Utilization Management

Outstanding Women in Business 2020: Dr. Christina Rama, Cone Health | The Business Journals | 9/10/2020

Outstanding Women in Business 2020: Dr. Christina Rama, Cone Health Sep 10, 2020, 2:09pm EDT Dr. Christina Rama Title: Executive medical director, Triad hospitalists and physician adviser, utilization management , Cone Health Business address: 1200 N. Elm St., Greensboro 27401 Education: Bachelor’s, pre-med, psychology, Franciscan University of Steubenville; associate, nursing, Dutchess Community College; M.D., Wake Forest University School of Medicine Why selected: As executive medical director at Cone Health, Rama …

A Pathway to Clinical and Administrative Data Integration | 9/8/2020

… administrative burdens and inefficiencies. Trigger Events for Sharing Clinical Data with Payers Source: Riplinger, Lauren, Alison Nicklas, and Chantal Worzala. “ONC Intersection of Clinical and Administrative Data Task Force.” AHIMA, 2020. Without a strong utilization management program in place to ensure appropriate and efficient care coordination and transitioning, providers risk retrospective claim denials. Ineffective discharge planning processes can result in increased readmission rates, adverse events, and patient dissatisfaction. Integration Matters …

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Market Chief Medical Officer (CMO) - Cypress, CA - UnitedHealth Group - Los Angeles, CA | 9/8/2020

… The CMO will produce and present weekly status reports, work plans, and results to the President of United Clinical Services on the performance of the market.• Quality and Affordability - The CMO has responsibilities for utilization management from a macro view: conducting hospital Joint Operations Committee meetings, contributing to–and implementing–regional Medical Cost Operating Team decisions, bed day action committee meetings with Inpatient Care Management (ICM), data sharing with physicians …

The smart Trick of select the best pharmacy That No One is Discussing | 9/7/2020

… Abide by all the subjects you treatment about, and we’ll produce the best tales for you to your homepage and inbox. InvestigateIn combination with the VIPPS certification, Convey Script is likewise NCQA-Licensed in utilization management and URAC-accredited being a mail-get pharmacy and pharmacy reward management service.They cite The point that a lot of in their consumers decide to shell out outside of pocket for their prescriptions in …

Onsite Physician Advisor East Chicago IN - UnitedHealth Group - East Chicago, IN | 9/6/2020

… growing non-clinical practice specialty of Physician Advisor with a career trajectory towards a provider or payor medical director and beyond. This position drives performance across our organization by communicating with hospital physicians and utilization management staff at client hospitals to champion best practices for evidence-based care and its documentation. The Physician Advisor will be responsible for establishing, maintaining, and strengthening the relationship with Optum client hospitals to appropriately …

Medical Director Clinical Advocacy and Support Telecommute - UnitedHealth Group - Phoenix, AZ | 9/6/2020

… and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost effectiveness of service for members. The Medical Director’s activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on pre-service benefit and coverage determination or medical necessity (according to the benefit package), and on communication regarding this process with both network and non-network physicians, as well …

Medical Director Medical Claims Review Telecommute - UnitedHealth Group - Louisville, KY | 9/6/2020

… and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost effectiveness of service for members. The Medical Director’s activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on pre-service benefit and coverage determination or medical necessity (according to the benefit package), and on communication regarding this process with both network and non-network physicians, as well …

Medical Director DMEPOS/MSK -Telecommute - UnitedHealth Group - Phoenix, AZ | 9/6/2020

… and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost effectiveness of service for members. The Medical Director’s activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on pre-service benefit and coverage determination or medical necessity (according to the benefit package), and on communication regarding this process with both network and non-network physicians, as well …

Medical Director Clinical Advocacy and Support Telecommute - UnitedHealth Group - Dallas, TX | 9/6/2020

… and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost effectiveness of service for members. The Medical Director’s activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on pre-service benefit and coverage determination or medical necessity (according to the benefit package), and on communication regarding this process with both network and non-network physicians, as well …

Getting My select the best pharmacy To Work | 9/6/2020

… does offer a broader academic history which will open far more Experienced development options, including a potential in training or management.In combination with the VIPPS certification, Specific Script can also be NCQA-Accredited in utilization management and URAC-accredited to be a mail-buy pharmacy and pharmacy benefit management service.They cite The truth that lots of of their prospects choose to pay out outside of pocket for their prescriptions in …

Utilization Mangement Medical Director - WellMed - San Antonio, TX - UnitedHealth Group - San Antonio, TX | 9/5/2020

… as well as completely and accurately capturing the patient diagnosis and assist OptumCare member servicing goals. This position is needed to support department work for full risk/full delegation. The Market Medical Director for Utilization Management will support WellMed Medical Management, Inc. by making utilization management determinations, identifying utilization trends suggesting possible over or under utilization of services and proactively suggesting improvements to WellMed Medical Management’s utilization management program. The …

5 ESSENTIAL ELEMENTS FOR WORKMEN’S COMPENSATION INSURANCE | 9/5/2020

5 ESSENTIAL ELEMENTS FOR WORKMEN’S COMPENSATION INSURANCE more info the disclosure, also to the extent practicable, an outline of the knowledge remaining disclosed.These consist of utilization management rules, which describe appropriate cure protocols and diagnostic tests for precise injuries.We are going to depend on that information and facts to present a high quality estimate, and we also use it to guard ourselves during the occasion of fraud or attempts to …

Can Platforms Help Reduce The $935 Billion In Wasteful Healthcare Spend? | Forbes | 9/3/2020

… between a doctor and the average patient (one-third of whom have limited health literacy ) facing a new diagnosis. Conflicting or competing interests (often financial) between constituents complicates things further; for instance, payers employ utilization management tools to try to reduce inappropriate use of high cost tests, procedures and prescription drugs, while doctors want to get their patients timely care and spend their time providing care (not processing paperwork). Beyond …

Medicare Advantage Plans Have Little to Show for In-Hospital HF Care | 9/2/2020

… of Harvard Medical School and Brigham and Women’s Hospital, reporting online in JAMA Cardiology . “The main influence of MA appears to be limiting the use of post-acute care facilities, which is likely a utilization management strategy aimed at reducing costs,” the authors suggested. “As MA continues to grow , it will be important to ensure that participating private plans provide an added value to the patients they cover to justify …

Earn Extra Income and Learn a New Skill Doing Utilization Review! | 9/2/2020

… utilization reviews on behalf of MRIoA. Dr. Sterling shares a lot of helpful information about doing utilization reviews and also mentions which specialties MRIoA is currently recruiting for. How did you get started in utilization management ? I was very unhappy in my career as a radiologist and I knew I needed a change. It was important for me to use my medical degree that I had worked so hard to …

Clinical Psychologist Anchorage, Alaska or Telecommute Within Alaska - UnitedHealth Group - Anchorage, AK | 9/2/2020

… behavioral health care for Medicaid recipients. Alongside the Chief Medical Officer and the Director of Clinical Operations, the Clinical Psychologist will function as a subject matter expert (SME) on Level of Care (LOC) guidelines, utilization management protocols, as well as care coordination and advocacy. The Clinical Psychologist will also be responsible for supporting the clinical integrity of the program. You’ll enjoy the flexibility to telecommute from anywhere within the Alaska …

Care Team Associate UM Prior Authorization Healthcare WellMed Texas - UnitedHealth Group - San Antonio, TX | 9/2/2020

… calls and data entry. This position requires working various shift hours and rotating/required weekends The Care Team Associate (CTA) for prior authorization department will effectively support the successful implementation and execution of all Utilization Management programs and processes. The Care Team Associate will provide support to the Utilization Management staff to ensure applicable program processes and operational responsibilities are met. The CTA will prepare the authorization by seeking out …

Registered Nurse RN Utilization Management Nurse WellMed Texas - UnitedHealth Group - San Antonio, TX | 9/2/2020

Registered Nurse RN Utilization Management Nurse WellMed Texas Registered Nurse RN Utilization Management Nurse WellMed Texas UnitedHealth Group San Antonio, Texas, United States 15 hours ago Apply Now Description Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm) Responsible for reviewing proposed …

The RFP: Your ticket to prior authorizations that work | 9/2/2020

… contribute to rising drug prices. These factors include the entry of new, high-cost drugs into the market that attract the attention of prescribers over lower-cost, therapeutically-equivalent alternatives for first-line treatment. Utilization management tools, such as prior authorizations (PA), help ensure that patients receive the best treatment for their condition while helping keep drug costs in check. Understandably, health plans are concerned about the cost, quality and …

Five Questions With: Mary Sullivan | 8/31/2020

In June, Mary Sullivan accepted the position of chief nursing officer at Bradley Hospital, where she has worked since 1991 as the director of utilization management . She will remain in that role while taking on her new responsibilities as chief nursing officer. Sullivan discusses how the hospital has changed over the past three decades, and what drew her to a career in health care. PBN: As you settle into your …

XSOLIS Names Chris Bayham as Chief Operating Officer | PR Newswire | 8/31/2020

… to support this incredibly talented team as we deliver client success and continue our forward momentum.” About XSOLIS XSOLIS is the healthcare technology firm creating an artificial intelligence-based network for objective, data-driven utilization management between payers and providers. To learn more, visit www.xsolis.com . SOURCE XSOLIS …

