Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... clinical staff. * Conduct reviews, in accordance with certification requirements, of insurance ...
Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... clinical staff. * Conduct reviews, in accordance with certification requirements, of insurance ...
Case Review Specialist - PR
Guaynabo, PR · On-site
Work collaboratively with clinical and non-clinical staff to facilitate case discussions * Fax ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...
Case Review Specialist - PR
Guaynabo, PR · On-site
Work collaboratively with clinical and non-clinical staff to facilitate case discussions * Fax ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...
Case Review Specialist - PR
Guaynabo, PR · On-site +1
Work collaboratively with clinical and non-clinical staff to facilitate case discussions * Fax ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...
Case Review Specialist - PR
Guaynabo, PR · On-site +1
Work collaboratively with clinical and non-clinical staff to facilitate case discussions * Fax ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...
... non-clinical, administrative behavioral health support services to the Puerto Rico Army National ... records reviews during Soldier Readiness Processing (SRP) events and Mobilization Station ...
... non-clinical, administrative behavioral health support services to the Puerto Rico Army National ... records reviews during Soldier Readiness Processing (SRP) events and Mobilization Station ...
Medical
Dental
Vision
Retirement
PTO
The Clinical Manager (CLM) of the Behavioral Health Contact Center is responsible for the depth of ... Provide backup to Utilization Review Department out of business hours including document in the ...
PR · On-site
Medical
Dental
Vision
Retirement
PTO
The Clinical Manager (CLM) of the Behavioral Health Contact Center is responsible for the depth of ... Provide backup to Utilization Review Department out of business hours including document in the ...
Experience leading teams that engage multiple stakeholders, including clinical/non-clinical ... product utilization and prescribing behavior. * Strong analytical skills with a track record of ...
Experience leading teams that engage multiple stakeholders, including clinical/non-clinical ... product utilization and prescribing behavior. * Strong analytical skills with a track record of ...
Director(a) De Formularios Y Medicamentos Especializados
San Juan, PR · On-site
$110 - $140/hr
Medical
Support the review of the Pharmacy sections of the Medicare Advantage BID and Commercial Policies ... Monitor specialty drug expenditures to ensure patients' appropriate utilization based on clinical ...
Director(a) De Formularios Y Medicamentos Especializados
San Juan, PR · On-site
$110 - $140/hr
Medical
Support the review of the Pharmacy sections of the Medicare Advantage BID and Commercial Policies ... Monitor specialty drug expenditures to ensure patients' appropriate utilization based on clinical ...
Pharmacist Call Center - San Juan, PR
San Juan, PR · On-site
$57 - $68.75/hr
Utilize prescription claims data to generate clinical recommendations according to Medication Therapy Management and Retrospective Drug Utilization Review program protocols providing clinical ...
Pharmacist Call Center - San Juan, PR
San Juan, PR · On-site
$57 - $68.75/hr
Utilize prescription claims data to generate clinical recommendations according to Medication Therapy Management and Retrospective Drug Utilization Review program protocols providing clinical ...
Evaluates the skills and services provided by the clinical staff through record review, field ... Assures that all care and staff interactions uphold the non-discrimination policy and are sensitive ...
Evaluates the skills and services provided by the clinical staff through record review, field ... Assures that all care and staff interactions uphold the non-discrimination policy and are sensitive ...
Case Review Representative
Guaynabo, PR · On-site +1
$13 - $15/hr
Our leadership is dedicated to building a culture based on respect, clinical excellence, innovation ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...
Case Review Representative
Guaynabo, PR · On-site +1
$13 - $15/hr
Our leadership is dedicated to building a culture based on respect, clinical excellence, innovation ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...
Case Review Representative
Guaynabo, PR · On-site
Our leadership is dedicated to building a culture based on respect, clinical excellence, innovation ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...
Case Review Representative
Guaynabo, PR · On-site
Our leadership is dedicated to building a culture based on respect, clinical excellence, innovation ... Our Current Solutions Through the use of OncoHealth's utilization management system, OneUM , our ...
$41K - $78K/yr
Maintain consistent presence in key accounts to promote confidence, safe utilization, and clinical ... be reviewed at www.bscbenefitsconnect.com. Actual compensation will be commensurate with ...
$41K - $78K/yr
Maintain consistent presence in key accounts to promote confidence, safe utilization, and clinical ... be reviewed at www.bscbenefitsconnect.com. Actual compensation will be commensurate with ...
Board Certified Behavior Analyst / BCBA
San Juan, PR · On-site
$85K/yr
Medical
Dental
Vision
Life
Retirement
PTO
We are committed to supporting long-term professional development in areas such as Clinical Leadership, Operations, Quality Assurance (QA), Utilization Review (UR), Assessments, Training ...
Quick apply
Board Certified Behavior Analyst / BCBA
San Juan, PR · On-site
$85K/yr
Medical
Dental
Vision
Life
Retirement
PTO
We are committed to supporting long-term professional development in areas such as Clinical Leadership, Operations, Quality Assurance (QA), Utilization Review (UR), Assessments, Training ...
... non-clinical, administrative medical support services to the Puerto Rico Army National Guard (PRARNG) Key Responsibilities: • Conduct comprehensive reviews of Service Member health and dental ...
... non-clinical, administrative medical support services to the Puerto Rico Army National Guard (PRARNG) Key Responsibilities: • Conduct comprehensive reviews of Service Member health and dental ...
