Registered Nurse - Case Manager/Utilization Review - Part Time Days Williamson HealthRegistered Nurse - Case Manager/Utilization Review - Part Time DaysMurfreesboro, TNThe flagship facility, Williamson Medical Center, which recently opened its new Boyer-Bryan West Tower, offers extensive women's services, state-of-the-art cardiology services, advanced surgical technologies, an award-winning obstetrics and NICU, leading-edge orthopaedics, outpatient imaging services, and distinct comprehensive emergency and inpatient services for both adult and pediatric patients. Timely reviews patients within 24 hours or next business day after admission and at a minimum of every 2 days thereafter for continued stay, applying appropriate criteria (Interqual®) and facilitating reimbursement for services with third payer parties, obtaining and entering authorization number/approval status and notes in Meditech.
NewMedical Records Specialist Part Time Weekdays HCA HealthcareMedical Records Specialist Part Time WeekdaysHendersonville, TNAs a Medical Records Specialist, you would be responsible for assisting the HIM Director by routinely performing duties in support of the management of the Horizon Patient Folder (HPF)/McKesson Patient Folder (MPF) workflow queues, working applicable worklists within 3M 360 Encompass, the resolution of unbilled accounts, and the processing of physician suspensions. Completes any certification program and continuing education that may be required by state law to accurately perform the duties of the birth certificate clerk completion and works under the guidelines and process as defined by the state.
Medical Records Specialist HCA HealthcareMedical Records SpecialistNashville, TNAs a Medical Records Specialist, you would be responsible for assisting the HIM Director by routinely performing duties in support of the management of the Horizon Patient Folder (HPF)/McKesson Patient Folder (MPF) workflow queues, working applicable worklists within 3M 360 Encompass, the resolution of unbilled accounts, and the processing of physician suspensions. Completes any certification program and continuing education that may be required by state law to accurately perform the duties of the birth certificate clerk completion and works under the guidelines and process as defined by the state.
Medical Review Officer (MRO) - Bid MaximusMedical Review Officer (MRO) - BidNashville, TNFull timeMaximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. - After completing all research, the physician must write a case rationale in the correct format that introduces the question at hand, summarizes the correct guideline, analyses the pertinent case details related to the guideline, and then make a final determination as to the medical necessity of the requested service.
Medical Records Director-LPN STONERIVERMedical Records Director-LPNMurfreesboro, TNFull timeThis role ensures timely documentation, supports clinical and administrative staff, and maintains confidentiality and integrity of all medical information within the skilled nursing facility. General PurposeThe Medical Records Director oversees the management, security, and accuracy of resident health records in compliance with federal, state, and facility regulations.
Quality Review and Audit Analyst MindlanceQuality Review and Audit AnalystFranklin, TNPerform various documentation and data audits with identification of gaps and/or inaccuracies in risk adjustment data and identification of compliance risks in support of IFP Risk Adjustment (RA) programs, including the Risk Adjustment Data Validation (RADV) audit and the Supplement Diagnosis submission program. Individual Contributor Job Purpose/Role Description Job Summary: The Risk Adjustment Quality & Review Analyst in IFP brings medical coding and Hierarchical Condition Category expertise to the role, evaluates complex medical conditions, determines compliance of medical documentation, identifies trends, and suggests improvements in data and processes for Continuous Quality Improvement (CQI).
Quality Review and Audit Analyst HireTalentQuality Review and Audit AnalystFranklin, TNadjustment data and identification of compliance risks in support of IFP Risk Adjustment (RA) programs, including the Risk Adjustment Data Validation (RADV) audit and the Supplement Diagnosis submission. expertise to the role, evaluates complex medical conditions, determines compliance of medical documentation, identifies trends, and suggests improvements in data and processes for Continuous Quality Improvement (CQI).
Clinical Quality Review Team Lead TriWest Healthcare AllianceClinical Quality Review Team LeadNashville, TNRemoteFull timeThe team lead supports clinical and non-clinical staff supporting CQM programs by providing training and onboarding of new staff; determining work assignments; performing audits for clinical records and/or work accuracy; and ensuring effective, consistent and accurate workflow. Technical Skills: Comprehensive knowledge of research methodology; proficient applying appropriate data analysis processes; knowledge of managed care principles and methods; knowledge in the application of clinical criteria; proficient with Microsoft Word, Excel, and PowerPoint.
NewClinical Review Clinician - Appeals - Behavioral Health Centene Corporation GroupClinical Review Clinician - Appeals - Behavioral HealthTN$27.02–$48.55 / hourPreferred Experience: 6+ years of Behavioral Health experience managing Behavioral Health member caseloads, IOP Clinical Counseling/Social Work, or direct Psychiatric Nursing in Outpatient, ALF, SNF, Community Mental Health and/or Managed Care settings preferred. Skilled at utilizing Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and other digital communication tools (e.g.