Soleo Health Named Preferred Provider by AscellaHealth in the Management of Its Hemophilia Patient Population | Business Wire | 8/31/2020

… captures, integrates and provides unlimited amounts of prescription data and healthcare outcome analytics in a real-time platform. “SoleMetrics will strengthen the power of our program as we work to improve patient compliance, control utilization management and realize incremental savings,” says Belazi. Drew Walk, Soleo Health’s chief executive officer, adds, “Over the years, Soleo Health has acquired deep and notable clinical experience in treating those with bleeding disorders. Additionally, SoleMetrics …

EXAMINE THIS REPORT ON WORKMEN COMPENSATION INSURANCE | 8/30/2020

… worker’s compensation protection will normally put their requirements initial. Providing Flexibility for Brokers and PolicyholdersWith agents from Coastline to Coastline, Companies delivers focused employees’ compensation insurance options for independent, entrepreneurial corporations.These include things like utilization management rules, which explain satisfactory therapy protocols and diagnostic assessments for specific accidents.Organizations are creating workplace safety courses as a method to invest of their corporation’s basic safety whilst simultaneously increasing employee welfare and productivity …

DETAILED NOTES ON WORKMEN COMPENSATION INSURANCE | 8/30/2020

… to. We minimize downtime to your wounded employees by partnering with thoroughly picked healthcare companies, pro doctor advisors, nurses and statements gurus that give good quality, Value-acceptable and well timed treatment.These consist of utilization management suggestions, which explain appropriate therapy protocols and diagnostic assessments for unique accidents.You will get back again to working your company correctly even though your wounded employee is within the mend, realizing we’ve acquired you …

Comment on How to Stay Excited and In Love with a Career in Medicine by Steve Schutzer, MD | 8/29/2020

… managed care The advent of managed care in the 80s opened up a slew of new career opportunities on the business side of medicine. Suddenly, doctors could be health plan medical directors, experts in utilization management , or Chief Medical Officers. They could run large practice groups or even run hospitals. Soon after the managed care revolution, the country went through serial efforts to reform our increasingly dysfunctional healthcare system (remember …

Health Management

Outstanding Women in Business 2020: Dr. Christina Rama, Cone Health | The Business Journals | 9/10/2020

… Rama, Cone Health Sep 10, 2020, 2:09pm EDT Dr. Christina Rama Title: Executive medical director, Triad hospitalists and physician adviser, utilization management, Cone Health Business address: 1200 N. Elm St., Greensboro 27401 Education: Bachelor’s, pre … professional goal? To complete two years of training in the Health Management Academy and obtain my master’s degree in health management. The training will require I complete a system-level project. What is your favorite …

Medicare

eQHealth Solutions Selected by Medicare Advantage Managed Care Company ApexHealth to Provide Utilization Management Services and Healthcare Analytics and Business Intelligence | Business Wire | 8/28/2020

by Hannah in Uncategorized BATON ROUGE, La.–(BUSINESS WIRE)– eqhealth–eQHealth Solutions Selected by Medicare Advantage Managed Care Company ApexHealth to Provide Utilization Management Services and Healthcare Analytics Share This Post …

NCQA

Blue Cross Blue Shield of Massachusetts earns ‘excellent’ status | PR Newswire | 8/18/2020

BOSTON Blue Cross Blue Shield of Massachusetts (Blue Cross) has earned an “Excellent” accreditation rating from NCQA (1) for its clinical quality, member experience and performance against operational standards for Commercial HMO/POS and PPO … in the following operational categories: Quality Management & Improvement Network Management Utilization Management Credentialing & Recredentialing Population Health Management Member Experience To see the current accreditation of all health plans, visit NCQA’s Health Plan Report Cards. Due …

HITRUST CSF

VirtualHealth Achieves HITRUST CSF® Certification to Manage Risk, Improve Security Posture, and Meet Compliance Requirements - Business Wire | 8/11/2020

VirtualHealth Achieves HITRUST CSF® Certification to Manage Risk, Improve Security Posture, and Meet Compliance Requirements HITRUST CSF Certification validates that VirtualHealth is committed to meeting key regulations and protecting sensitive information. August 11, 2020 10:00 … of timesaving, intelligent, and configurable automation to case, disease, and utilization management. The platform ingests clinical data (i.e. provider notes, claims data, lab information) and non-clinical data (i.e. community services, groceries, pharmacies, therapies, education …

HITRUST

VirtualHealth Achieves HITRUST CSF® Certification to Manage Risk, Improve Security Posture, and Meet Compliance Requirements - Business Wire | 8/11/2020

VirtualHealth Achieves HITRUST CSF® Certification to Manage Risk, Improve Security Posture, and Meet Compliance Requirements HITRUST CSF Certification validates that VirtualHealth is committed to meeting key regulations and protecting sensitive information. August 11, 2020 10:00 … of timesaving, intelligent, and configurable automation to case, disease, and utilization management. The platform ingests clinical data (i.e. provider notes, claims data, lab information) and non-clinical data (i.e. community services, groceries, pharmacies, therapies, education …

Home Health

MCG Health Launches Machine Learning Solution to Help Hospital Systems Prioritize Case Workload | PRWeb | 7/28/2020

… pace, the [Indicia for Effective Focus] tool helps them prioritize which cases to review first.” -Lisa Swift, Director of Centralized Utilization Management, Franciscan Alliance SEATTLE MCG Health , part of the Hearst Health network, announces it … percent of discharged patients, 205 million insured individuals, 103 million home health visits and 3.2 billion dispensed prescriptions. The Hearst Health network includes FDB (First Databank), Zynx Health , MCG , Homecare Homebase and MHK (formerly MedHOK …

Precision Medicine

MCG Health Launches Machine Learning Solution to Help Hospital Systems Prioritize Case Workload | PRWeb | 7/28/2020

… pace, the [Indicia for Effective Focus] tool helps them prioritize which cases to review first.” -Lisa Swift, Director of Centralized Utilization Management, Franciscan Alliance SEATTLE MCG Health , part of the Hearst Health network, announces it … formerly MedHOK). Hearst also holds a minority interest in the precision medicine and oncology analytics company M2Gen . Follow Hearst Health on Twitter @HearstHealth and LinkedIn @Hearst-Health . Share article on social media or email: View …

Population Health

The Global Care Management Solution Market is expected to grow from USD 10,434.14 Million in 2019 to USD 26,995.42 Million by the end of 2025 at a Compound Annual Growth Rate (CAGR) of 17.16% | Globe Newswire | 6/24/2020

… Healthcare Providers. On the basis of Application, the Care Management Solution Market is studied across Case Management, Disease Management, and Utilization Management. On the basis of Geography, the Care Management Solution Market is studied across … Part of Mediware Information Systems, Inc.), Health Catalyst, LLC, i2i Population Health, IBM Corporation, Koninklijke Philips N.V., Medecision, Inc., Salesforce.Com, Inc., TCS Healthcare Technologies, and ZeOmega Inc.. FPNV Positioning Matrix:The FPNV Positioning Matrix evaluates …

Durable Medical Equipment

CareCentrix Receives Renewal of NCQA Utilization Management Accreditation | PR Newswire | 4/24/2020

… April 24, CareCentrix, the leader in home-based and post-acute care (PAC) services, announced the renewal of its NCQA Utilization Management Accreditation. NCQA Utilization Management Accreditation, a voluntary review process, is a quality assessment … with critical needs like skilled nursing, therapies, infusion, oxygen and durable medical equipment. These services improve outcomes and reduce costs as patients recover and age at home. About CareCentrix CareCentrix partners with providers and payors …

Medicaid

Online Case Management Boot Camp: Strategies for Success in the Acute Care Setting and Beyond (May 18, 2020) | Globe Newswire | 4/21/2020

… utilization management, transitional planning and compliance. The Centers for Medicare and Medicaid Services (CMS) has incorporated changes that impact on payments related to readmissions, length of stay and cost of care. Who is in a better place to address these issues than case managers and social workers! Finally, how do you measure your impact on the cost and quality of care and the reimbursement your organization receives for that care …

COVID-19

How Chicago Is Becoming The Frontline Of Innovation – Forbes | 4/14/2020

… Angeles, Ohio, Tampa Bay, and Chicago, allowing them to share what they’re learning and doing to help their communities address COVID-19. These conversations have unearthed great examples of health systems working with startups to … assist with virtual training, workflow design, provider-nurse engagement, and utilization management. mHUB: Innovation center mHUB has a group of entrepreneurs and engineers collaborating to produce PPE for frontline health care workers. The group, led …

CDC

How Chicago Is Becoming The Frontline Of Innovation – Forbes | 4/14/2020

… management pathways for COVID-19 cases, and can rapidly update them with the latest clinical evidence and guidelines from the CDC. AgileMD is offering their solution at no charge to any hospital that wants it … assist with virtual training, workflow design, provider-nurse engagement, and utilization management. mHUB: Innovation center mHUB has a group of entrepreneurs and engineers collaborating to produce PPE for frontline health care workers. The group, led …

