• Appeals Nurse

    Evolent (Albany, NY)
    …focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and procedures ... work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators...Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to company… more
    Evolent (05/10/25)
    - Related Jobs

  • Medical Director - Pacific SW Region

    Humana (Albany, NY)
    …this knowledge in their daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, review ... with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health… more
    Humana (05/10/25)
    - Related Jobs

  • Medical Director - Care Plus - Florida

    Humana (Albany, NY)
    …this knowledge in their daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, review ... with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health… more
    Humana (04/24/25)
    - Related Jobs

  • Case Manager- Case Management

    Arnot Health (Elmira, NY)
    …processes related to the management of patient care. The Case Manager will review all patients for utilization management and appropriate discharge planning. The ... f. The Case Manager tracks and trends LOS, resource utilization , outliers, readmissions, denials, delay days and satisfaction of...need and available resources. ** 16. Coordinates services, ie home help, DME etc, based on patient… more
    Arnot Health (05/08/25)
    - Related Jobs

  • Medical Director - Florida

    Humana (Albany, NY)
    …with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health ... health insurance, other healthcare providers, clinical group practice management. + Utilization management experience in a medical management review … more
    Humana (04/24/25)
    - Related Jobs

  • Nurse Case Manager - Full Time, Days

    Nuvance Health (Poughkeepsie, NY)
    …or BSN preferred. Must have current RN license. Preferred experience in Utilization Review /Management.Company: Vassar Brothers Medical Center Org Unit: 1190 ... general supervision of the Director, The Nurse Case Manager role provide clinically- based case management to support the delivery of effective and efficient patient… more
    Nuvance Health (04/26/25)
    - Related Jobs

  • Clinical Appeals Nurse (RN)

    Molina Healthcare (Yonkers, NY)
    …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... Medical Officer on denial decisions. + Resolves escalated complaints regarding Utilization Management and Long-Term Services & Supports issues. + Identifies and… more
    Molina Healthcare (05/10/25)
    - Related Jobs

  • Director Physician Advisor

    Catholic Health Services (Melville, NY)
    …Initiatives Maintains knowledge of regulatory and accreditation requirements related to utilization review (UR), discharge planning (DP), LOC and clinical ... York, as applicable. Certification by American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) preferred. 4. Knowledge, Skills and… more
    Catholic Health Services (03/05/25)
    - Related Jobs

  • Director, Clinical Pharmacy

    CenterWell (Albany, NY)
    …potential market events that would drive unanticipated changes in cost and utilization . The team also leads our trend detection process, responsible for identifying ... month, quarter over quarter and year over year trend review and ad hoc as needed + Proactively monitors...time that is best for your schedule **Work at Home requirements:** To ensure Home or Hybrid… more
    CenterWell (05/11/25)
    - Related Jobs

  • Clinical Assessment Manager

    Actalent (White Plains, NY)
    …of experience in care/case management, disease management, population health management, utilization review , quality assurance, or discharge planning (preferably ... clinical onboarding and reassessment, UAS-NY completion, comprehensive assessment, medication review , and post-hospital discharge evaluation. The Clinical Assessment Manager… more
    Actalent (05/03/25)
    - Related Jobs