• Pharmacist, Utilization Management ( UM )

    Molina Healthcare (Buffalo, NY)
    **JOB DESCRIPTION** **Job Summary** Molina Pharmacy Services /Management staff work to ensure that Molina members have access to all medically necessary prescription ... drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review, patient… more
    Molina Healthcare (07/27/25)
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  • Clinical UM Nurse 2

    CenterWell (Albany, NY)
    …of senior-focused primary care, one of the largest providers of home health services , and fourth largest pharmacy benefit manager , CenterWell is focused on ... provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members,...non compact licensure + 3 - 5 years of Medical Surgery, Heart, Lung or Critical Care Nursing experience… more
    CenterWell (08/01/25)
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  • Utilization and Appeals Manager

    Catholic Health Services (Melville, NY)
    Overview Catholic Health is one of Long Island's finest health and human services agencies. Our health system has over 16,000 employees, six acute care hospitals, ... three nursing homes, a home health service , hospice and a network of physician practices across...Island's Top Workplace! Job Details The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews and appeals according… more
    Catholic Health Services (07/24/25)
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  • Behavioral Health Care Manager II

    Elevance Health (Latham, NY)
    …essential face-to-face onboarding and skill development. The **Behavioral Health Care Manager II** is responsible for managing psychiatric and substance abuse or ... healthcare in a cost effective setting in accordance with UM Clinical Guidelines and contract. + Refers cases to...approvals only, reviews requests for Applied Behavioral Analysis (ABA) services only, and there is licensed staff supervision. +… more
    Elevance Health (07/02/25)
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  • Care Manager - Readmission Specialist

    Stony Brook University (Stony Brook, NY)
    …of health issues, address them, document them, and look for available services . * Help patients understand their medical conditions, treatment plans, ... Care Manager - Readmission Specialist **_Position Summary_** _At Stony...medical clearance from Stony Brook Medicine's Employee Health Services * + Complete electronic reference check with a… more
    Stony Brook University (07/15/25)
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  • RN Case Manager

    Stony Brook University (Stony Brook, NY)
    …examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services * + Complete electronic reference check with a minimum of three (3) ... RN Case Manager **Position Summary** At Stony Brook Medicine, a...a valuable member of our team, who provides clinical services to our patient population. Qualified candidates will demonstrate… more
    Stony Brook University (07/16/25)
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  • Case Manager , RN (Multiple Openings!)

    Excellus BlueCross BlueShield (Rochester, NY)
    …corporate, NYS Department of Health (DOH), Centers for Medicaid & Medicare Services (CMS), Federal Employee Program (FEP) and National Committee for Quality ... professional clinical judgment to determine a member's appropriateness for case management services . + Initiates case management, as outlined in the Case Management… more
    Excellus BlueCross BlueShield (06/18/25)
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  • Care Manager RN - (Remote)

    Highmark Health (Albany, NY)
    …management strategies including: review of appropriateness of health care services , application of criteria to ensure appropriate resource utilization, ... of quality issues. Monitors and analyzes the delivery of health care services ; educates providers and members on a proactive basis; and analyzes qualitative… more
    Highmark Health (07/12/25)
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  • Registered Nurse (RN) - Utilization Management

    Rochester Regional Health (Rochester, NY)
    …and/or CMS guidelines. Responsibilities include managing the workflow with the standard UM sources for potential inpatient medical necessity denials. Assists and ... denial management as needed across the organization. RESPONSIBILITIES: + Review standard UM sources for potential inpatient medical necessity denials. Review… more
    Rochester Regional Health (08/02/25)
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  • Director Physician Advisor

    Catholic Health Services (Melville, NY)
    Overview Catholic Health is one of Long Island's finest health and human services agencies. Our health system has over 16,000 employees, six acute care hospitals, ... three nursing homes, a home health service , hospice and a network of physician practices across the island. At Catholic Health, our primary focus is the way we treat… more
    Catholic Health Services (06/27/25)
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