Healthcare Supply Chain

Group Purchasing Reduces Healthcare Supply Chain Costs by 13% | RevCycle Intelligence | 4/1/2020

Group Purchasing Reduces Healthcare Supply Chain Costs by 13% Group purchasing organizations also helped increase competition, transparency, and even emergency preparedness for events like COVID-19, a new report shows. Group purchasing organizations (GPOs) are … report, HSCA reported that those non-price services included drug utilization management, drug shortage prevention and mitigation, cybersecurity, value-based purchasing, healthcare-associated infections, and emergency preparedness. The latter service will likely play a key …

URAC

ENVISIONRX CONTINUES TO ACHIEVE RECOGNITION FOR EXCELLENCE IN MANAGING PHARMACY BENEFITS | Globe Newswire | 3/31/2020

Utilization Management and Health Information Products Certification for Pharmacy Benefits Information from the National Committee for Quality Assurance (NCQA), a private, nonprofit organization dedicated to improving healthcare quality that accredits and certifies a wide range of healthcare organizations. These achievements add to those the company already holds, including accreditations from URAC for Pharmacy Benefit Management and Drug Therapy Management. The pharmacies division of EnvisionRxOptions also holds accreditations for its mail …

National Committee for Quality Assurance

ENVISIONRX CONTINUES TO ACHIEVE RECOGNITION FOR EXCELLENCE IN MANAGING PHARMACY BENEFITS | Globe Newswire | 3/31/2020

NCQA Accreditation and Certification add to the pharmacy benefit manager’s growing list of industry recognitions March 31, 2020 10:43 ET Source: EnvisionRxOptions TWINSBURG, Ohio, March 31, EnvisionRx , a pharmacy benefit manager (PBM) and division of EnvisionRxOptions, a wholly owned subsidiary of Rite Aid Corporation , today announced it has received Accreditation in Utilization Management and Health Information Products Certification for Pharmacy Benefits Information from the National Committee for Quality Assurance (NCQA …

HIPAA

Welltok Deploys COVID-19 Communications and Resources Nationwide | PR Newswire | 3/24/2020

… channel capabilities include text, email, automated voice (IVR), AI chatbot and direct mail, which are all delivered through the company’s HIPAA compliant and HITRUST certified systems. Over the past several weeks and for the foreseeable … recipients so that they will be most effective and welcomed. Utilization management: organizations are scrambling to defer non-essential in-clinic visits and manage necessary non-COVID-19 appointments like pre-natal care, chronic disease …

Medical Claims Review

Medical Claims Review Coordinator Healthcare WellMed San Antonio TX - UnitedHealth Group - San Antonio, TX | 12/6/2019

Medical Claims Review (MCR) Supervisor, this position is responsible for processing Utilization Management (UM) Inventory. MCR Coordinator is responsible for handling customer service or provider calls as needed. Coordinates UM processes with WellMed Medical Directors, UM Nurses, hospitals, physicians and other various departments. MCR Coordinator is responsible for providing clerical support to WellMed clinical staff for their medical necessity review process. MCR Coordinator is expected to maintain production and quality …

Clinical Decision Support

(USA-ND-Bismarck) RN Utilization Managment Specialist - Patient Access Management | 12/4/2019

Hours Per Shift: 8 hr JOB SUMMARY Conduct level of care medical necessity reviews within patient’s medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements … pre-admission surgical reviews prior to admission. Reviews include InterQual clinical decision support criteria to ensure both the appropriateness of medical services and effective cost control. Ability to determine appropriate action for referring cases that …

Behavioral Health

(USA-PA-Pittsburgh) Clinical Care Manager - Maternity - Southern Allegheny & Washington Counties (RN) | 12/4/2019

… reduces unnecessary ER utilization and hospital readmissions. Coordinate and modify the care plan with member, caregivers, PCP, specialists, community resources, behavioral health contractor, and other health plan and system departments as appropriate. Review member’s current … health insurance experience required. 1 year of experience in clinical, utilization management, home care, discharge planning, and/or case management preferred. OB or maternity nursing experience highly preferred. Excellent organizational skills. High level of oral …

Case Management

Board Certified Hematologist Onsite Physician Advisor Duarte CA - UnitedHealth Group - Los Angeles, CA | 12/4/2019

… provider or payor medical director and beyond. This position drives performance across our organization by communicating with hospital physicians and utilization management staff at client hospitals to champion best practices for evidence-based care and … Primary Responsibilities: Conduct medical necessity reviews of cases referred by case management to ensure medical necessity and regulatory requirements are met for level of care Meet with case management, social work, and other healthcare team …

Utilization Review

Board Certified Hematologist Onsite Physician Advisor Duarte CA - UnitedHealth Group - Los Angeles, CA | 12/4/2019

… provider or payor medical director and beyond. This position drives performance across our organization by communicating with hospital physicians and utilization management staff at client hospitals to champion best practices for evidence-based care and … and contract requirements Serve as a physician member of the Utilization Review Committee, which may require non-clinical medical staff privileges application Provide education on utilization management topics (e.g. documentation) to the medical and UM …

Nursing Education

(USA-ND-Bismarck) RN Utilization Managment Specialist - Patient Access Management | 12/4/2019

Hours Per Shift: 8 hr JOB SUMMARY Conduct level of care medical necessity reviews within patient’s medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements … program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA). Currently holds an …

Discharge Planning

(USA-MI-Traverse City) Preadmission Planner | 12/3/2019

Job Information Munson Healthcare Preadmission Planner in Traverse City , Michigan ENTRY REQUIREMENTS Graduate of an accredited school of nursing. Nursing Baccalaureate Degree preferred. Currently licensed in the State of Michigan. Minimum of (3) years experience in acute care setting within the past (5) years. Recent experience should include care of surgical patients, patient assessment, patient teaching, admission planning and discharge planning. Utilization Management and Case Management experience preferred. Candidate should …

Pain Management

Bhawna Jha Brings Pain Management to UAMS (Movers & Shakers) | 12/2/2019

Dr. Bhawna Jha has joined the Department of Neurology at the University of Arkansas for Medical Sciences in Little Rock. Jha is an interventional pain management specialist. She was a pain physician at Corda Pain Institute in Cherry Hill, New Jersey, and was an associate medical director at AIM Specialty Health, where she worked in utilization management. She is a graduate of Pt. J.L.N.M. Medical College in Raipur, India, and …

Formulary Management

Clinical Pharmacist | 11/27/2019

Profile WellCare Health PlansReviews Medicare and Medicaid members’ claims history to ensure clinical appropriateness and optimum care while performing utilization management activities including dose optimization and formulary management for prior authorizations and coverage determination requests. Monitors quality of prior authorization and coverage determination requests for our Medicare and Medicaid lines of business. Monitors pharmacy performance to ensure all regulatory state and federal contractural requirements are met. Develops and maintains medication …

Change Healthcare

XSOLIS Names Chris Bayham as Chief Operating Officer | PR Newswire | 8/31/2020

… senior leadership team of Brookdale Senior Living. Before that, he served as Senior Vice President and Chief Information Officer at Change Healthcare. During his time at Change Healthcare, the organization merged with McKesson Technology Solutions … creating an artificial intelligence-based network for objective, data-driven utilization management between payers and providers. To learn more, visit www.xsolis.com . SOURCE XSOLIS …

McKesson

XSOLIS Names Chris Bayham as Chief Operating Officer | PR Newswire | 8/31/2020

… Senior Vice President and Chief Information Officer at Change Healthcare. During his time at Change Healthcare, the organization merged with McKesson Technology Solutions and grew to $3 billion in annual revenue, culminating in an IPO … creating an artificial intelligence-based network for objective, data-driven utilization management between payers and providers. To learn more, visit www.xsolis.com . SOURCE XSOLIS …

Hearst Health

MCG Health Launches Machine Learning Solution to Help Hospital Systems Prioritize Case Workload | PRWeb | 7/28/2020

… Utilization Management, Franciscan Alliance SEATTLE MCG Health , part of the Hearst Health network, announces it has successfully piloted its new machine learning solution, Indicia for Effective Focus , and it is now available for licensing. MCG is partnering with five major hospital systems for continued development and enhancement of this solution: Avera McKennan Hospital, Baptist Health System, Erlanger Health System, Franciscan Alliance, and IU Health. Indicia for Effective Focus prioritizes utilization …

MCG Health

MCG Health Launches Machine Learning Solution to Help Hospital Systems Prioritize Case Workload | PRWeb | 7/28/2020

MCG Health Launches Machine Learning Solution to Help Hospital Systems Prioritize Case Workload Share Article Leader in evidence-based guidance introduces a new tool to support accurate level of care determinations MCG Health is the … which cases to review first.” -Lisa Swift, Director of Centralized Utilization Management, Franciscan Alliance SEATTLE MCG Health , part of the Hearst Health network, announces it has successfully piloted its new machine learning solution, Indicia for …

Evolent Health

Beacon Healthcare Systems Names Manish Nautiyal Senior Vice President of IT Development and Infrastructure | Business Wire | 4/29/2020

