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St. Luke's University Health Network
Overview
The RN Clinical Review Appeals Specialist conducts retrospective reviews of patient medical records and claims data to ensure accurate coding and DRG assignment. They develop appeal arguments and facilitate communication with various stakeholders to resolve documentation and coding issues.
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Compensation
Salary not listed
Posted
7 days ago
MRIoA
The Physician Advisor will apply clinical expertise to evaluate medical service requests, interpret benefit language and medical policies, and make sound coverage determinations. Core duties include performing clinical coverage reviews, documenting outcomes according to standards, and participating in peer-to-peer discussions with treating providers.
14 days ago
The role involves applying clinical expertise to evaluate medical service requests, interpret benefit language and medical policies, and make sound coverage determinations based on established guidelines. Responsibilities also include documenting review outcomes and engaging in peer-to-peer discussions with treating providers when necessary.
Luminis Health
The Case Manager coordinates patient care to ensure safe and seamless transitions across the healthcare continuum using evidence-based guidelines. They are responsible for assessing patient needs, managing observation stays, and maintaining accurate clinical documentation to support quality care and regulatory compliance.
$35 - $50 / HOUR
1 month ago
Missouri Delta Medical Center
The Case Manager performs utilization reviews using established criteria for admissions, concurrent, and focused cases, referring unjustified cases to the physician advisor. They are also responsible for collecting and analyzing data to enhance patient care and support Quality Improvement, Risk Management, and Utilization Review activities.
Sentara Health
The Physician Advisor conducts timely and compliant medical necessity reviews and manages denials, including facilitating peer-to-peer discussions and writing appeal letters to support the centralized Utilization Review process for hospital facilities. This role also involves direct communication and education with attending physicians regarding status changes, regulatory requirements, and documentation integrity to support medical necessity.
2 months ago
Best Care
This role is responsible for the overall management and communication of clinically-based appeals between the Health System and various payers, requiring review of cases, utilization of guidelines, and management of appeal documentation and communication.
The primary function is to provide clerical and operational support for the Physician Utilization Management Program, which involves administrative assistance to the Medical Director and Physician Advisors. Key duties include gathering medical records data for appeals, organizing data for submission, tracking outcomes of various coordination efforts, and maintaining program statistics and scorecards.
3 months ago
Nicklaus Children's Hospital
The RN Case Manager plans, assesses, implements, monitors, and evaluates healthcare services using Utilization Resource Management and Transition of Care functions to ensure quality care and cost-effective utilization. This role involves coordinating medical needs for pediatric patients, screening charts for admission criteria, and proactively resolving barriers to safe discharge.
INSIGHT Surgical Hospital
The ED Utilization Review/Case Manager facilitates appropriate hospital resource use by verifying acute inpatient criteria and assisting with timely discharge needs. This role serves as a central communicator, collaborating with internal and external parties on discharge planning and utilization review activities.
Riverview Health
The Clinical Case Manager is responsible for analyzing patient records, managing admission and concurrent reviews to prevent payer denials, and coordinating service approvals with payors within required timeframes. This role involves comparing medical records to care guidelines, communicating with the treatment team regarding length of stay and discharge readiness, and supporting utilization review processes including appeals and peer reviews.
Samaritan Health Services
This role involves reviewing all hospital admissions and continued stays, classifying patients according to regulations, and facilitating interdisciplinary care plans in collaboration with patients and families. The Case Management Team RN also acts as a liaison between the hospital, physician, and payer to secure maximum reimbursement and coordinates complex discharge planning.
$40 - $60 / HOUR
HonorHealth
The coordinator assists in administering Utilization Management functions by organizing workflow, communicating internally and externally, tracking information, and creating reports, primarily supporting operations and payer communication to gain admission approvals through clinical review and appeals.
AmTrust Financial Services, Inc.
The primary purpose is to provide comprehensive quality telephonic case management to proactively drive a medically appropriate return to work through engagement with the injured employee, provider, and employer. Responsibilities include utilization review, pharmacy oversight, and care coordination while partnering with adjusters on a holistic approach for each claim.
$66,900 - $91,000 / YEAR
The primary purpose is to provide comprehensive quality telephonic case management to proactively drive a medically appropriate return to work by engaging the injured employee, provider, and employer. Responsibilities include utilization review, pharmacy oversight, and coordinating treatment while maximizing quality and cost-effectiveness of care.
