- Molina Healthcare (Albany, NY)
- …to roadmap of deliverables and timelines and implementing solutions to maximize national HEDIS audit success. * Partner with other teams to ensure data quality ... communicate risks and issues to stakeholders and leadership. * Create, review , and approve program documentation, including plans, reports, and records. *… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …recommendations and/or decisions on Utilization or Case Management activities. Utilization review activities include: reviews of requests for broad range of medical ... clinical reviews with attending physicians or other providers to discuss review determinations with providers and external physicians. + Conduct clinical appeal… more
- Molina Healthcare (Albany, NY)
- …requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial process. + Monitors appropriate care and services ... Public Health, Healthcare Administration, etc. **PREFERRED EXPERIENCE:** + Peer Review , medical policy/procedure development, provider contracting experience. + Experience… more
- Datavant (Albany, NY)
- …+ Previous Medicare Advantage Risk Adjustment, CDI, Medicaid, Commercial RA, and HEDIS experience. + Familiarity with HIPAA patient privacy requirements. + Excellent ... protected status. To learn more about our commitment, please review our EEO Commitment Statement here (https://www.datavant.com/eeo-commitment-statement) . Know Your… more
- Excellus BlueCross BlueShield (Dewitt, NY)
- …for opportunities to educate, support, coach, coordinate care and review treatment options, through collaboration with providers and community-based resources. ... all regulatory requirements are being met, such as NYS DOH, CMS, NCQA, and HEDIS , serving as internal auditor within the group. + Responsible for all aspects of… more
- Centene Corporation (Latham, NY)
- …procedures, and goals in compliance with internal and external guidelines + Review and implement new technological tools and processes and foster team concept ... claims or member/provider services) preferred. Knowledge of NCQA and HEDIS technical specifications. Master's degree preferred. **License/Certificates:** Current state's… more
- Centene Corporation (New York, NY)
- …Assurance (NCQA) Accreditation and/or Healthcare Effectiveness Data and Information Set ( HEDIS ) performance. + Ensure health plan is compliant and become/remain ... accredited with NCQA + Review and implement new technological tools and processes and fosters team concept with internal and external constituencies. + Present… more
- Elevance Health (Latham, NY)
- …for coordinating member service, utilization, access, care management and/or concurrent review to ensure cost effective utilization of health, mental health, and ... adherence to National Committee for Quality Assurance (NCQA) standards and HEDIS reporting. + Hires, trains, coaches, counsels, and evaluates performance of… more
- St. Mary's Healthcare (Amsterdam, NY)
- …other departments including physicians and nursing staff. . Participates in process review and improvement meetings. . Makes crucial decisions to achieve success by ... with the Compliance and Privacy Officer. . Oversees insurance, auditing reviews (ie, HEDIS and /Risk Adjustment), to ensure staff is completing requests in a timely… more
- Catholic Health Services (Melville, NY)
- …new staff. Participates in staff meetings and huddles as appropriate. Participates in Hedis , GPRO, and other quality programs as needed Enters provider orders into ... the electronic record for provider review and signature Preforms AWV Patient counseling and instruction on health maintenance goals Position Requirements and… more