… Evolent Health. There he was responsible for providing services to claims, providers and utilization management clinical business teams within the company. Immediately prior, Nautiyal worked for 10 years at Molina Healthcare, including serving as associate vice president/director of IT operations and maintenance. In that capacity Nautiyal oversaw the technology development and operations teams responsible for managing applications related to claims, eligibility, providers, clinical systems and portals. Beacon Healthcare Systems …

CVS

TriNet Provides Small and Medium Size Businesses with Latest on Health Insurance Carrier Offerings During COVID-19 Pandemic | PR Newswire | 4/6/2020

… current climate to better serve plan participants. For example, all carriers TriNet contracts with have waived their telemedicine copays and CVS Health will send Aetna members who have a confirmed COVID-19 diagnosis a care … a confirmed COVID-19 diagnoses who have been identified via utilization management processes following inpatient hospitalization. The care package will contain CVS supplies to help relieve symptoms as well as personal and household cleaning supplies …

CVS Health

TriNet Provides Small and Medium Size Businesses with Latest on Health Insurance Carrier Offerings During COVID-19 Pandemic | PR Newswire | 4/6/2020

… current climate to better serve plan participants. For example, all carriers TriNet contracts with have waived their telemedicine copays and CVS Health will send Aetna members who have a confirmed COVID-19 diagnosis a care … a confirmed COVID-19 diagnoses who have been identified via utilization management processes following inpatient hospitalization. The care package will contain CVS supplies to help relieve symptoms as well as personal and household cleaning supplies …

UnitedHealth

Onsite Physician Advisor Pontiac MI - UnitedHealth Group - Pontiac, MI | 12/7/2019

… provider or payor medical director and beyond. This position drives performance across our organization by communicating with hospital physicians and utilization management staff at client hospitals to champion best practices for evidence-based care and … Physician Advisor Solutions is part of the growing family of UnitedHealth Group companies. We help smooth out the interplay between each hospital client and the various payers. How? We serve as an expert partner on …

UnitedHealth Group

Onsite Physician Advisor Pontiac MI - UnitedHealth Group - Pontiac, MI | 12/7/2019

… provider or payor medical director and beyond. This position drives performance across our organization by communicating with hospital physicians and utilization management staff at client hospitals to champion best practices for evidence-based care and … Physician Advisor Solutions is part of the growing family of UnitedHealth Group companies. We help smooth out the interplay between each hospital client and the various payers. How? We serve as an expert partner on …

Anthem, Inc.

(USA-NY-Melville) Utilization Management Rep I- Remote- PS30806 | 12/4/2019

Anthem, Inc Utilization Management Rep I- Remote- PS30806 in Melville , New York Utilization Management Rep I- Remote- PS30806 Location: United States Requisition : PS30806 Post Date: 7 hours ago Your Talent. Our Vision. At HealthLink, Inc., a proud member of the Anthem, Inc. family of companies, providing access to a broad network of quality health care partners and custom health care plans to reduce overall costs, it’s a powerful combination. It’s …

Optum360

Board Certified Hematologist Onsite Physician Advisor Duarte CA - UnitedHealth Group - Los Angeles, CA | 12/4/2019

utilization management staff at client hospitals to champion best practices for evidence-based care and its documentation. The Physician Advisor will be responsible for establishing, maintaining, and strengthening the relationship with Optum360 Physician Advisor Solutions client hospitals to appropriately optimize the use of Optum360 Physician Advisor Solutions services. Training will be provided by Optum. The Physician Advisor will join a team of on-site physician advisors across the country. Primary …

Oncology Analytics

Oncology Analytics Appoints Dr. Lee Newcomer as Strategic Advisor | PR Newswire | 12/4/2019

ATLANTA Oncology Analytics , a leading technology-enabled service company that provides health plans, providers, and patients with an evidence-based, analytics focused approach to utilization management, purpose-built for oncology, has announced the appointment of Dr. Lee Newcomer as a strategic advisor. Dr. Newcomer is a board-certified oncologist with more than 30 years of experience in oncology management, first as a practicing oncologist, and then in the healthcare industry …

DaVita

(USA-NV-Las Vegas) RN, Utilization Management | 12/4/2019

DaVita Medical Group RN, Utilization Management in Las Vegas , Nevada SUMMARY The Utilization nurse will review prior authorization requests or inpatient concurrent review for medical appropriateness by using established clinical protocols to determine medical necessity of the request. UM nurses will utilize CMS,MCG, , and Health Plan specific guidelines as well as, collaborate with members of the team. The UM nurse will collaborate with the Physician Reviewer and/or Medical …

Optum

Medical Director Specialty Pharmacy Programs Telecommute - Minneapolis, MN, , USA #jobs #Minneapolis pls RT | 11/26/2019

Job Detail for Medical Director Specialty Pharmacy Programs Telecommute Job Location: UnitedHealth Group, Minneapolis, MN, , USA Job Detail for Medical Director Specialty Pharmacy Programs Telecommute Job Location: UnitedHealth Group, Minneapolis, MN, , USA Jobs In Medical Director Specialty Ph… Jobs In Medical Direct… Jobs In Medical D… The Optum Specialty MedicalDirector will provide utilization management services for our clients andclinical guidance for our next-generation comprehensive specialty pharmacysolution. This solution will …

ZeOmega

2019 Healthcare Payer Analytics Market Trends Report with Profiles on 18 Leading Vendors - ResearchAndMarkets.com | Business Wire | 11/25/2019

… Practice Data for Payer Analytics Claims Data Integrated Clinical and Claims Data Emerging Data Sources Payer Use Cases Cost and Utilization Management Quality Management Care Management Risk Management Payment Management Predictive Analytics Value-based Healthcare … Health MedeAnalytics Medecision Milliman Optum Philips SCIO-EXL SPH Analytics ZeOmega TABLES AND FIGURES CHAPTER 1: EXECUTIVE SUMMARY Figure 1.1: Payer Analytics Vendors and Vendor Types CHAPTER 2: PAYER ANALYTICS TECHNOLOGIES AND APPLICATIONS Table 2.1 …

Cerner

2019 Healthcare Payer Analytics Market Trends Report with Profiles on 18 Leading Vendors - ResearchAndMarkets.com | Business Wire | 11/25/2019

… Practice Data for Payer Analytics Claims Data Integrated Clinical and Claims Data Emerging Data Sources Payer Use Cases Cost and Utilization Management Quality Management Care Management Risk Management Payment Management Predictive Analytics Value-based Healthcare … Execution Ratings Vendor Market Execution Ratings VENDOR PROFILES Arcadia.io CareEvolution Cerner Corporation Certilytics, Inc Change Healthcare Clarify Health Solutions Cotiviti Health Catalyst HealthEC IBM Watson Health MedeAnalytics Medecision Milliman Optum Philips SCIO-EXL SPH Analytics …

eviCore

Highlighted Presentations from the 2018 Clinical Pathways Congress | 11/15/2019

… they began determining what these criteria should entail. They then compared the established criteria to the pathways programs of Anthem, eviCore, eviti, New Century Health, Value Pathways (National Comprehensive Cancer Network), and Via Oncology. Through … picked up the conversation and transitioned to the topic of utilization management strategies in care systems and how to perform a return-on-investment analysis when determining whether to buy or build a pathways program …

New Century Health

Highlighted Presentations from the 2018 Clinical Pathways Congress | 11/15/2019

… determining what these criteria should entail. They then compared the established criteria to the pathways programs of Anthem, eviCore, eviti, New Century Health, Value Pathways (National Comprehensive Cancer Network), and Via Oncology. Through their discussions … picked up the conversation and transitioned to the topic of utilization management strategies in care systems and how to perform a return-on-investment analysis when determining whether to buy or build a pathways program …

Sentry Data Systems

SENTRY DATA SYSTEMS: launches pharmacy claims management solution to help reduce denials and improve claims processing | 11/6/2019

Sentry Data Systems, Inc., a leader in pharmacy procurement and utilization management, 340B compliance and advanced healthcare analytics solutions, today announced the addition of Claims Manager Plus, an innovative new solution that helps hospitals adhere to payer reporting requirements — minimizing payer denials and accelerating payment for 340B covered entities’ Medicaid pharmacy claims. Claims Manager Plus ingests a hospital’s daily claims file and runs it through a sophisticated rules engine to …

Express Scripts

Health Care From the Medical Director POV | Managed Care Magazine | 10/23/2019

… a house-hold name, Miller became well known in health care and pharmaceutical circles as the chief medical officer of Express Scripts for 12 years. He’s now the chief clinical officer at Cigna, a job … strong clinical background, especially because the majority of them handle utilization management, says Adler. “If you just try to go from the residency and become a medical director, I don’t think that’s good.” His advice …

Care Management Technologies

Blue Cross and Blue Shield of Kansas City Selects Altruista’s GuidingCare Platform for Care Management | PRWeb | 10/22/2019

… serves 32 counties in Missouri and Kansas and has a strong community focus as the largest locally based plan in their market. Blue KC looked for a single platform to integrate care management, utilization management, pharmacy, reporting, and coordination with members and providers. They found it in GuidingCare. “We needed a strong, innovative partner with Blues experience to unify multiple care management functions onto one member-centric platform,” said Raelene …

