- Humana (Albany, NY)
- …a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The Medical Director ... or data requires an in-depth evaluation of variable factors. The Medical Director actively uses their medical background, experience, and judgement to make… more
- Humana (Albany, NY)
- …of our caring community and help us put health first The Medical Director actively uses their medical background, experience, and judgement to make determinations ... weekend with compensated days off during the work week The Medical Director 's work includes reviewing of all submitted medical records, synthesizing complex… more
- Healthfirst (NY)
- **Duties/Responsibilities:** + Provide strategic direction and leadership to UM leaders and teams executing department functions including prior authorizations, ... by ensuring optimum quality of member care in a cost-effective manner + Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …is right for you, we encourage you to apply! Job Description: The Medical Director participates in the broad array of activities of the Medical Services area ... appeal case reviews and may require peer-to-peer discussions with providers regarding UM case review determinations. + Provides clinical expertise on ARD cases,… more
- BronxCare Health System (Bronx, NY)
- …activities and monitoring on a quarterly basis and reports findings/analysis to Director . - Conducts educational/feedback sessions with UM staff related to ... order to prepare a response for submission in appeal. - In absence of Director , will review denial correspondence to determine validity of denial reason and course… more
- Evolent (Albany, NY)
- …Be Doing:** **What You'll Be Doing:** Evolent is seeking an experienced Managing Director of Product Management to help Evolent grow by partnering with Payers to ... 'jobs to be done' and practice workflows, with a preference for expertise in UM workflows + Exceptional verbal and written communication skills, with the ability to… more
- Molina Healthcare (Syracuse, NY)
- …at the most effective setting. *Evaluates effectiveness of utilization management ( UM ) practices - actively monitoring for over and under-utilization. * Educates ... and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. * Assumes leadership relative to knowledge, implementation, training, and supervision of… more
- Guthrie (Cortland, NY)
- …less than one year of experience) Summary The LPN Utilization Management ( UM ) Reviewer, in collaboration with Care Coordination, Guthrie Clinic offices, other ... Office, is responsible for the coordination of Utilization Management ( UM ) processes and requirements of prior authorization/certification for reimbursement of… more
- Evolent (Albany, NY)
- …within the **RN/LVN/LPN** scope of practice, under the Medical Director 's direction, using independent nursing judgement and decision-making, physician-developed ... and refers cases that do not meet established clinical criteria to the Medical Director . + Appropriately identifies and refers quality issues to UM Leadership. +… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …Behavioral Health, Respiratory Therapy, Registered Dietitian, Registered Nurse, Medical Director , Pharmacist, Geriatrics, etc.) to ensure continuity and coordination ... + Case Management Certification required + Broad understanding of multiple areas (ie UM and CM). At this level, incumbent is required to know multiple functional… more