Case Manager
Manati, PR · On-site
$17 - $21.75/hr
Medical
Dental
Vision
Retirement
PTO
... your clinical expertise while contributing to the well-being of individuals in your community ... Participate in utilization review process: data collection, trend review, and resolution actions.
Case Manager
Manati, PR · On-site
$17 - $21.75/hr
Medical
Dental
Vision
Retirement
PTO
... your clinical expertise while contributing to the well-being of individuals in your community ... Participate in utilization review process: data collection, trend review, and resolution actions.
Case Manager
$17 - $21.75/hr
Medical
Dental
Vision
Retirement
PTO
... your clinical expertise while contributing to the well-being of individuals in your community ... Participate in utilization review process: data collection, trend review, and resolution actions.
Case Manager
$17 - $21.75/hr
Medical
Dental
Vision
Retirement
PTO
... your clinical expertise while contributing to the well-being of individuals in your community ... Participate in utilization review process: data collection, trend review, and resolution actions.
Medical
Dental
Vision
Retirement
PTO
Performs clinical study site management/monitoring activities in compliance with ICH-GCP, Sponsor ... non-visit contact reports appropriately in a timely manner.Collects, reviews, and monitors required ...
Medical
Dental
Vision
Retirement
PTO
Performs clinical study site management/monitoring activities in compliance with ICH-GCP, Sponsor ... non-visit contact reports appropriately in a timely manner.Collects, reviews, and monitors required ...
Clinical Research Associate (CRA) - Cardiovascular (Remote)
Florida, PR · On-site
Medical
Dental
Vision
Retirement
PTO
Performs clinical study site management/monitoring activities in compliance with ICH-GCP, Sponsor ... non-visit contact reports appropriately in a timely manner. * Collects, reviews, and monitors ...
Clinical Research Associate (CRA) - Cardiovascular (Remote)
Florida, PR · On-site
Medical
Dental
Vision
Retirement
PTO
Performs clinical study site management/monitoring activities in compliance with ICH-GCP, Sponsor ... non-visit contact reports appropriately in a timely manner. * Collects, reviews, and monitors ...
Clinical Research Associate (CRA) - Immunology-Remote
Medical
Dental
Vision
Retirement
PTO
Performs clinical study site management/monitoring activities in compliance with ICH-GCP, Sponsor ... non-visit contact reports appropriately in a timely manner. * Collects, reviews, and monitors ...
New
Clinical Research Associate (CRA) - Immunology-Remote
Medical
Dental
Vision
Retirement
PTO
Performs clinical study site management/monitoring activities in compliance with ICH-GCP, Sponsor ... non-visit contact reports appropriately in a timely manner. * Collects, reviews, and monitors ...
New
Non Clinical Utilization Review information
What is the difference between Non Clinical Utilization Review vs Clinical Utilization Review?
| Aspect | Non Clinical Utilization Review | Clinical Utilization Review |
|---|---|---|
| Credentials | Typically requires healthcare administration, insurance, or case management certifications | Requires clinical licenses such as RN, MD, or other healthcare provider credentials |
| Work Environment | Office-based, insurance companies, or healthcare organizations | Hospitals, clinics, or healthcare facilities |
| Employer & Industry Usage | Insurance companies, third-party administrators, healthcare organizations | Hospitals, clinics, healthcare providers |
| Search & Comparison Intent | Understanding administrative and insurance-focused review roles | Understanding clinical decision-making and patient care review roles |
Non Clinical Utilization Review involves assessing healthcare services from an administrative perspective, focusing on insurance policies and coverage. Clinical Utilization Review involves healthcare professionals evaluating patient care and clinical necessity. Both roles are essential in healthcare but differ mainly in credentials, work environment, and focus area.
What are popular job titles related to Non Clinical Utilization Review jobs in Puerto Rico?
For Non Clinical Utilization Review jobs in Puerto Rico, the most frequently searched job titles are:
What job categories do people searching Non Clinical Utilization Review jobs in Puerto Rico look for?
The top searched job categories for Non Clinical Utilization Review jobs in Puerto Rico are:
- Fulltime Cigna Utilization Review Nurse
- Temporary Medical Utilization Review Physician
- Utilization Review
- Cigna Utilization Review Remote
- Remote Utilization Review
- Utilization Review 1099
- Full Time Weekend Utilization Review
- Remote Optum Utilization Review
- Remote Physical Therapy Utilization Review
- Optum Utilization Review Nurse
What cities in Puerto Rico are hiring for Non Clinical Utilization Review jobs?
Cities in Puerto Rico with the most Non Clinical Utilization Review job openings:
Full-time
Re-posted 3 days ago
Job description
Overview
PURPOSE STATEMENT:
Proactively monitor utilization of services for patients to optimize reimbursement for the facility.
ResponsibilitiesESSENTIAL FUNCTIONS:
- Act as liaison between managed care organizations and the facility professional clinical staff.
- Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
- Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
- Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
- Conduct quality reviews for medical necessity and services provided.
- Facilitate peer review calls between facility and external organizations.
- Initiate and complete the formal appeal process for denied admissions or continued stay.
- Assist the admissions department with pre-certifications of care.
- Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
OTHER FUNCTIONS:
- Perform other functions and tasks as assigned.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
- Required Education: High school diploma or equivalent.
- Preferred Education: Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
- Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred
LICENSES/DESIGNATIONS/CERTIFICATIONS:
- Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
- CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.
- First aid may be required based on state or facility requirements.
ADDITIONAL REGULATORY REQUIREMENTS:
While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.
We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual's characteristics protected by applicable state, federal and local laws.
Employment Type: FULL_TIME