VitalHub

VitalHub Enters Australian Market with State-wide Deal | Globe Newswire | 10/15/2019

October 15, 2019 07:30 ET Source: Vitalhub Corp. TORONTO, Oct. 15, 2019 (GLOBE NEWSWIRE) – VitalHub Corp. (the “Company” or “VitalHub”) (TSXV: VHI) is pleased to announce its entry into the Australian market, having signed a provincial deal with the Tasmanian Health Service (“Tasmania”). At the onset of the project, VitalHub subsidiary, the Oak Group, completed a Clinical Utilization Management Review study (the “Study”) across 1,000 medical, surgical, and mental health …

AdventHealth

XSOLIS Partners with AdventHealth for Data-Driven Utilization Management | PR Newswire | 8/19/2019

… 19, XSOLIS, the company channeling health care data into predictive intelligence and action, today announced that it has partnered with AdventHealth to implement real-time predictive analytics for utilization review in its hospitals. Through the … on the forefront of health care transformation is no surprise. Utilization management as we know it today is broken, but there is a patient-centered, data-driven path forward,” said Joan Butters , CEO and cofounder …

Merck

AMCP Partnership Forum on Prior Authorization Develops Recommendations to Improve Process | Markets Insider | Business Insider | 7/3/2019

… not approved for coverage unless certain evidence-based conditions are met, such as trying an alternative therapy first. An essential utilization management tool, prior authorizations are designed to ensure patients receive the most appropriate medications … Care & Specialty Pharmacy . Sponsors of this event were Mallinckrodt Pharmaceuticals, Merck, the National Pharmaceutical Council, and Takeda. The Partnership Forum is the latest in AMCP’s efforts to make prior authorizations more efficient. The AMCP Professional …

Casenet

Casenet Launches Innovation Hub to Develop Advanced Population Health Technology Solutions | PRWeb | 6/5/2019

Casenet® LLC, a population health technology company, today announced the creation of the Casenet Advanced Solutions Unit, a cross-functional team of experts tasked with developing innovative population health products and services that solve real … in KLAS®, modular, highly scalable, configurable and interoperable care and utilization management system that centralizes all disparate system data, driving comprehensive member focus, staff productivity, internal and external care team coordination, provider and member engagement …

Cambia Health Solutions

(USA-WA-Seattle) Associate Medical Director Behavioral Health | 11/24/2019

Cambia Health Solutions Associate Medical Director Behavioral Health in Seattle , Washington Overview Associate Medical Director Behavioral Health Portland, OR; Seattle, WA; Tacoma, WA At Cambia, our values are fundamental to achieving our Cause of transforming … internal or external stakeholders to promote understanding of care management, utilization management and quality programs. Participates on various teams to provide clinical input on medical policy reviews and development and may participate on committees that …

Nicole Oishi Joins Collective Medical as Head of Success | Business Wire | 1/4/2018

… Cambia Health Solutions, where she served as vice president of clinical services for Regence, a national BCBSA health plan serving two million members across Washington, Oregon, Idaho and Utah. While in that role, Oishi was responsible for a team of 450 employees covering utilization management, case and care management, quality management—which included leading Regence to full NCQA Accreditation—pre- and post-service clinical review, clinical analytics, reporting and clinical …

Morgan Stanley

Nabriva Therapeutics plc (NBRV) CEO Ted Schroeder on Q3 2019 Results - Earnings Call Transcript | Seeking Alpha | 11/13/2019

… Officer Jennifer Schranz - Chief Medical Officer Steve Gelone - President & Chief Operating Officer Conference Call Participants Alan Carr - Needham Ishmael Asante - Morgan Stanley Jason Gerberry - Bank of America Robert Driscoll - Wedbush Thomas Yip - H.C. Wainwright Operator … lives have access to XENLETA with the majority having no utilization management either Prior Authorization or Step Edits required. Coverage is primarily driven by Express Scripts and Anthem who had XENLETA to their commercial formularies …

Laboratory Corporation of America Holdings (LH) CEO David King on Q3 2019 Results - Earnings Call Transcript | Seeking Alpha | 10/24/2019

… Coldwell - Baird Donald Hooker - KeyBanc Mark Massaro - Canaccord Matt Larew - William Blair Derik De Bruin - Bank of America Ricky Goldwasser - Morgan Stanley Operator Ladies and gentlemen, thank you for standing by. And welcome to the … in Florida. Certainly there was some market push-back about utilization management. But there were significant savings realized. There was a much higher level of network adherence from physician so it certainly works. And in …

William Blair

Amedisys, Inc. (AMED) CEO Paul Kusserow on Q3 2019 Results - Earnings Call Transcript | Seeking Alpha | 10/30/2019

… Executive Officer Scott Ginn - Chief Financial Officer Chris Gerard - Chief Operating Officer Conference Call Participants Brian Tanquilut - Jefferies Matthew Larew - William Blair Justin Bowers - Deutsche Bank Joanna Gajuk - Bank of America John Ransom - Raymond James … around individualized patient-specific care plans, as well as optimizing utilization management. It has been truly inspiring to see the entire organization rally around our strategies to address the impact of PDGM. And I want …

Evolent Health, Inc. (EVH) CEO Frank Williams on Q1 2019 Results - Earnings Call Transcript | Seeking Alpha | 5/8/2019

… 2019 5:00 PM ET Company Participants Frank Williams - Co-Founder, CEO & Chairman Nicholas McGrane - CFO Conference Call Participants Ryan Daniels - William Blair & Company Robert Jones - Goldman Sachs Group James Stockton - Wells Fargo Securities Sean Wieland … a wide range of health plan services, including claims adjudication, utilization management and care and disease management services to approximately 70,000 Premera Blue Cross members. This includes approximately 45,000 Washington State exchange and 25,000 Alaska …

Piper Jaffray

Molina Healthcare Inc. (MOH) CEO Joe Zubretsky on Q3 2019 Results - Earnings Call Transcript | Seeking Alpha | 10/30/2019

… Lynch Stephen Tanal - Goldman Sachs Cal Sternick - Cowen and Company Steven Valiquette - Barclays Matthew Borsch - BMO Capital Markets Sarah James - Piper Jaffray David Styblo - Jefferies Operator Good morning and welcome to Molina Healthcare’s Third Quarter … know. We outsourced some of our very specialized and esoteric utilization management capabilities. We outsourced our nurse advice line earlier this year. So most of the large-scale outsourcing has been done, but not all …

Laboratory Corporation of America Holdings (LH) CEO David King on Q3 2019 Results - Earnings Call Transcript | Seeking Alpha | 10/24/2019

… Call Participants Lisa Gill - JPMorgan Jack Meehan - Barclays Kevin Caliendo - UBS Kevin Ellich - Craig-Hallum Ralph Giacobbe - Citi Bill Quirk - Piper Jaffray Erin Wright - Credit Suisse Eric Coldwell - Baird Donald Hooker - KeyBanc Mark Massaro - Canaccord … in Florida. Certainly there was some market push-back about utilization management. But there were significant savings realized. There was a much higher level of network adherence from physician so it certainly works. And in …

Goldman Sachs

Evolent Health, Inc. (EVH) CEO Frank Williams on Q1 2019 Results - Earnings Call Transcript | Seeking Alpha | 5/8/2019

… Participants Frank Williams - Co-Founder, CEO & Chairman Nicholas McGrane - CFO Conference Call Participants Ryan Daniels - William Blair & Company Robert Jones - Goldman Sachs Group James Stockton - Wells Fargo Securities Sean Wieland - Piper Jaffray Companies Anne Samuel … a wide range of health plan services, including claims adjudication, utilization management and care and disease management services to approximately 70,000 Premera Blue Cross members. This includes approximately 45,000 Washington State exchange and 25,000 Alaska …

Amgen Inc. (AMGN) CEO Bob Bradway on Q1 2019 Results - Earnings Call Transcript | Seeking Alpha | 5/1/2019

… Head of Global Commercial Operations David Reese - Head of R&D Conference Call Participants Matthew Harrison - Morgan Stanley Terence Flynn - Goldman Sachs Ying Huang - Bank of America-Merrill Lynch Geoffrey Porges - Leerink Partners Kennen Mackay … year-over-year, as we continue to secure improved payer utilization management criteria through contracting. We will continue to work with health plans, PBMs and the US administration to get lower list price Repatha to …

Merrill Lynch

Amgen Inc. (AMGN) CEO Bob Bradway on Q1 2019 Results - Earnings Call Transcript | Seeking Alpha | 5/1/2019

… Head of R&D Conference Call Participants Matthew Harrison - Morgan Stanley Terence Flynn - Goldman Sachs Ying Huang - Bank of America-Merrill Lynch Geoffrey Porges - Leerink Partners Kennen Mackay - RBC Capital Markets Carter Gould - UBS Equities … year-over-year, as we continue to secure improved payer utilization management criteria through contracting. We will continue to work with health plans, PBMs and the US administration to get lower list price Repatha to …

Molina Healthcare, Inc. (MOH) CEO Joseph Zubretsky on Q1 2019 Results - Earnings Call Transcript | Seeking Alpha | 4/30/2019

