- CVS Health (Albany, NY)
- …high-quality healthcare for members. We are seeking a dedicated Utilization Management ( UM ) Nurse Consultant to join our remote team. **Key Responsibilities** ... Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care… more
- Molina Healthcare (NY)
- …this position we are hiring for a float team to support PEGA UM systems throughout multiple states.** **JOB DESCRIPTION** **Job Summary** Molina Healthcare Services ... within required timelines. + Refers appropriate prior authorization requests to Medical Directors. + Requests additional information from members or providers in… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …Community Health Assessment (CHA) Tools to determine functional status, medical , behavioral, psychological, and community resource needs for coordinating, ... integrating, and monitoring the use of medical and health care services for members. The SN...and health care services for members. The SN CHA Nurse may also perform other technical and administrative tasks… more
- Excellus BlueCross BlueShield (Buffalo, NY)
- …+ Develops and implements the BH sections of the Quality Management/Utilization Management (QM/ UM ) Plan, including having the BH Medical Director for Children's ... provides support for the Case Management (CM) and Registered Nurse (RN) reviewers and manages the denial process. +...clinical setting). + A minimum of ten (10) years medical experience and strong working knowledge of QM/ UM… more
- Molina Healthcare (Albany, NY)
- …Summary** Responsible for serving as the primary liaison between administration and medical staff. Assures the ongoing development and implementation of policies and ... procedures that guide and support the provisions of medical staff services. Maintains a working knowledge of applicable national, state, and local laws and… more
- BronxCare Health System (Bronx, NY)
- …projects and committees as determined by Director. Qualifications CERTIFICATION/LICENSURE : Registered Nurse or physician or a foreign medical graduate preferred ... and Customer Service. - Reviews and denials notification letters along with the medical records and all pertinent documentation related to the episode of care being… more
- Molina Healthcare (Syracuse, NY)
- …or a compact licensure. The ideal candidate will have experience with UM and prior authorization, within both Physical Health and Behavioral Health. Candidates ... within required timelines. + Refers appropriate prior authorization requests to Medical Directors. + Requests additional information from members or providers in… more
- Humana (Albany, NY)
- …+ Serves as subject matter expert on NCQA Health Plan Accreditation UM requirements, advising stakeholders on compliance, and facilitating NCQA UM ... Health; MED-Deeming accreditation standards knowledge is a plus. + Registered Nurse or Behavioral Health Licensed Professional. + Managed care, Medicaid health… more
- Mount Sinai Health System (New York, NY)
- …to appropriate departments + Monitors Concurrent Nurse denial phone calls for UM Nurse to follow + Prioritizes work as per department protocol (IPRO ... record keeping. Responsible for accurate filing of records, obtaining medical records and mailing of both internal and external...Implements first step of appeals process to assist Appeals Nurse and Enter Denial information in Allscripts + Meets… more
- Ellis Medicine (Schenectady, NY)
- …The Discharge Planner's primary function is to work with the Social Worker, Nurse Case Manager, or Utilization Management Nurse to facilitate patient discharge ... in utilization management activities under the direction of a registered nurse and/or social worker. Responsibilities include maintaining case files, updating… more