- Molina Healthcare (Albany, NY)
- **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within ... compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical /medical reviews of previously denied cases in which… more
- Healthfirst (NY)
- …degree + Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case ... and Responsibilities:** + Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity,… more
- Evolent (Albany, NY)
- …- **Required** + Minimum of 5 years in Utilization Management, health care Appeals , compliance and/or grievances/complaints in a quality improvement environment- ... to Standard processing, documenting accordingly. + Works closely with the appeals -dedicated Clinical Reviewers to ensure timely adjudication of processed… more
- Catholic Health Services (Melville, NY)
- …clinical expertise/reference for specialty services as needed to adequately prepare clinical review and/or appeal. Demonstrates aptitude and skill in applying ... Long Island's Top Workplace! Job Details The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews... to MCC in response to physician order, or review of updated clinical information Acts as… more
- Molina Healthcare (Rochester, NY)
- …Experience. **Required Experience** * 7 years' experience in healthcare claims review and/or Provider appeals and grievance processing/resolution, including 2 ... and DRG/RCC pricing), and IPA. + 2 years supervisory/management experience with appeals /grievance and/or claims processing within a managed care setting.… more
- BronxCare Health System (Bronx, NY)
- …area is preferred. -The Appeal Manager should have experience as a nurse in acute care clinical setting who is able to providing guidance, direction and training ... arrive in letter and electronic format. Collaborating with the Department Denial and Appeals Coordinators, Physician Advisors, and the clinical staff, the Appeal… more
- CVS Health (Albany, NY)
- … system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. This is a ... As a Medical Director you will focus primarily on review appeal cases for denied medical services. This includes...*Two (2) or more years of experience in Health Care Delivery System eg, Clinical Practice and… more
- Humana (Albany, NY)
- …practitioner issues. manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an a grievance, ... appeal or further request is warranted. The Grievances & Appeals Representative 4 + Review documents +...serve to achieve their best health - delivering the care and service they need, when they need it.… more
- Humana (Albany, NY)
- …health first** The Corporate Medical Director (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director ... and communication skills + 5 years of established, post-residency clinical experience + Knowledge of the managed care... clinical experience + Knowledge of the managed care industry including Medicare, Medicaid and/or Commercial products +… more
- Independent Health (Buffalo, NY)
- …ICD-10-PCS coding guidelines and financial policies/contracts. + Responsible for all reconsideration clinical appeals to include review of records, ... They will aid in training other team members, evaluating appeals , and share audit trends across the team. Expertise...coding system preferred. + Experience and proficiency reviewing health care delivery against clinical quality, as well… more