… BMO Capital Markets Equity Research Joshua Raskin - Nephron Research LLC Sarah James - Piper Jaffray & Co. Kevin Fischbeck - Bank of America Merrill Lynch Dave Styblo - Jefferies LLC Stephen Cano - Goldman Sachs. Peter Costa - Wells Fargo Steven … more importantly improvement in our claims payment integrity process, frontline utilization management, quality and risk adjustment effort and the repricing benefit of our newly re-contracted pharmacy agreement. Our first quarter 2019 performance was positively …

Leerink Partners

Amgen Inc. (AMGN) CEO Bob Bradway on Q1 2019 Results - Earnings Call Transcript | Seeking Alpha | 5/1/2019

… Conference Call Participants Matthew Harrison - Morgan Stanley Terence Flynn - Goldman Sachs Ying Huang - Bank of America-Merrill Lynch Geoffrey Porges - Leerink Partners Kennen Mackay - RBC Capital Markets Carter Gould - UBS Equities Yaron Werber - Cowen and … year-over-year, as we continue to secure improved payer utilization management criteria through contracting. We will continue to work with health plans, PBMs and the US administration to get lower list price Repatha to …

Molina Healthcare, Inc. (MOH) CEO Joseph Zubretsky on Q1 2019 Results - Earnings Call Transcript | Seeking Alpha | 4/30/2019

… Kubota - VP, IR Joseph Zubretsky - President and CEO Thomas Tran - CFO Conference Call Participants Shehryar Amir - Wolfe Research Ana Gupte - Leerink Partners LLC Matthew Borsch - BMO Capital Markets Equity Research Joshua Raskin - Nephron Research LLC … more importantly improvement in our claims payment integrity process, frontline utilization management, quality and risk adjustment effort and the repricing benefit of our newly re-contracted pharmacy agreement. Our first quarter 2019 performance was positively …

DaVita Medical Group

(USA-NV-Las Vegas) RN, Utilization Management | 12/4/2019

DaVita Medical Group RN, Utilization Management in Las Vegas , Nevada SUMMARY The Utilization nurse will review prior authorization requests or inpatient concurrent review for medical appropriateness by using established clinical protocols to determine medical necessity of the request. UM nurses will utilize CMS,MCG, , and Health Plan specific guidelines as well as, collaborate with members of the team. The UM nurse will collaborate with the Physician Reviewer and/or Medical …

Kaiser Permanente

Going Places | 11/23/2019

Going Places A LOOK AT WHO’S ON THE MOVE ON OAHU SHELLY MASON joins Kaiser Permanente Hawaii as director of utilization management. She is responsible for all aspects of utilization management including evaluating the medical necessity and efficiency of hospital acute care procedures and post-care discharge options, and partnering with care delivery teams to ensure members receive the highest-quality, coordinated care. PAULA OGIMI advances to assistant vice president …

Genesis Healthcare

(USA-MD-Baltimore) Social Services Specialist I (Full Time) | 11/21/2019

Job Information Genesis Healthcare Social Services Specialist I (Full Time) in Baltimore , Maryland POSITION SUMMARY: The Social Services Specialist I works with patients/residents and their family members/significant others within the facility through use … in designated center meetings at request of Social Services Director (Utilization Management, Customer at Risk, Care Planning, etc.) Advocacy Works with the interdisciplinary team to promote and protect resident rights and the psychosocial well being …

IVX Health

Two Health IT Veterans Join XSOLIS’ Board | PR Newswire | 11/20/2019

NASHVILLE, Tenn. XSOLIS, the company using artificial intelligence to redesign utilization management between payers and providers, today announced two additions to its Board of Directors: Doug Ghertner and George Lazenby, IV. Their additions to the Board were approved unanimously on November 18, 2019 . Mr. Ghertner currently serves as CEO of IVX Health, a national provider of infusion and injection therapy for individuals with complex chronic conditions. Prior to joining IVX …

Sanford Health

(USA-SD-Sioux Falls) Utilization Management RN Supervisor – Patient Access | Sanford Health | 11/18/2019

Job Title: Utilization Management RN Supervisor Patient Access Multi-City City: Multi-City State: Multi-State Department : Patient Access Representative Job Schedule: Full Time Shift: Days Hours Per Shift: 8 hr JOB SUMMARY Direct supervisor … and subsequently maintains required department specific competencies and certifications. About Sanford Health: At Sanford Health, we are dedicated to the work of health and healing. Every day, we show that commitment by delivering the highest …

Providence Health

(USA-OR-Portland) RN - Care Manager | 11/13/2019

Providence Health & Services RN - Care Manager in Portland , Oregon Description: Providence is calling a Registered Nurse - Care Manager (0.2 FTE, Days) to Providence St. Vincent in Portland, OR. The schedule for this RN Care Manager … timely discharge or transfer. Apply clinical expertise and knowledge of utilization management principles to care facilitation and discharge planning. Fully partners with and promotes focused programs such as Utilization Management and Clinical Documentation Specialists. Qualifications …

Covenant Health

RN Utilization Management - Knoxville, TN, , USA #jobs #Knoxville pls RT | 11/11/2019

Job Detail for RN Utilization Management Job Location: Covenant Health, Knoxville, TN, , USA Job Detail for RN Utilization Management Job Location: Covenant Health, Knoxville, TN, , USA Jobs In Rn Utilization Managem Knoxville Jobs In Rn Utilization… Jobs In Rn Utiliz… OverviewRN Utilization Management IFull Time, 80 hours per pay period; day shift (hours/days may vary based on need).Position Summary:The RN Utilization Management I will perform utilization management

Sutter Health

(USA-CA-Modesto) Occupational Therapist - Home Health | 11/8/2019

Sutter Health Occupational Therapist - Home Health in Modesto , California Position Overview: Under the supervision of the Clinical Manager, the Occupational Therapist is responsible for the delivery of appropriate, adequate, effective, efficient direct patient care services … of care within an interdisciplinary team and participating in effective utilization management and control of patient supplies. Consistently provides care based on the age-related needs of the unique population with consideration of their development …

St. Joseph Health

(USA-CA-Anaheim) Utilization Management Assistant | 10/31/2019

Job Information St. Joseph Health / Covenant Health Utilization Management Assistant in Anaheim , California Job Summary: Under the direction of the Utilization Supervisor/ Manager, this position is responsible for the distribution, review, accurate and timely processing of SJHH patient referrals requested from providers. Essential Functions: Responsible for verification of member’s eligibility (reporting to enrollment if not in IDX) and checks benefits of members for services requested per evidence of coverage guidelines …

Alameda Health System

(USA-CA-San Leandro) Patient Authorization Coordinator | 10/29/2019

utilization management functions in a timely manner. Provides key essential administrative support to ensure pre- registration and support utilization management operations are smooth and timely. The Patient Authorization department ensures that Alameda Health System receive timely authorization for services rendered at AHS for their patient population. Performs related duties as required. DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification. However, employees may …

Premier Health

Patient Status Analyst - Dayton, OH, , USA #jobs #Dayton pls RT | 10/25/2019

Job Detail for Patient Status Analyst Job Location: Premier Health Partners, Dayton, OH, , USA Job Detail for Patient Status Analyst Job Location: Premier Health Partners, Dayton, OH, , USA Jobs In Patient Status Anal Dayton Jobs In Patient Status… Jobs In Patient S… The Patient Status Analyst (PSA) is a registered professional nurse with knowledge and expertise in process analysis/improvement, utilization management, CMS rules of participation and status assignment, and …

UPMC

(USA-PA-Williamsport) Professional Care Manager - Williamsport Hospital - Full-Time | 8/18/2019

UPMC Professional Care Manager - Williamsport Hospital - Full-Time in Williamsport , Pennsylvania Description UPMC Susquehanna Williamsport has an opening for a Professional Care Manager in the Case Management Department. This Professional Care Manager position will support the Emergency Department and will be primarily Monday through Friday and the shift is 12p-8p. The Care Manager (CM) coordinates the clinical and financial plan for patients. Performs overall utilization management, resource management, discharge …

Molina Healthcare

Beacon Healthcare Systems Names Manish Nautiyal Senior Vice President of IT Development and Infrastructure | Business Wire | 4/29/2020

utilization management clinical business teams within the company. Immediately prior, Nautiyal worked for 10 years at Molina Healthcare, including serving as associate vice president/director of IT operations and maintenance. In that capacity Nautiyal oversaw the technology development and operations teams responsible for managing applications related to claims, eligibility, providers, clinical systems and portals. Beacon Healthcare Systems is home to the healthcare industry’s leading compliance and risk management technologies, providing …

CareCentrix

CareCentrix Receives Renewal of NCQA Utilization Management Accreditation | PR Newswire | 4/24/2020

HARTFORD, Conn. , April 24, CareCentrix, the leader in home-based and post-acute care (PAC) services, announced the renewal of its NCQA Utilization Management Accreditation. NCQA Utilization Management Accreditation, a voluntary review process, is a quality assessment program that focuses on consumer protection and customer service improvement. “CareCentrix is committed to helping patients heal and age at home, and the renewal of our NCQA Utilization Management Accreditation is a testament …

