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

Translates regulatory and coding requirements into practical guidance for internal teams and external partners Serves as a clinical subject matter resource during internal, vendor, or provider discussions Assists Director and Manager as needed to develop, introduce and support overall goals Develops linkages with specific departments on behalf of the Clinical Review area such as Data Management, Legal, Network Management, Compliance, Pharmacy and Complementary Networks. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the positions scope and responsibility, internal pay equity and external market salary data.

YEAR

Medica Health Plans Inc

Supervisor, Clinical Quality Review

Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an "excluded person" by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare. What You Will Be Doing: Serve as the Physician match reviewer in Radiation Oncology and imaging cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.

HOUR

Evolent

Radiation Oncology Field Medical Director

IRecruitee

Approximately 1,780 MCW physicians and approximately 905 advanced practice providers care for more than 484,000 patients of all ages annually at Froedtert Hospital, Zablocki VA Medical Center, Children’s Wisconsin, and many other hospitals and clinics throughout eastern Wisconsin, representing more than 5.1 million patient visits annually. The BRC occupies 95,000 ft2 and is staffed by 30-40 animal health technicians, 3 veterinarians (BRC Director and 2 Staff Veterinarians), 3 surgical team members (veterinary technicians), 3 Animal Husbandry Supervisors, a Veterinary Technical Services Supervisor, and an administrative team.

Medical College of Wisconsin

Assistant Professor, Staff Veterinarian - Biomedical Resource Center, Office of Research

Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.

Guidehealth

Utilization Management Registered Nurse (RN) - Remote

Job Summary: The RN Second-Level CDI & Quality Reviewer is a senior-level clinical documentation professional responsible for performing in-depth, concurrent and retrospective reviews of medical records to ensure accurate documentation that supports correct Diagnosis-Related Group (DRG) assignment and other quality-based outcomes. In addition to validating query appropriateness and documentation practices, this role analyzes Patient Safety Indicators (PSIs), Hospital-Acquired Conditions (HACs), and other publicly reported hospital quality metrics.

Clinical Reviewer Jobs in Wisconsin

Utilization Clinical Reviewer TriWest Healthcare Alliance

Utilization Management Clinical Reviewer TriWest Healthcare Alliance

Supervisor, Clinical Quality Review Medica Health Plans Inc

Radiation Oncology Field Medical Director Evolent

Assistant Professor, Staff Veterinarian - Biomedical Resource Center, Office of Research Medical College of Wisconsin

Utilization Management Registered Nurse (RN) - Remote Guidehealth

RN CLIN DOCUMENT SPEC QUALITY- ENTERPRISE QUALITY CDI/UR/DM Froedtert & The Medical College of Wisconsin

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