- Cognizant (Albany, NY)
- …. Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with ... or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances , precertification, initial and concurrent reviews .… more
- Molina Healthcare (Rochester, NY)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- Molina Healthcare (NY)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- Molina Healthcare (NY)
- …actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * Attends or chairs committees ... JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and ...* Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for… more
- Independent Health (Buffalo, NY)
- …for the collection and review of medical records specific to quality complaints/ grievances and appeals as indicated in support of a high performing health ... Medical Director . This position will prepare written responses to appeals and complaints/ grievances , establish plans of correction and provide education… more
- City of New York (New York, NY)
- …and administer the contractual grievance process. Serve as Hearing Officer for grievances and disciplinary appeals . Represent the agency at hearings before ... planning, payroll management, compliance, labor relations, and policy implementation. The Director of Labor and Employee Relations will report to the Deputy… more
- Highmark Health (Albany, NY)
- …medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances , and other reviews as assigned. Compose clear ... current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and… more