Registered Nurse (RN) - Case Manager Frye Regional Medical CenterRegistered Nurse (RN) - Case ManagerHickory, NCFrye Regional Medical Center is a 355-bed hospital offering acute care hospital, home to the Frye Regional Brain Center, Heart Center, Cancer Center, Emergency Services, General and Vascular Surgery, Orthopedics, Surgical Weight Loss, Women's Birthing Center and Inpatient Rehabilitation that has been offering exceptional care to the Hickory NC community since 1911. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities.
Utilization 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.
Clinical 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.
Psychologist Reviewer Centene Corporation GroupPsychologist ReviewerRaleigh, NCRemote$87,700–$157,800 / yearPosition Purpose: Authorize, direct and monitor care for behavioral health and/or substance abuse problems according to clinical information given by providers and internal criteria for medical necessity and appropriateness of care. For ABA Reviewers only, working knowledge of psychological tests and testing procedures, diagnostic evaluations and evidence-based practices designed for individuals with Autism Spectrum Disorder.
Cardiology 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.
Claims 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.
Sr 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.
NewCLINICAL RESEARCH NURSE COORDINATOR Duke UniversityCLINICAL RESEARCH NURSE COORDINATORDurham, NC$66,265–$107,096 / yearComposed 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. The Health System encompasses Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, Duke Health Integrated Practice, Duke Primary Care, Duke Home Care and Hospice, Duke Health and Wellness, and multiple affiliations.
Clinical Research Coordinator Duke UniversityClinical Research CoordinatorDurham, NC$59,829–$99,960 / yearDescription of Clinical Responsibilities: Clinical responsibilities: Type of Research: This full-time, onsite Clinical Research Professional (CRP) will support research initiatives enrolling adult pulmonary participants, led by Principal Investigators (PIs) within Dukes School of Medicine Clinical Research Unit (CRU), Division of Pulmonary Medicine. 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 RESEARCH COORDINATOR Duke UniversityCLINICAL RESEARCH COORDINATORDurham, NC$61,026–$101,959 / yearMay code quantitative data using statistical tools to prepare for analysis under direct supervision from Biostatistician and PI or critically examine and interpret qualitative, unstructured and semi structured data, and rigorously explain findings in relation to the research context; includes the use of qualitative data analysis software (e.g., NVivo, Atlas.ti) to code and categorize the 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.
Manager, Inpatient and Post Acute Services PacificSource Health PlansManager, Inpatient and Post Acute ServicesNC$91,587.15–$160,277.52 / yearThe Manager of Utilization Management (UM) for Inpatient, Post-Acute and Dual Eligible Special Needs (DSN oversees and directs the utilization management process for inpatient admissions, post-acute care services, and DSNP members). Develop and track metrics to evaluate utilization trends, authorization outcomes, readmission rates, and other key performance indicators, presenting monthly/quarterly dashboards and reports to senior leadership with actionable insights for continuous improvement.
Manager, Inpatient and Post Acute Services PacificSourceManager, Inpatient and Post Acute ServicesNorth CarolinaThe Manager of Utilization Management (UM) for Inpatient, Post-Acute and Dual Eligible Special Needs (DSN oversees and directs the utilization management process for inpatient admissions, post-acute care services, and DSNP members). Develop and track metrics to evaluate utilization trends, authorization outcomes, readmission rates, and other key performance indicators, presenting monthly/quarterly dashboards and reports to senior leadership with actionable insights for continuous improvement.
NewCoordinator, UM Intake EvolentCoordinator, UM IntakeRaleigh, NC$18–$20 / hourWe require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. In support of our daily operations, this individual also works with our clinical team, which includes our medical reviews: LVNs, LPNs, and RNs along with our behavioral health reviewers: LMSWs, LCSW, and LPCs, and Clinical Reviewers.
NewUtilization Review RN Appeals Specialist CaroMont HealthUtilization Review RN Appeals SpecialistGastonia, NCThis 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.