Aetna

TriNet Provides Small and Medium Size Businesses with Latest on Health Insurance Carrier Offerings During COVID-19 Pandemic | PR Newswire | 4/6/2020

… serve plan participants. For example, all carriers TriNet contracts with have waived their telemedicine copays and CVS Health will send Aetna members who have a confirmed COVID-19 diagnosis a care package of CVS supplies … a confirmed COVID-19 diagnoses who have been identified via utilization management processes following inpatient hospitalization. The care package will contain CVS supplies to help relieve symptoms as well as personal and household cleaning supplies …

WellCare Health

Magellan Health’s PBM Division Unveils Care Management Plan - November 27, 2019 - Zacks.com | 11/27/2019

… population health management plan, aims at finding out the lapses in care and implements a method to eradicate the same. Utilization management program Navigate UM makes sure that members get the right care at reasonable … ranked stocks like Select Medical Holdings Corporation ( SEM - Free Report ) , WellCare Health Plans, Inc. ( WCG - Free Report ) and Genesis Healthcare, Inc. ( GEN - Free Report ) . (Strong Buy) stocks here. Select Medical Holdings operates critical illness recovery …

Magellan Health

Magellan Rx Management’s MRx Navigate Offers Integrated Care Management, Focused On Customer And Member Healthcare Needs | Health IT Outcomes | 11/25/2019

Magellan Rx Management, the pharmacy benefit management (PBM) division of Magellan Health, Inc. (NASDAQ: MGLN), has launched MRx Navigate, a comprehensive care management program that offers integrated, high-touch and high-tech solutions, focusing on … to reduce or eliminate those gaps. Navigate UM is a utilization management program that ensures appropriate care and reduces cost across medical and behavioral services, concurrent review of inpatient admission, transition of care assessment, and …

Blue Cross and Blue Shield of Illinois

(USA-TX-Abilene) Utilization Management Coordinator - Registered Nurse (RN) | 11/12/2019

Home View All Jobs ( 2,439,701 ) Job Information Blue Cross and Blue Shield of Illinois, Montana, N Utilization Management Coordinator - Registered Nurse (RN) in Abilene , Texas Description: THIS POSITION IS INITIALLY BASED IN THE OFFICE AND CAN BE BASED IN RICHARDSON, TX OR ABILENE, TX. - This position has the ability to work-from-home after training (approximately 9 months to 1 year) subject to business needs if one is meeting their …

Humana

UM Administration Coordinator 2 - Washington, DC, , USA #jobs #Washington pls RT | 11/10/2019

Job Detail for UM Administration Coordinator 2 Job Location: Humana, Washington, DC, UM Administration Coordinator 2 Job Location: Humana, Washington, DC, , USA Jobs In Um Administration Coordinato … Jobs In Um Administrat… Jobs In Um Admini… DescriptionThe UM Administration Coordinator 2 contributes to administration of utilization management. The UM Administration Coordinator 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.ResponsibilitiesThe …

Passport Health Plan

Evolent Health Inc (EVH) Q3 2019 Earnings Call Transcript | The Motley Fool | 11/6/2019

… oriented care model over a large geographic region and payers tend to managed care with claims based data and a utilization management approach versus a whole patient focus. This tension ultimately leads to friction between … John, I’d like to give an update on our partner Passport Health Plan. Since the beginning of the year, we’ve worked hand in hand with the leadership team at Passport, including Scott Bowers, the new …

New Mexico Health Connections

Evolent Health Inc (EVH) Q3 2019 Earnings Call Transcript | The Motley Fool | 11/6/2019

… oriented care model over a large geographic region and payers tend to managed care with claims based data and a utilization management approach versus a whole patient focus. This tension ultimately leads to friction between … year and largely due to the amended reinsurance agreement with New Mexico Health Connections or NMHC entered into during the fourth quarter of 2018. Our owned health plan, True Health served an average of just …

Health Net

(USA-AZ-Tucson) Acuity IT Systems Consultant | 11/2/2019

… Health Network (BHN), and Banner’s Population Health Services Organization. Business user include Prior Auth, Medical Management, Case Management, Utilization Management, and Behavior Health. In the Acuity IT Systems Consultant role within Acuity, you will assist in integrating Acuity (BUHP and Banner Health Network) and to support all Lines of Business within the Insurance Division. Integrated system will serve approximately 551,000 members and 540 users, doubling the current support needs. You …

AmeriHealth

(USA-PA-Philadelphia) Clinical Care Reviewer, Utilization Management, Registered Nurse | 10/29/2019

AmeriHealth Caritas Clinical Care Reviewer, Utilization Management, Registered Nurse in Philadelphia , Pennsylvania Clinical Care Reviewer, Utilization Management, Registered Nurse Location: Philadelphia, PA ID : 18213 Your career starts now. We’re looking for the next generation of health care leaders. At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation’s leaders in health care solutions, we offer our associates the opportunity …

Cigna

Health Care From the Medical Director POV | Managed Care Magazine | 10/23/2019

Steve Miller, MD, now at Cigna, and Alan Adler, MD, recently retired from Independence Blue Cross in Philadelphia, reflect on their roles as medical directors and the current state of American health care. October 23 … strong clinical background, especially because the majority of them handle utilization management, says Adler. “If you just try to go from the residency and become a medical director, I don’t think that’s good.” His advice …

UnitedHealthcare

National Infusion Center Association Responds to UnitedHealthcare’s Decision to Steer Members to Self-Administered Injectables | PRWeb | 10/15/2019

National Infusion Center Association Responds to UnitedHealthcare’s Decision to Steer Members to Self-Administered Injectables Share Article Non-profit representing infusion patients and their providers addresses UnitedHealthcare’s recent decision to steer its members to self … impose non-medical switching practices for several medications. Cost-driven utilization management practices like non-medical switching have received significant scrutiny from health care providers, patients, politicians, and patient advocacy groups like NICA for limiting …

Amerigroup

(USA-IN-Indianapolis) Utilization Management Representative I-III - Cary, NC - PS26205 | 8/27/2019

Anthem, Inc Utilization Management Representative I-III - Cary, NC - PS26205 in Indianapolis , Indiana Utilization Management Representative I-III - Cary, NC - PS26205 Location: United States Requisition : PS26205 Post Date: 7 hours ago Your Talent. Our Vision. At Healthy Blue , a strategic alliance of Blue Cross NC and Amerigroup, an Anthem Inc. company, it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater …

The Health Plan

Toney HealthCare Announces Innovative Solution to Provide Clinical Services for Health Plans in Support of Their Members | PR Newswire | 6/4/2019

… of Business (LOB) or a defined population that may be expanding or underserved. The THCC team becomes an extension of the health plan, fully integrated within the health plan’s clinical operations. The Insource Partnership program … care skill sets, THCC provides services in: Medical and Behavioral Utilization Management to ensure the right care is delivered at the right time in the right way Medical and Behavioral Case Management to help members …

Premera Blue Cross

Evolent Health, Inc. (EVH) CEO Frank Williams on Q1 2019 Results - Earnings Call Transcript | Seeking Alpha | 5/8/2019

… Premera Blue Cross, a not-for-profit independent licensee of the Blue Cross Blue Shield Association that serves 2 million customers. Evolent will provide Premera Blue Cross with a wide range of health plan services, including claims adjudication, utilization management and care and disease management services to approximately 70,000 Premera Blue Cross members. This includes approximately 45,000 Washington State exchange and 25,000 Alaska federal exchange lives. Evolent will also provide …

Paul T. Sheils

P&R Dental Strategies’ Data Used in Pediatric Dental Pulpotomy Study | PR Newswire | 8/25/2020

… to answer our hypothesis. This study emphasizes that pulpotomies performed by pediatric dentists significantly outlast those performed by general dentists.” Paul T. Sheils , CEO of P&R Dental Strategies, said: “P&R Dental Strategies is … an enterprise-level suite of quality measurement, claim review and utilization management, provider profiling, fraud and abuse prevention and network development solutions to customers seeking to contain costs and maximize efficiency across their businesses. P …

P&R Dental Strategies Announces the Recipients of the 2019 DentaQual® Leaders in Quality® EliteStar® Dentist Awards | PR Newswire | 10/8/2019

… patterns, treatment history, adherence to clinical protocols and other metrics that demonstrate statistically superior behavior when compared to their peers. Paul T. Sheils , CEO of P&R Dental Strategies, said: “Quality dental care deserves to … an enterprise-level suite of quality measurement, claim review and utilization management, provider profiling, fraud and abuse prevention and network development solutions to customers seeking to contain costs and maximize efficiency across their businesses. P …

Margaret E. O'Kane

CareCentrix Receives Renewal of NCQA Utilization Management Accreditation | PR Newswire | 4/24/2020

… April 24, CareCentrix, the leader in home-based and post-acute care (PAC) services, announced the renewal of its NCQA Utilization Management Accreditation. NCQA Utilization Management Accreditation, a voluntary review process, is a quality assessment … utilization management in accordance with the strictest quality standards,” said Margaret E. O’Kane, President of NCQA. CareCentrix’s network of 8,000 home-health agency locations supports 14,500 patients daily with critical needs like skilled nursing, therapies …

