- Humana (St. Paul, MN)
- …part of our caring community and help us put health first** The Compliance Nurse 2 reviews utilization management activities and documentation to ensure adherence to ... to prevent and detect fraud, waste, and abuse. The Compliance Nurse 2 work assignments are varied and frequently...skills to make an impact** **Required Qualifications** + Active Registered Nurse license in a state that is part… more
- Dignity Health (Bakersfield, CA)
- …for a compliant denial notice for determination. - Escalates non-compliant cases to UM compliance and consistently reports on denial activities. - Collaborates ... coordinate with the Medical Director as needed. - Ensure compliance with turnaround times and accuracy standards are met....specific to member's condition and request. - Ensures the UM nurse reviewer has provided the appropriate reference for… more
- Humana (Boise, ID)
- …to assess outcome and metrics of market compliance with NCQA must pass UM elements. + ** Audit Calibration:** Verify findings to maintain data quality and ... Role:** Serve as key advisors to market management on compliance -related matters related to audit findings. +...Peer Review Literature, etc. + Working knowledge of NCQA UM letter requirements and compliance best practices.… more
- Houston Methodist (Houston, TX)
- …position provides guidance to staff and is responsible for staffing, budget compliance , contributing to staffing decisions such as hiring and terminating employment, ... also implements training, monitoring and operations initiatives that secure compliance with ethical and legal business practices and accreditation/regulatory/… more
- Molina Healthcare (UT)
- …within the Delegation Oversight Department. Oversees delegated activities to ensure compliance primarily with NCQA, CMS and State Medicaid requirements including ... The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates are compliant all applicable State, CMS, and NCQA requirements, as… more
- Molina Healthcare (Farmington, CT)
- **KNOWLEDGE/SKILLS/ABILITIES** + Performs monthly auditing of registered nurse and other clinical functions in Utilization Management ( UM ), Case Management (CM), ... Disease Management (DM). + Monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May...regulatory audits as subject matter expert and fulfilling different audit team roles as required by management. + Maintains… more
- Dignity Health (Bakersfield, CA)
- …**Minimum Qualifications:** - 3 years managed care experience - 1 year minimum of UM Delegation Oversight audit experience with Health Plan or large MSO - ... DHCS, CMS, and DHMC regulatory requirements **Preferred Qualifications:** - 3-5 years UM /Case Management delegation oversight audit experience with a Health Plan… more