Utilization Review Director - Addiction Recovery Summit Behavioral Healthcare LLCUtilization Review Director - Addiction RecoveryTNAbility to communicate professionally and effectively with multidisciplinary team members, managed care organizations and business office, providing needed information in a logical, concise manner using technical language that accurately describes client's condition. About the Job: PURPOSE STATEMENT: The Director of Utilization Management is responsible for the overall management of the UM department by leading and facilitating review of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria.
Remote Coding Quality Education Review Specialist ($5k sign on bonus!) LifePoint Health IncRemote Coding Quality Education Review Specialist ($5k sign on bonus!)Brentwood, TNRemoteCertifications: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician (CCS-P), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Professional Coder (CPC), Certified Inpatient Coder (CIC), Certified Outpatient Coder (COC), or other comparable nationally recognized acute care coding credential provided through AHIMA or AAPC. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities.
Lead Reviewing Physician Consultant (Bid) MaximusLead Reviewing Physician Consultant (Bid)Nashville, TNFull timeAfter completing all research, the physician must write a case rationale in the correct format that introduces the question at hand, summarizes the correct guideline, analyses the pertinent case details related to the guideline, and then make a final determination as to the medical necessity of the requested service. Maximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment.
Mental Health Reviewing Consultant (Bid) MaximusMental Health Reviewing Consultant (Bid)Nashville, TNFull timeMaximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. - After completing all research, the physician must write a case rationale in the correct format that introduces the question at hand, summarizes the correct guideline, analyses the pertinent case details related to the guideline, and then make a final determination as to the medical necessity of the requested service.
Alternate Vision Reviewing Physician Consultant (BID) MaximusAlternate Vision Reviewing Physician Consultant (BID)Nashville, TNFull timeMaximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. - Maintain working knowledge of Office of Personnel Management (OPM) medical and suitability policies and ensure all consultations reflect current clinical best practices, regulatory requirements, and program objectives.
Utilization Review Specialist Charlie HealthUtilization Review SpecialistNashville, TNRemotePlease note that this role is not available to candidates in Alaska, Maine, Washington DC, New Jersey, California, New York, Massachusetts, Connecticut, Colorado, Washington State, Oregon, or Minnesota. Given the complex nature of insurance these days, it is crucial to have timely communication with these payors so that families can focus on what's important, getting their loved ones the care they need.
HH Clinical Record Auditor BrightSpring Health ServicesHH Clinical Record AuditorNashville, TNThe Clinical Record Auditor is a clinician that conducts a comprehensive assessment of home health clinical records to ensure clinical documentation requirements are met, that it is clear, reflects the care provided, the patient's response to care, meets regulatory and company requirements, reflects patient eligibility, and supports billing requirements. Through the Company's service lines, including pharmacy, home health care, and rehabilitation, we provide comprehensive and more integrated care and clinical solutions in all 50 states to over 475,000 customers, clients and patients daily.
Orthopedic Spine Surgeon - Medical Reviewer (TN) Dane StreetOrthopedic Spine Surgeon - Medical Reviewer (TN)TNRemoteIn this role, you will apply your clinical expertise to conduct comprehensive medical record reviews and provide objective, evidence-based opinions on cases involving spinal conditions, injuries, treatments, and surgical interventions. Dane Street is seeking experienced Board-Certified Orthopedic Spine Surgeons licensed in Tennessee to join our growing panel of independent physician reviewers.
NewMedical Reviewer III - Home Health and Hospice BlueCross BlueShield of South CarolinaMedical Reviewer III - Home Health and HospiceNashville, TennesseeRequired Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area. Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations.
NewMedical Reviewer III - Home Health and Hospice CGS AdministratorsMedical Reviewer III - Home Health and HospiceNashville, TennesseeRequired Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area. Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations.
NewNetwork Medical Director - (Field-based /Remote) UnitedHealth Group IncNetwork Medical Director - (Field-based /Remote)Nashville, TNRemote$248,500–$373,000 / yearThe fraudulent LinkedIn messages and emails, which do not originate from any Executives LinkedIn account or of UnitedHealth Group's email domains, or those of any of its operating divisions, supposedly conducts an interview via a Zoom meeting, offers a work from home job at Optum, emails an application, sends a fake check by next day delivery through USPS and asks recipients to pay a vendor a large dollar amount. Collaborates in teaching clinicians and clinical operations teams about Medicare Risk Adjustment, CMS STARs/HEDIS, and overall population health approach to patient care in both formal presentations and off the cuff at impromptu opportunities.
