Medical Director, Claims & Utilization Review
Texas Health Institute
UnitedHealth Group is seeking a Medical Director to provide physician support for Enterprise Clinical Services. The role focuses on clinical knowledge applied to benefit coverage determinations and cost-efficient, high-quality care. You will work with network and non-network physicians to ensure timely and accurate determinations. Requirements include an MD or DO with an active license, board certification in Medicine, and 5+ years of post-residency clinical experience. #J-18808-Ljbffr Texas Health Institute
$248.5k - $373k
...as we deliver clinical coverage and medical claims reviews. Our role is to empower providers and... ...manage health care costs. The Medical Director provides physician support to Enterprise... ...of clinical knowledge in various utilization management activities with a focus on...ClaimsRemote jobMinimum wageFull timeWork experience placementLocal area- Integra Partners seeks an experienced Utilization Review Medical Director to lead clinical reviews of DMEPOS requests within a remote UM environment. You will ensure decisions meet Medicare/Medicaid guidelines and internal policies while maintaining timely throughput and...SuggestedRemote job
- Integra Partners, a national DMEPOS network administrator, seeks a remote Utilization Review Medical Director. You will conduct clinical reviews of DMEPOS requests, ensure determinations meet Medicare/Medicaid guidelines, and maintain high-quality documentation in a fast...SuggestedRemote jobFull time
- Hawaii Medical Service Association is seeking a Concurrent Nurse Reviewer for the Facility Utilization Review Unit. The role requires applying clinical... ...stays and suspended claims for HMSA members. Under minimal... ...coordinate with medical directors, case management, and other...Claims
- ...BlueCross BlueShield South Carolina subsidiary, seeks a Medical Reviewer II (RN) to perform medical claim reviews and determine medical necessity using... ...guidelines. The role documents decisions and supports utilization review across multiple services. The position is remote...ClaimsRemote jobFull time
- UnitedHealth Group's Optum unit seeks a Medical Director to lead the Focus Claims Review program, overseeing medical services, provider discussions, and policy development. This role emphasizes quality and coordination across reviews. You can work remotely from anywhere...ClaimsRemote job
$68k - $133k
...middle of the pay range Oversight of the nurse review teams that conducts medical necessity review as part of HMSA Utilization Management program that includes prior authorization, payment determination, post-service claim reviews, QI specific programs, out-of-network...ClaimsWork experience placementWork at office- Optum seeks a Medical Director to provide physician support for Enterprise Clinical Services, focusing on post-service benefit determinations and medical necessity decisions. You will lead clinical reviews, collaborate with hospital networks, and contribute to cost-effective...ClaimsRemote job
- Optum, a global health services company, seeks a Medical Director to lead the Focus Claims Review team. You will oversee medical claim review quality, coordinate with physicians and other providers, and set policies and clinical criteria for medical programs and services...ClaimsRemote job
$88.85k
...and to support the safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented,...ClaimsFull time- The Utilization Review Nurse gathers demographic and clinical information on prospective, concurrent... ...out-patient treatment, certifies the medical necessity and assigns an appropriate... ...communicates issues of concern to the appropriate claims staff/customer Collects data and...ClaimsMinimum wageWork at officeLocal areaRemote workFlexible hours
- Job Description Join Hilo Benioff Medical Center and be part of a team that proudly cares... ...Professional Nurse III to support our Utilization Review and Appeals functions. This role is... ...progress. Assist with appeals of denied claims by analyzing records, identifying discrepancies...ClaimsFull timeShift workWeekend work
- ...hours are required to address utilization review cases. Roles and... ...monitoring of cases involving medical decisions and quality of care... ...certification, reimbursement, and claim denials/appeals. Employ active... ...relationship with Medical Director on CM and UM cases....ClaimsLive inRemote workFlexible hoursWeekday work
- ## Utilization Review NurseApplyremote type: Hybridlocations: 1301 6th Ave W - BRADENTON, FLposted... ...requirements. This role reviews medical information submitted by treating providers... ...with physicians, healthcare providers, claims professionals, and internal team members...ClaimsWork at officeImmediate startRemote workFlexible hours2 days per week
$71.1k - $97.8k
