11 utilization management rn coder jobs found

A leading global healthcare organization is seeking a Utilization Management RN Coder. This role involves reviewing patient medical records and composing appeal letters while ensuring compliance with coding guidelines. Candidates must have an Associate's Degree, relevant coding certifications, and an unrestricted RN license. With a culture focused on inclusion and career development, the organization offers competitive salary ranging from $60,200 to $107,400 annually and the flexibility to telecommute from anywhere within the U.S. #J-18808-Ljbffr

Overview Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. Utilization Management RN Coder will accurately and efficiently review and extract pertinent case details from patient medical records; and craft strongly defensible appeal letters per process instructions and the department's/company's guidance. They will have working knowledge to use encoders and select appropriate, supportable appeal arguments from evidence-based, peer-reviewed medical...

Job Description Bienvivir All-Inclusive Senior Health ("Bienvivir") is a community-based, patient-centered, comprehensive health care delivery system that advocates and promotes quality of life, optimum independence, dignity, and choices in a nurturing environment for frail seniors. Since 1987, Bienvivir has served the frail seniors of El Paso, Texas through the provision of the Program of All-Inclusive Care for the Elderly ("PACE"). PACE is a unique managed care benefit for frail seniors (referred to as participants) age 55 and older who are certified by the state as needing nursing home level care and who reside in a PACE service area. PACE programs coordinate and provide comprehensive medical and support services so that participants can remain independent and stay in their homes for as long as safely possible. BENEFITS for Full and Part-time employees who work 30 or more hours per week: We pay 100% of the MEDICAL monthly premiums for Employee Only coverage. We pay...

*This is a hybrid role based in West Hills, CA* *ACTIVE LVN or RN license required AND CPC* *Key Responsibilities:* * Audit denied provider and member claims for accuracy and compliance * Review and process claims in accordance with UM guidelines and regulatory standards * Analyze benefit structures and system configurations (EZCap or similar) * Collaborate with cross-functional teams to resolve claim issues and process gaps * Document findings, prepare reports, and present trends to leadership * Support automated adjudication systems and identify strategies to reduce errors * Ensure HIPAA and PHI compliance throughout all claim review activities * Participate in special projects related to claim denials and appeals *Required Qualifications:* * Active LVN or RN license (California) * 2+ years of experience in Utilization Management (UM) * Hands-on experience with HMO/Medicare claims, audits, and denials * Familiarity with claims processing systems (EZCap or...

Clinical Nurse Auditor Payment Integrity We are seeking an experienced Clinical Nurse Auditor to join our Payment Integrity team. In this role, you will leverage your clinical expertise, medical coding proficiency, and auditing skills to identify, monitor, and analyze unusual utilization patterns and potential fraud by healthcare providers. You will conduct prepayment claims reviews, post-payment audits, and comprehensive provider record reviews to ensure accurate billing, compliance with payer regulations, and integrity in reimbursement practices. This position requires a Registered Nurse (RN) with coding certifications such as CPC (Certified Professional Coder), CIC (Certified Inpatient Coder), CDI (Clinical Documentation Improvement), or a similar credential, through AAPC or AHIMA. Knowledge of commercial insurance plans, Medicare, and Medicaid programs is essential. How You Will Make an Impact Investigations and Audits: Conduct in-depth medical reviews through prepayment...

Job Description Job Description Medical CoderJob at a Glance Location: onsite in Columbia, SC Contract: W2 only, contract-to-hire Pay: $36 /hour Key Responsibilities Determines methodology to identify cases for validation review. Conducts validation reviews/coordinates rates adjustments with appropriate claims area. Creates monthly/quarterly reports to present to each line of business providing information on records review, outcomes, trends, and savings that directly impact medical costs and contracting rates. Manages records retrieval, release, HIPAA compliance, and all aspects of document management. Serves as expert resource on methodology and procedures for medical records and coding issues. Required Skills 4 years of recent clinical experience in defined specialty area, or 4 years utilization review/case management/clinical/or a combination; 2 of the 4 years must be clinical. Required Licenses a RHIT, RHIA, CIC, CPMA, or CPC An active,...

Payment Integrity Nurse Coder RN III, $10,000 SIGN ON BONUS Job Category: Clinical Department: Claims Integrity Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 12330 Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Payment Integrity Nurse Coder RN III is responsible for investigating, reviewing, and providing clinical and/or...

Description: Are you interested in building a career with other TOP PERFORMERS? Effingham Health System is committed to providing exceptional care and services in an environment that supports professional growth, diversity, and inclusion. Every team member's experience and work-life balance are a priority in our organization. EHS culture encourages and supports individuals in pursuing their career goals and well-being by providing work-life balance, flexible scheduling, career development, and all the benefits and perks you need for yourself and your family. New Grads are welcome to apply. Benefits Retirement plans 403 (b) and 457 Health insurance Dental Insurance Vision insurance Prescription Drug Plan Hospital Discount Flexible spending account Paid time off Extended Days off (Sick time) Employee assistance program Strive365 Wellness Program Basic Life insurance (Employer Paid) Voluntary Life insurance/Accident/Critical Illness Disability (LTD and STD) Tuition...

Payment Integrity Nurse Coder RN III Job Category: Clinical Department: Managed Care Services Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 12165 Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan, serving more than 2 million members. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents. The Payment Integrity Nurse Coder RN III is responsible for investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical record review for Payment Integrity and Utilization...

Title: Clinical Supervisor Job Code: 000747 FLSA Status: Non - Exempt Reports To : Clinical Director - Nursing Position Objective The Clinical Supervisor directly supervises staff and is a clinical expert practitioner specific to the unit at education/staff development functions as well as designated management functions to promote high quality, cost effective health care. This position has authority to perform supervisory duties including but not limited to hiring, evaluating performance, issuing final disciplinary actions under the review of Human Resources, and recommending discharge in collaboration with members of management and Human Resources Essential Functions 1. 1. Clinical Decision Making/Judgment • Demonstrates expert clinical knowledge and skill in the specialization of the unit or initiative. • Provides for the coordination of patient care throughout the continuum for areas of responsibility. • Serves as an expert clinician,...

Position Objective The Clinical Supervisor directly supervises staff and is a clinical expert practitioner specific to the unit at education/staff development functions as well as designated management functions to promote high quality, cost effective health care. Title: Clinical Supervisor Job Code: 000747 FLSA Status: Non – Exempt Reports To: Clinical Director - Nursing Essential Functions 1. Clinical Decision Making/Judgment – Demonstrates expert clinical knowledge and skill in the specialization of the unit or initiative. Provides for the coordination of patient care throughout the continuum for areas of responsibility. Serves as an expert clinician, acting as a clinical resource for the staff. Works collaboratively with other disciplines in problem analysis and resolution for pathways, protocols, and patient care delivery. Expertly organizes and reprioritizes patient care activities based on subtle and overt environmental changes. Assists others in prioritizing...