Health Care | Life Sciences, Senior Associate - Registered Nurse / Certified Coder Ankura Consulting Group LLCHealth Care | Life Sciences, Senior Associate - Registered Nurse / Certified CoderTNRegistered Nurse with active license, unrestricted license • Bachelor of Science in Nursing from an accredited college/university • Substantial clinical experience with demonstrated ability to interpret clinical documentation and medical necessity • Certified Professional Coder (CPC) with coding experience across inpatient, outpatient, and professional services • Familiar with the revenue cycle process and facility and professional claims • Demonstrates excellent communication skills, both written and oral • Experience managing small projects and teams • Familiar with accessing and identifying clinical documentation in electronic medical record systems • Proficient in Excel, Word, and PowerPoint and able to draft reports and presentations and present findings • Ability to problem solve, multi-task, and prioritize assignments • Understands the importance of privileged and confidential communication • Willingness to travel when needed • Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future. Our clients include academic medical centers, health systems, physician practice groups, post- and sub-acute providers, health plans, pharmacies, and pharmacy benefit management companies, as well as pharmaceutical and medical device manufacturers.
NewSr Outpatient Coder Houston Methodist HospitalSr Outpatient CoderTNMust have one of the following: • RHIT - Certified Health Information Technician (AHIMA) • RHIA - Registered Health Information Administrator (AHIMA) • CCS - Certified Coding Specialist (AHIMA) • CCA - Certified Coding Associate (AHIMA) • CCS-P - Certified Coding Specialist Physician-Based (AHIMA) • CPC - Certified Professional Coder (AAPC). Must have one of the following: •RHIT - Certified Health Information Technician (AHIMA) •RHIA - Registered Health Information Administrator (AHIMA) •CCS - Certified Coding Specialist (AHIMA) •CCA - Certified Coding Associate (AHIMA) •CCS-P - Certified Coding Specialist Physician-Based (AHIMA) •CPC - Certified Professional Coder (AAPC).
Coding Quality Reviewer RightWorksCoding Quality ReviewerNashville, TennesseeYou will perform internal quality assessment reviews on Health Information Management Service Center(HSC) coders to ensure compliance with national coding guidelines, the HSC coding policies and the Company coding policies for complete, accurate and consistent coding which result in appropriate reimbursement and data integrity. Lead, coordinate and perform all functions of quality reviews (routine, pre-bill, policy driven and incentive plan driven)for inpatient and outpatient coding across multiple HSCs.
NewSpecial Investigation Unit (SIU) Manager CVS Health CorpSpecial Investigation Unit (SIU) ManagerTN$54,300–$159,120 / yearThe Certified Professional Coder (CPC) Manager will oversee a team of medical coders within the Special Investigations Unit (SIU) to ensure compliance with coding practices through comprehensive record reviews for medical, behavioral, transportation, and other healthcare providers. Ensure staff provide detailed written summaries of medical record review findings and ensure the team articulates findings effectively to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, and state regulators.
Inpatient Coder Houston Methodist HospitalInpatient CoderTNHouston Methodist also includes a research institute; a comprehensive residency program; international patient services; freestanding comprehensive care clinics, emergency care and imaging centers; and outpatient facilities. The health system consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the Texas Medical Center, seven community hospitals and one long-term acute care hospital throughout the Greater Houston metropolitan area.
NewClinical Reviewer, RN/LPN (Remote - TN) Maximus IncClinical Reviewer, RN/LPN (Remote - TN)Nashville, TNRemoteMaximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. This position plays a key role in helping eligible children and their families access healthcare coverage, home and community-based services, and other critical supports that enable children to remain safely at home and actively participate in their communities.
Program Integrity Clinical Specialist (RN or PA Req'd) TriWest Healthcare AllianceProgram Integrity Clinical Specialist (RN or PA Req'd)Nashville, TNRemoteFull timeTechnical Skills: Knowledge of TRICARE policies and procedures, knowledge of Case Management, Utilization Management, and Quality Management practices and principles, and knowledge of Managed Care concepts, alternative care treatments, and community resources. • Research and investigate medical issues as they relate to potential fraud and abuse cases, to include perform anti-fraud and abuse pre-payment reviews or post-payment reviews.
Claims Reviewer TriWest Healthcare AllianceClaims ReviewerNashville, TNRemoteFull timeProficient with claim and coding tools and resources, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management, and/or the Claims Subcontractor as needed.
Coding Quality Auditor Houston Methodist HospitalCoding Quality AuditorTNSKILLS AND ABILITIES Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles Knowledge of an electronic medical record and imaging systems Working knowledge of medical terminology, anatomy and physiology Proficiency with electronic encoder application AHIMA designated ICD-10 Approved Trainer preferred. Houston Methodist also includes a research institute; a comprehensive residency program; international patient services; freestanding comprehensive care clinics, emergency care and imaging centers; and outpatient facilities.
Utilization Clinical Reviewer TriWest Healthcare AllianceUtilization Clinical ReviewerNashville, TNRemoteFull timeApplies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources.