Current jobs related to Medical Necessity Reviewer - Atlanta, Georgia - Piedmont Healthcare Corporate

  • Medical Director

    2 weeks ago

    Atlanta, Georgia, United States Innova Solutions Full time

    Job Title: Medical Director - Utilization ReviewInnova Solutions is seeking a highly skilled Medical Director to lead our Utilization Review team. As a key member of our clinical leadership team, you will be responsible for overseeing the review of medical necessity and appeal decisions, ensuring that our clients receive high-quality care while minimizing...

  • Clinical Review Nurse Specialist

    2 weeks ago

    Atlanta, Georgia, United States Spectraforce Technologies Full time

    Clinical Review Nurse Job DescriptionSpectraforce Technologies is seeking a skilled Clinical Review Nurse to join our team. As a Clinical Review Nurse, you will play a critical role in ensuring the quality and accuracy of medical necessity reviews.Key Responsibilities:Conduct thorough medical necessity reviews using clinical criteria and guidelinesDocument...

  • Clinical Review Nurse

    2 weeks ago

    Atlanta, Georgia, United States Axelon Services Corporation Full time

    Job Title: Clinical Review Nurse - Prior AuthorizationAt Axelon Services Corporation, we are seeking a highly skilled Clinical Review Nurse to join our team. As a Clinical Review Nurse, you will play a critical role in ensuring the quality and cost-effectiveness of medical care for our members.Key Responsibilities:Analyze prior authorization requests to...

  • Utilization Review Nurse Specialist

    4 weeks ago

    Atlanta, Georgia, United States Sonder Health Plans Full time

    Job SummarySonder Health Plans is seeking a skilled Utilization Review Nurse to join our team. As a Utilization Review Nurse, you will play a critical role in ensuring that healthcare services are administered with quality, cost efficiency, and within compliance.Key ResponsibilitiesConduct thorough reviews of member treatment records to ensure medical...

  • Clinical Review Nurse I

    2 weeks ago

    Atlanta, Georgia, United States Elevance Health Full time

    Clinical Review Nurse IWe are seeking a skilled Clinical Review Nurse I to join our team at Elevance Health. As a Clinical Review Nurse I, you will play a critical role in reviewing and making medical determinations on prior authorization requests to ensure that they meet the benefits carried by our members.Key Responsibilities:Assess the necessity and...

  • Utilization Review Nurse

    4 weeks ago

    Atlanta, Georgia, United States Sonder Health Plans Full time

    Job Title: Utilization Review NurseAt Sonder Health Plans, we are seeking a skilled Utilization Review Nurse to join our team. As a Utilization Review Nurse, you will play a critical role in ensuring that healthcare services are administered with quality, cost efficiency, and within compliance.Key Responsibilities:Conduct concurrent reviews of member...

  • Utilization Review Nurse Specialist

    4 weeks ago

    Atlanta, Georgia, United States Children's Healthcare of Atlanta Full time

    Job SummaryWe are seeking a skilled Utilization Review Nurse to join our team at Children's Healthcare of Atlanta. As a Utilization Review Nurse, you will play a critical role in ensuring that patients receive the most appropriate level of care while minimizing unnecessary costs.Key ResponsibilitiesConduct pre-screening assessments of prospective patients to...

  • Inpatient Utilization Review Coordinator

    2 weeks ago

    Atlanta, Georgia, United States Kaiser Permanente Full time

    Job Summary:Kaiser Permanente is seeking a highly skilled Inpatient Utilization Review Coordinator to join our team. As a key member of our Utilization Management department, you will be responsible for conducting thorough reviews of inpatient admissions to ensure that care is being delivered in the most appropriate setting. This role requires strong...

  • Cardiology Physician Clinical Review Specialist

    1 week ago

    Atlanta, Georgia, United States Evolent Health Full time

    About the Role:Evolent Health is seeking a highly skilled Cardiology Physician Clinical Reviewer to join our utilization management team. As a key member of our team, you will play a crucial role in ensuring that patients receive the best possible care while working in a non-clinical environment.Key Responsibilities:Serve as the specialty match reviewer in...

  • Medical Records Analyst

    2 weeks ago

    Atlanta, Georgia, United States Piedmont Healthcare Full time

    Job SummaryWe are seeking a skilled Medical Records Analyst to join our team at Piedmont Healthcare. As a key member of our coding team, you will be responsible for reviewing, analyzing, and coding medical record documentation to ensure accurate and complete information is abstracted into our information system. Your expertise will be crucial in reviewing...

  • HEDIS Medical Record Reviewer

    2 weeks ago

    Atlanta, Georgia, United States ICONMA Full time

    HEDIS Reviewer II Job DescriptionAt ICONMA, we are seeking a highly skilled HEDIS Reviewer II to join our team. As a HEDIS Reviewer II, you will play a critical role in ensuring the accuracy and completeness of medical records for HEDIS quality reporting.Responsibilities:HEDIS Medical Record Review: Participate in the collection and review of medical records...

  • Medical Case Review Specialist

    7 days ago

    Atlanta, Georgia, United States Hall Booth Smith, P.C Full time

    Job Summary:The Atlanta office of Hall Booth Smith, P.C. is seeking a skilled Legal Nurse Consultant to assist attorneys with medical aspects of litigation. This role requires regular attendance in the office and is not a remote position. The ideal candidate will have a RN Degree coupled with work experience in a clinical setting, with expertise in medical...

  • Medical Records Analyst

    4 weeks ago

    Atlanta, Georgia, United States Piedmont Healthcare Full time

    Job SummaryWe are seeking a skilled Medical Records Analyst to join our team at Piedmont Healthcare. As a Medical Records Analyst, you will be responsible for reviewing, analyzing, and coding medical record documentation to ensure accurate and complete information.Key ResponsibilitiesReview and analyze medical record documentation to identify and code...

  • Behavioral Health Care Specialist

    4 weeks ago

    Atlanta, Georgia, United States Careers Integrated Resources Inc Full time

    Job Title: Behavioral Health Care CoordinatorJob Location: RemoteJob Duration: 6 months+ (Possible Extension)Shift: Monday to Friday 8:00 am - 5:00 pmJob Description:We are seeking a skilled Behavioral Health Care Coordinator to join our team at Careers Integrated Resources Inc. As a key member of our team, you will be responsible for ensuring accurate and...

  • Nurse Reviewer

    2 weeks ago

    Atlanta, Georgia, United States Zelis Healthcare Full time

    Job Summary: Zelis Healthcare is seeking a skilled Nurse Reviewer to join our team. As a key member of our revenue integrity team, you will be responsible for conducting thorough reviews of medical claims to ensure accuracy and compliance with regulatory guidelines.Key Responsibilities: Conduct in-depth reviews of medical claims to identify potential errors...

  • Nurse Reviewer

    2 weeks ago

    Atlanta, Georgia, United States Adecco US, Inc. Full time

    Adecco US, Inc. Job OpportunityAdecco US, Inc. is seeking a skilled Nurse Reviewer to join our team. This is a remote opportunity that offers a unique chance to work on a COC/SPD project and contribute to building out coding for benefit plans.Key Responsibilities:Determine which codes belong to the language in the benefit plansReview what peers have...

  • Commercial Reviewer

    2 weeks ago

    Atlanta, Georgia, United States MountainSeed Appraisal Management LLC Full time

    Job Title: Commercial ReviewerMountainSeed Appraisal Management LLC is seeking a highly skilled Commercial Reviewer to join our team. As a Commercial Reviewer, you will play a critical role in ensuring the accuracy and quality of commercial real estate appraisals.Key Responsibilities:Perform detailed technical and compliance reviews of commercial real estate...

  • Nurse Reviewer Position

    2 weeks ago

    Atlanta, Georgia, United States Adecco US, Inc. Full time

    Nurse Reviewer Job DescriptionAdecco Healthcare & Life Sciences is seeking a skilled Nurse Reviewer to join our team. This is a remote opportunity that offers flexibility and work-life balance.Job SummaryWe are looking for a highly motivated and detail-oriented Nurse Reviewer to work on a COC/SPD project. The successful candidate will be responsible for...

  • Quality Assurance Nurse Reviewer

    4 weeks ago

    Atlanta, Georgia, United States Spectraforce Technologies Inc Full time

    Job Title: Quality Assurance Nurse ReviewerJob Description:The Quality Assurance Nurse Reviewer will work under the direction of the HEDIS Quality Assurance Team Lead and other company personnel to perform quality assurance reviews on medical records.The candidate will validate abstracted medical record data and enter findings electronically into a specified...

  • Clinical Quality Specialist

    3 days ago

    Atlanta, Georgia, United States Sonder Health Plans, Inc. Full time

    Job SummaryThe Utilization Review Nurse is a critical member of our team at Sonder Health Plans, Inc. The ideal candidate will possess strong clinical knowledge, excellent communication skills, and the ability to work effectively in a fast-paced environment.As a Utilization Review Nurse, you will be responsible for ensuring that health care services are...

Medical Necessity Reviewer

2 months ago

Atlanta, Georgia, United States Piedmont Healthcare Corporate Full time
Job Summary

Piedmont Healthcare Corporate is seeking a skilled Clinical Appeals Specialist to join our team. As a key member of our appeals process, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.

Key Responsibilities
  • Conduct detailed reviews of patient medical records to extract relevant clinical information
  • Draft and edit narratives for appeals documentation and briefs
  • Stay up-to-date with current medical coding, federal and state hospital Utilization Review (UR) regulations, and Medicare guidelines
  • Collaborate with internal and external legal resources to ensure the best possible outcomes in response to process or guideline changes
  • Assist the Senior Director with research and preparation for beneficiary hearings before the Administrative Law Judge (ALJ)
  • Potentially testify as an expert witness in ALJ hearings
Requirements
  • Graduate from an accredited School of Nursing
  • Seven (7) years of clinical experience in a healthcare setting using electronic medical records or acute hospital utilization review using InterQual or Milliman
  • Current License in the State of Georgia as a Registered Nurse or NLC/eNLC Multistate License
  • Working knowledge of medical coding, case management, government and contracted payers
  • Experience with clinical software such as SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites is desired
Preferred Qualifications
  • IQCI Certification
  • MicroSoft Word and Excel proficiency
  • HealthPort systems experience