As the Gastroenterology (GI) Clinical Research Nurse Coordinator (CRNC) you will support the divisional research portfolio by utilizing clinical nursing assessment skills to plan, provide, supervise, and document professional nursing care utilizing the nursing process for research participants in accordance with physician orders, study protocols, and established policies and procedures.

Duke University

Clinical Research Nurse Coordinator

You'll join a fast-paced, growth-oriented environment where you can continue impacting patient access to innovative therapies, apply regulatory knowledge across multiple therapeutic areas, influence drug development strategies earlier in the product lifecycle, and serve as a trusted advisor to industry leaders. If you have built your career at the FDA as a Clinical Pharmacology Reviewer, Master Reviewer, Team Lead, or other senior role as a subject matter expert in Clinical Pharmacology, this role offers a unique opportunity to leverage your regulatory expertise across a diverse portfolio of innovative development programs.

The expertise and passion for excellence shared by our people around the world unites us in our mission and drives our success. As a premier service provider to the global biopharmaceutical industry, we give you the opportunity to work with industry-leading clients in an exciting, collaborative environment where career choices and development paths are abundant, and projects are challenging. In fact, PAREXEL works with the top 50 global pharmaceutical companies, the top global biotech companies, and hundreds of small and emerging companies. With over 30 years of experience, we have supported the development of some of the most important treatments of our time, including nearly all of the 50 top selling drugs currently on the market. We offer our employees the ability to make a difference globally, while we support them locally in environments full of challenge, collaboration, flexibility and industry-leading growth potential. Discover a career at PAREXEL, where exciting challenges and opportunities await you.

Parexel International Corp

Vice President, Regulatory Science - Clinical Pharmacology SME

Composed of more than 2,600 faculty physicians and researchers, nearly 2,000 students, and more than 6,200 staff, the Duke University School of Medicine along with the Duke University School of Nursing, and Duke University Health System comprise Duke Health, a world-class academic medical center. You will be responsible for all day to day study activities (such as subject consent and enrollment, data collection and entry, participant compensation, study monitoring activities, etc.), and will work with the lead coordinator to manage regulatory tasks (such as study start up and close out, IRB tasks, etc.).

Clinical Research Coordinator

Participates in or leads day-to-day clinical research data operations conducted by Principal Investigator(s) within the Leukemia Clinical Research Team (CRT) as part of the Hematologic Malignancies and Cellular Therapies (HMCT) research groups within Duke Cancer Institute's (DCI) Oncology Clinical Research Unit (CRU); performs a variety of duties involved in the collection, compilation, documentation, and analysis of clinical research data. Composed of more than 2,600 faculty physicians and researchers, nearly 2,000 students, and more than 6,200 staff, the Duke University School of Medicine along with the Duke University School of Nursing, and Duke University Health System comprise Duke Health, a world-class academic medical center.

Clinical Data Manager

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. The Behavioral Health Utilization Management Representative I - Backoffice Support is responsible for processing precertification, prior authorization, and post-service requests for governmental and commercial lines of business.

HOUR

Elevance Health Inc

Utilization Management Representative I - Backoffice Support

This position also facilitates collaboration between the Utilization Review Specialists, Medical Staff, Physician Advisor, Nursing staff, Commercial Payers, VA, Managed Medicare Organizations, Medicare, and Medicaid (Center for Medicare/Medicaid Services) to ensure correct admission status as dictated by medical necessity criteria for correct reimbursement for level of care provided and to ensure that any denial is thoroughly reviewed and that an appeal letter, if warranted, is well written and submitted in a timely manner. Additionally, works with outside surgical offices when called upon, to provide Medicare Inpatient Only List knowledge to ensure that surgical procedures are correctly called in and billed appropriately.

CaroMont Health

Utilization Review RN Appeals Specialist

Retrospectively reviews discharged medical record for medical necessity criteria and sends pertinent clinical information to meet guidelines for additional length of stay to MCO via fax, Provider Link, or telephone. For all observation patients in assigned areas, daily reviews of medical necessity will be performed and documented in medical review, including daily status update while patient is in observation status.

Utilization Review Specialist LPN

Processes incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for precertification and/or prior authorization, and reviews supporting documentation (clinical notes/labs when applicable) to meet payer-specific criteria. Responds to telephone and written inquiries from clients, providers and in-house departments; communicates authorization status updates to providers/clinical staff, and supports denial follow-up by coordinating additional medical necessity information when needed.

Elevance Health

Utilization Management Representative II

Minimum Requirements: Requires MA/MS in social work counseling or a related behavioral health field or a degree in nursing and minimum of 3 years of experience with facility-based and/or outpatient psychiatric and substance abuse or substance abuse disorder treatment; or any combination of education and experience which would provide an equivalent background. However, for states that do not require licensure a Board Certified Behavioral Analyst (BCBA) is also acceptable if all of the following criteria are met: performs UM approvals only, reviews requests for Applied Behavioral Analysis (ABA) services only, and there is licensed staff supervision.

Clinical Reviewer Jobs in North Carolina

Utilization Clinical Reviewer TriWest Healthcare Alliance

Utilization Management Clinical Reviewer TriWest Healthcare Alliance

Second Level Reviewer-Clinical Documentation Integrity Guidehouse

Second Level Reviewer-Clinical Documentation Integrity Guidehouse Inc

Physician Reviewer - (Ophthalmology, Otolaryngology, OB/GYN) Dane Street, LLC

Physician Reviewer - (Ophthalmology, Otolaryngology, Ob/Gyn) Dane Street, LLC

Clinical Research Nurse Coordinator Duke University

Vice President, Regulatory Science - Clinical Pharmacology SME Parexel International Corp

Clinical Research Coordinator Duke University

Clinical Data Manager Duke University

Utilization Management Representative I - Backoffice Support Elevance Health Inc

Utilization Review RN Appeals Specialist CaroMont Health

Utilization Review Specialist LPN CaroMont Health

Utilization Management Representative II Elevance Health

Behavioral Health Care Manager I Elevance Health

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