- Molina Healthcare (Yonkers, NY)
- …in healthcare provider engagement or payer-provider program management. + Familiarity with clinical , quality , or risk adjustment program workflows. + Proficiency ... Engagement** plays a key role in driving risk adjustment and quality performance outcomes through effective program management, operational execution, and provider… more
- Evolent (Albany, NY)
- …Evolent for the mission. Stay for the culture. **What You'll Be Doing:** As a Clinical Reviewer , Nurse, you will be a key member of the utilization management ... while providing better health outcomes. **Collaboration Opportunities:** As a Clinical Reviewer , Nurse, you will routinely interact...**What You Will Be Doing:** + Functions in a clinical review capacity to evaluate all cases,… more
- Help at Home (Brooklyn, NY)
- …Collaborate with Operations, Intake, and Quality & Compliance teams to develop, review , and implement clinical protocols tailored to the needs of high-volume ... a growing client base exceeding 5,000 individuals and leads a multidisciplinary clinical team to deliver high- quality , cost-effective, and person-centered care… more
- Elevance Health (Latham, NY)
- …state(s). + Requires a minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and a minimum of 5 years ... **Diagnosis Related Group Clinical Validation Auditor-RN** **Virtual:** This role enables associates...the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims. **How… more
- University of Rochester (Rochester, NY)
- …criteria and protocols. Performs meticulous chart review and enters clinical data into the quality databases to identify opportunities for ... records and data to identify patient care, process, and system issues (hospital and external) related to the care...- Statistical knowledge preferred - Clinical chart review and abstraction experience preferred - Quality … more
- Catholic Health (Buffalo, NY)
- …3-5 years Medical Surgical experience required. + 3-5 years Home Care clinical experience preferred (CHHA, licensed, long term home care) KNOWLEDGE, SKILLS, ABILITY ... to travel to various buildings and departments within the Catholic Health System + Must possess strong interpersonal skills necessary to work with medical… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …the diagnosis and treatment of members' medical health conditions, applying established clinical review criteria, guidelines and medical policies and contractual ... benefits as well as State and Federal Mandates. May perform clinical review telephonically, electronically, or on-site, depending on customer and departmental… more
- Mount Sinai Health System (New York, NY)
- …individual interfaces directly with MSMC Departments, Administrators, Nursing, Medical and Quality Leadership, and Clinical Staff, managing the educational and ... **Job Description** **Job Title: Clinical Program Manager (Nurse Practitioner)-Dermatology ISM- Mount Sinai...System is one of the largest academic medical systems in the New York metro area, with more… more
- Centene Corporation (New York, NY)
- …completion utilizing appropriate review criteria. Identifies and refers all potential quality issues to the Clinical Quality Management Department, and ... Utilization Review Nurse I provides first level clinical review for all outpatient and ancillary...all potential quality issues and grievances to Clinical Quality Management and suspected fraud and… more
- Excellus BlueCross BlueShield (Buffalo, NY)
- …unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted ... leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to… more