CareCentrix Receives Renewal of NCQA Utilization Management Accreditation | PR Newswire | 4/24/2020

… April 24, CareCentrix, the leader in home-based and post-acute care (PAC) services, announced the renewal of its NCQA Utilization Management Accreditation. NCQA Utilization Management Accreditation, a voluntary review process, is a quality assessment … utilization management in accordance with the strictest quality standards,” said Margaret E. O’Kane, President of NCQA. CareCentrix’s network of 8,000 home-health agency locations supports 14,500 patients daily with critical needs like skilled nursing, therapies …

Adam Sabloff

VirtualHealth Partners with MCG Health to Optimize Utilization Management Workflows | PRWeb | 4/7/2020

VirtualHealth Partners with MCG Health to Optimize Utilization Management Workflows Share Article VirtualHealth’s HELIOS platform is fully integrated with the latest version of MCG Cite CareWebQI MCG is used by nine of the largest U.S. health plans and nearly 2,000 hospitals. “By thoughtfully incorporating MCG’s latest content into our custom workflows, we are offering a truly frictionless utilization management capability that is fully integrated with care management workflows,” - Adam Sabloff

VirtualHealth Revolutionizes Utilization Management with Integrated Platform | Business & Finance | manchestertimes.com | Business Wire | 4/7/2020

… VirtualHealth , provider of HELIOS , the leading SaaS care management platform, today announced the launch of a fully integrated, ground-breaking utilization management product. The innovative design places user experience and intelligent automation front and center … decades-old technology, creating inefficiencies and affecting staff performance,” said Adam Sabloff, VirtualHealth CEO. “We have been working thoughtfully on this challenge and we’re excited to finally welcome these critical workflows into the 21st century …

Robert Grant

National Association Creates Standards of Practice and Scope of Services for the Physician Advisor Role | PRWeb | 11/12/2019

… Robert Grant, MD, MSc, FACS, physician advisor and chairman of the Utilization Management Committee at New York Presbyterian hospital. “As the delivery of high-quality patient care in the most cost-effective manner becomes ever more important, the physician advisor role continues to evolve in dynamic and impactful ways.” To understand the interdependencies among all who provide care coordination and utilization management services, APLCM worked collaboratively with the American Case …

National Association Creates Standards of Practice and Scope of Services for the Physician Advisor Role | 11/12/2019

… Robert Grant, MD, MSc, FACS, physician advisor and chairman of the Utilization Management Committee at New York Presbyterian hospital. “As the delivery of high-quality patient care in the most cost-effective manner becomes ever more important, the physician advisor role continues to evolve in dynamic and impactful ways.” To understand the interdependencies among all who provide care coordination and utilization management services, APLCM worked collaboratively with the American Case …

Roberto Garcia-Rodriguez

Triple-S Management Corporation Reports Third Quarter 2019 Results | PR Newswire | 11/7/2019

… year-over-year growth in Medicare premiums and valuable bottom line contributions from our Life and P&C segments,” said Roberto Garcia-Rodriguez , President and Chief Executive Officer. “We’ve continued strengthening our product offerings, improving … past practice Ability to successfully implement the Company’s disease management, utilization management and Star ratings programs Ability to maintain Federal Employees, Medicare and Medicaid contracts Volatility in the securities markets and investment losses and defaults …

Triple-S Management Corporation Announces Conversion of Remaining Class A Shares Into Class B Shares and Elimination of Dual Class Equity Structure | PR Newswire | 7/17/2019

… August 7 , 2019. “We are pleased to convert our remaining Class A shares and thereby simplify our capital structure,” said Roberto Garcia-Rodriguez , President and Chief Executive Officer. “We believe a single class of publicly … past practice Ability to successfully implement the Company’s disease management, utilization management and Star ratings programs Ability to maintain Federal Employees, Medicare and Medicaid contracts Volatility in the securities markets and investment losses and defaults …

Roberto Garcia

Triple-S Management Corporation Reports Third Quarter 2019 Results | PR Newswire | 11/7/2019

… year-over-year growth in Medicare premiums and valuable bottom line contributions from our Life and P&C segments,” said Roberto Garcia-Rodriguez , President and Chief Executive Officer. “We’ve continued strengthening our product offerings, improving … past practice Ability to successfully implement the Company’s disease management, utilization management and Star ratings programs Ability to maintain Federal Employees, Medicare and Medicaid contracts Volatility in the securities markets and investment losses and defaults …

Triple-S Management Corporation Announces Conversion of Remaining Class A Shares Into Class B Shares and Elimination of Dual Class Equity Structure | PR Newswire | 7/17/2019

… August 7 , 2019. “We are pleased to convert our remaining Class A shares and thereby simplify our capital structure,” said Roberto Garcia-Rodriguez , President and Chief Executive Officer. “We believe a single class of publicly … past practice Ability to successfully implement the Company’s disease management, utilization management and Star ratings programs Ability to maintain Federal Employees, Medicare and Medicaid contracts Volatility in the securities markets and investment losses and defaults …

Frank Williams

Evolent Health Inc (EVH) Q3 2019 Earnings Call Transcript | The Motley Fool | 11/6/2019

… Earnings Conference Call for the quarter ended September 30, 2019. [Operator Instruction] Your host for the call today is Mr. Frank Williams, Chief Executive Officer of Evolent Health. This call will be archived and available … tend to managed care with claims based data and a utilization management approach versus a whole patient focus. This tension ultimately leads to friction between payers and providers and sub-optimal cost and clinical outcomes …

Evolent Health Partners with Maryland Physicians Care to Support Medicaid Operations in Maryland | PR Newswire | 11/5/2019

… operations by providing the Identifi platform and a wide range of health plan operations services, including claims processing, care management, utilization management, provider data management, member portals, analytics, risk adjustment and payment integrity. “After an … services to its members,” said Evolent Health Chief Executive Officer Frank Williams . “We look forward to leveraging our robust health plan and clinical platform to help MPC optimize health services for more than 200,000 Medicaid …

Travis Leonard

Sentry Data Systems launches pharmacy claims management solution to help reduce denials and improve claims processing | PR Newswire | 11/5/2019

DEERFIELD BEACH, Fla. , Nov. 5, Sentry Data Systems, Inc., a leader in pharmacy procurement and utilization management, 340B compliance and advanced healthcare analytics solutions, today announced the addition of Claims Manager Plus, an innovative new … in value-based solutions that best serve our customers,” says Travis Leonardi , CEO and founder of Sentry Data Systems. “We’re acutely aware of the impact resulting from delayed or denied claims on an organization’s revenue …

Sentry Data Systems Announces Industry Research Results: More Than Half of Hospital Executives Recognize Analytics as Crucial to Mitigating Drug Diversion Risks | PR Newswire | 11/8/2017

… risk for hospitals today and Sentry is uniquely positioned to help our customers proactively mitigate this potentially devastating threat,” said Travis Leonardi , CEO of Sentry Data Systems. “We apply Comparative Rapid Cycle Analytics™ to identify … FL , Sentry Data Systems, a pioneer in automated pharmacy procurement, utilization management and 340B compliance, is leading the healthcare industry in turning real-time data into real-world evidence through Comparative Rapid Cycle Analytics™ to …

Steve Miller

Health Care From the Medical Director POV | Managed Care Magazine | 10/23/2019

Steve Miller, MD, now at Cigna, and Alan Adler, MD, recently retired from Independence Blue Cross in Philadelphia, reflect on their roles as medical directors and the current state of American health care. October 23 … strong clinical background, especially because the majority of them handle utilization management, says Adler. “If you just try to go from the residency and become a medical director, I don’t think that’s good.” His advice …

Cigna Uses Industry Consolidation to Increase Access to Gene Therapy | HealthPayer Intelligence | 9/9/2019

… a new challenge for America’s healthcare system, and this challenge will grow as more therapies are approved by the FDA,” Steve Miller, MD, Cigna’s executive vice president and chief clinical officer said in a press … be getting the best price. They will be getting uniform utilization management,” said Miller in a video on Cigna’s site. “They will also be getting this with just a cost recovery model for us, so …

Susan A. Cantrell

AMCP Partnership Forum on Prior Authorization Develops Recommendations to Improve Process | Markets Insider | Business Insider | 7/3/2019

… not approved for coverage unless certain evidence-based conditions are met, such as trying an alternative therapy first. An essential utilization management tool, prior authorizations are designed to ensure patients receive the most appropriate medications … in addressing recent concerns around prior authorization,” said AMCP CEO Susan A. Cantrell , RPh, CAE. “This Forum will result in recommendations that will allow stakeholders throughout the health care system to enhance efficiencies and decrease …

AMCP Develops Concepts for Effective Prior Authorization and Utilization Management Practices | PR Newswire | 6/14/2019

… unless certain evidence-based conditions for appropriate use are met. “The practice helps improve patient outcomes by encouraging the use of therapies that have established evidence of efficacy and safety,” says AMCP CEO Susan A. Cantrell , RPh, CAE. “Evidence-based prior authorization programs also play a crucial role in reducing waste and error, along with unnecessary medication use and costs. PAs allow us to remain good stewards of our health …