- Molina Healthcare (Atlanta, GA)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... clinical/ medical reviews of retrospective medical claim reviews, medical claims and...Claims Auditing, Medical Necessity Review and Coding experience +… more
- State of Georgia (Fulton County, GA)
- …additional experience in the analysis of medical services documentation and related claims 2) Utilization Review 3) Case Management 4) Analysis of CPT codes ... Nurse Investigator Georgia - Fulton - Atlanta (https://careers.georgia.gov/jobs/64040/other-jobs-matching/location-only)...clinical experience AND one (1) year experience working with medical claims . Preference will be given to… more
- Elevance Health (Atlanta, GA)
- …experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing ... the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims...you will make an impact:** + Analyzes and audits claims by integrating medical chart coding principles,… more
- Elevance Health (Atlanta, GA)
- ** Nurse /CPC - Clinical Fraud Investigator Senior - SIU Fraud...control. + Review and conducts analysis of claims and medical records prior to payment. + ... + Performs in-depth investigations on identified providers as warranted. + Examines claims for compliance with relevant billing and processing guidelines and to… more
- Molina Healthcare (Atlanta, GA)
- …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... the likelihood of a formal appeal being submitted. + Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge,… more
- Evolent (Atlanta, GA)
- …+ Determines medical necessity and appropriateness of services using clinical review criteria. + Accurately documents all review determinations and contacts ... for the mission. Stay for the culture. **What You'll Be Doing:** The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are… more
- Elevance Health (Atlanta, GA)
- **Telephonic Nurse Case Manager I - $3000 Sign-On Bonus Offered** **Location: This is a virtual position, but you must reside in the State of Georgia.** **Work** ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager I** is responsible for telephonic care...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisor's on the development of… more
- Elevance Health (Atlanta, GA)
- **Telephonic Nurse Case Manager II** **Location: This is a virtual position. Candidates must reside within 50 miles of an Elevance Health Pulse Point location.** ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for performing care...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Prime Therapeutics (Atlanta, GA)
- …staff, cardholders, and pharmacies. + Escalates medical exception requests to nurse , pharmacist or physician on the utilization review clinical team when ... Expert within the organization. + Conducts Program Integrity Audits including outreach and review of medical records to audit authenticity of provider response… more
- Highmark Health (Atlanta, GA)
- … review basis. Review process includes a review of medical documentation, itemized bills, and claims data to assure appropriate level of payment and ... rejection and the proper action to complete the retrospective claim review with the goal of proper...in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder or… more