Become a part of our caring community The Utilization Management Nurse 2 uses clinical... ...coordination, documentation and communication of medical services or benefit administration... ...of experience in prior authorization, claims review, utilization management, or other healthcare...ClaimsFull timeTemporary workApprenticeshipWork at officeRemote workWork from homeHome officeMonday to Friday- ...implementation of strategies that promote medical management, practice... ...management programs (e.g., utilization, prior authorization, case... ...assigned area/s (e.g., utilization review/quality assurance, case... ...predetermination reviews and reviews of claim determinations, providing...ClaimsPrivate practiceLive inRemote work
$236.5k
...clinical professional on our Medical Management/Health... ...leadership of all for utilization management, cost... ...activities. Performs medical review activities pertaining... ...Assists Chief Medical Director in planning and... ...care quality. Reviews claims involving complex, controversial...ClaimsRemote jobFull timePart timeWork at officeFlexible hoursWeekend work$210k - $260k
...program by determining the medical appropriateness of services by reviewing clinical information and... ...to the Managing Medical Director for Cohere Health, this... ...-based criteria while utilizing clinical acumen and knowledge... ...data with post‑service claims validation, we’re...ClaimsRemote jobFlexible hours$200k - $270k
...Primary Responsibilities The Medical Director (MD) reports directly to the... ...provide independent medical review where required by law, rule,... ...medical expertise for utilization management and care management... ...data from medical and pharmacy claims and medical record reviews to...ClaimsContract workFor contractorsWeekend workAfternoon shift- UnitedHealth Group seeks a Medical Director to lead clinical coverage reviews and benefit determinations within Enterprise Clinical Services. You will collaborate... ...knowledge, communication, and remediation of utilization management. You can work remotely from anywhere in...Remote job
- Sacbar is seeking a Medical Director of Prior Authorization and Utilization Management in Palm Springs, CA. The role focuses on prior authorization, concurrent review, and utilization management with a flexible hybrid remote arrangement. The position offers a competitive...Remote workRelocation packageFlexible hours
- WellMed, part of the Optum family, is seeking a Medical Director for Utilization Management to support utilization determinations and identify trends... ...current with CMS criteria, and participating in case reviews and medical necessity determinations. Qualified candidates...Remote job
$54k - $103k
...direction, conducts on-site Claim audits of Auto Physical Damage... ...levels of customer service. Reviews and makes recommendations regarding... ...Claims Quality Review Director Skills, Knowledge & Abilities... ...a sense of urgency; able to utilize and manage all available resources...ClaimsWork experience placementWork at officeLocal area- UnitedHealth Group in Minnesota seeks a Medical Director to provide physician support for... ...determinations and medical necessity reviews. The role partners with a multidisciplinary... ...effective, high-quality care, advances utilization management, and communicates policies...Remote job
- ...senior auditing RN to perform retrospective chart reviews on Readmission and Place of Service Claims, applying clinical guidelines and considering claims... ...auditing systems. The ideal candidate has 5-7+ years in Utilization/Case Management with an ICU/CCU background, and...ClaimsRemote job
- ...FL, is seeking a Physician Advisor to educate and advise Utilization Management, HIM, Revenue Cycle, Patient Access, and managed... ...and denial prevention. The role provides physician-level review of utilization, claims management, and quality assurance for inpatient,...Claims
- ...Blue Shield of Mississippi seeks an RN Medical Reviewer, FEP to perform thorough clinical reviews... ...pre-service requests and post-service claims for medical and medical drug services.... ...document decisions clearly, and monitor utilization trends for potential Care Management...Claims
- UnitedHealth Group is seeking a Medical Director to lead the Focus Claims Review program. This role oversees medical services coordination, provider discussions, and policy development related to medical claim reviews. In addition, you may assist in directing clinical...ClaimsRemote job
- Optum, a part of UnitedHealth Group, seeks a Medical Director to provide physician support for Enterprise Clinical Services. You will lead clinical reviews for benefit determinations, collaborate with leadership to implement processes, and ensure high-quality, cost-effective...Claims
- UnitedHealth Group is seeking a Medical Director to lead the Focus Claims Review program, ensuring quality and coordination of medical services for claims reviews. The role involves provider discussions, appeals, and policy guidance, with remote work flexibility across...ClaimsRemote job
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