TriWest Healthcare AllianceUtilization Clinical Reviewer TriWest Healthcare AllianceUtilization Clinical ReviewerCharlotte, NCRemoteFull timeApplies 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.
CVS Health CorpPrior Authorization Clinical Reviewer CVS Health CorpPrior Authorization Clinical ReviewerNC$26.01–$74.78 / yearApplication of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
TriWest Healthcare AllianceClinical Quality Reviewer TriWest Healthcare AllianceClinical Quality ReviewerCharlotte, NCRemoteFull timeo Bachelor's in Nursing or Certified Professional in Healthcare Quality (CPHQ) o 1 or more years team lead or supervisory experience o 1 year experience in Quality Management o 1 year experience with data analysis and reporting o Experience with InterQual or similar criteria sets o General knowledge of Medicare, Veterans Administration, or other government health care programs. Technical Skills: General knowledge of Medicare, Veterans Administration, or other government health care programs; knowledge in the application of clinical criteria: InterQual, Milliman, PAS-LOS, ICD-9-CM, DSM, CPT-4, and HCPCs; Proficient with Microsoft Word and Excel.
MMSNewCardiology Medical Reviewer (Project-Based) - Remote MMSCardiology Medical Reviewer (Project-Based) - RemoteRaleigh, NCRemotePart timeWith a global footprint across four continents, MMS not only maintains an industry-leading customer satisfaction rating but also fosters a collaborative and inclusive work environment where employees can thrive. Responsible for strategies in pre and post marketing risk management, as well as keeping abreast of pharmacovigilance methods and trends in published literature and global regulations.
TriWest Healthcare AllianceClaims Reviewer TriWest Healthcare AllianceClaims ReviewerCharlotte, NCRemoteFull timeProficient with claim and coding tools and resources, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management, and/or the Claims Subcontractor as needed.
Zelis Healthcare, Inc.NewInpatient DRG Reviewer-3 Zelis Healthcare, Inc.Inpatient DRG Reviewer-3NCWhere the regrouped 'new DRG' differs from what was originally claimed by the provider, write a customer facing 'rationale' or 'findings' statement, highlighting the problems found and justifying the revised choices of new codes and DRG, based on the clinical evidence obtained during the review. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.
TriWest Healthcare AllianceSr Claims Reviewer TriWest Healthcare AllianceSr Claims ReviewerCharlotte, NCRemoteFull timeProficient with claim and coding tools such as Supercoder, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. This role will serve as a SME and will collaborate with Claims leadership, Training, the Claims Content Specialist, and internal business partners to ensure procedures and training materials are accurate and complete.
Duke UniversityNewCLINICAL RESEARCH COORDINATOR Duke UniversityCLINICAL RESEARCH COORDINATORDurham, NC$59,829–$99,960 / yearIn the Bellwether Collaborative for Health Justice, we look for a diverse pool of applicants including those from historically marginalized groups - people with histories of incarceration, people with disabilities, women, people who are lesbian, gay, bisexual, transgender, gender non-conforming, people with lived experiences of addiction and mental health conditions, people of color, first and second generation college students, first and second generation immigrants, rural backgrounds, veterans, and people from different socioeconomic backgrounds. Interpersonal Skills: The hired candidate will build successful, respectful, collaborative relationships with participants, community partners, and institutional stakeholders (e.g., community-based organizations, healthcare providers, and criminal legal system partners), using culturally responsive and trauma-informed approaches.
Zp Group LlcNewRemote Utilization Management/Review Nurse Zp Group LlcRemote Utilization Management/Review NurseCary, NCRemote$65,000–$75,000 / yearLocation: Remote (Eligible in Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming). This role applies clinical expertise, regulatory knowledge, and critical thinking to support high-quality, compliant care decisions while collaborating with providers and internal teams.
UNC HealthNewUtilization Review Nurse UNC HealthUtilization Review NurseKinston, NC$32.48–$38.98 / hourTo accomplish these goals, the UR, Nurse applies established criteria to evaluate the appropriateness of admission, level of care, continued hospitalization and readiness for care transition; assures timely movement of patients throughout the continuum of care by conducting concurrent review and proactively resolving care, service, or transition of care delays/issues as necessary; in collaboration with the care team. Responsibilities: Patients/Families, Hospital staff, Medical staff, Community agencies, and Insurance Companies are served by conducting interpersonal relationships in a manner that projects a positive image of the department and hospital.