- Evolent (Albany, NY)
- …of the request and provides clinical rationale for standard and expedited appeals . + Utilizes medical/clinical review guidelines and parameters to assure consistency ... by any state or federal health care program, including Medicare or Medicaid, and is not identified as an...General Service Administration (GSA), or reprimanded or sanctioned by Medicare . + No history of a major disciplinary or… more
- Evolent (Albany, NY)
- …of best practices. + Provides clinical rationale for standard and expedited appeals . + Discusses determinations (peer to peer phone calls) with requesting physicians ... by any state or federal health care program, including Medicare or Medicaid, and is not identified as an...General Service Administration (GSA), or reprimanded or sanctioned by Medicare . + No history of a major disciplinary or… more
- Molina Healthcare (Buffalo, NY)
- …treatment * Provides second level BH clinical reviews, BH peer reviews and appeals * Supports BH committees for quality compliance. * Implements clinical practice ... State (TX) Medical License, free of sanctions from Medicaid or Medicare . **Preferred Experience** * Peer Review, medical policy/procedure development, provider… more
- Merck (Albany, NY)
- …of patient enrollment process, payer coverage policies, prior authorization process, appeals process, patient support programs, and Hub operations to Field Access ... or reimbursement support * Strong knowledge of health insurance structures ( Medicare Part B, Medicaid, commercial) and related access processes, including benefit… more
- Cognizant (Albany, NY)
- …billing, with strong knowledge of RARC and CARC codes. . Expertise in Medicare , Medicaid, Managed Care, and Commercial payer processes. . Deep understanding of ... reporting. . Excellent verbal and written communication skills for documentation and appeals . . Ability to meet productivity and quality standards in a fast-paced… more
- Highmark Health (Albany, NY)
- …through paid clams review. + Participate as pharmacy representative in onsite member appeals and grievances sessions. + Serve as a resource for technical staff. + ... offerings and rules/regulations across multiple states. They must also be familiar with Medicare drug benefit design offerings that may differ by state, while being… more
- Molina Healthcare (Syracuse, NY)
- …* Provides second level behavioral health clinical reviews, peer reviews and appeals . * Supports behavioral health committees for quality compliance. * Implements ... compliance with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). * Assists with the recruitment and orientation… more
- Elderwood (Amherst, NY)
- …to provide concurrent updates as requested by Insurance Companies, handles Third Party appeals , peer to peers as applicable and with clinical oversight provided by ... experience within the HMO Managed Care Insurance Companies + Knowledge of Medicare and Medicaid Managed Care Policies and Utilization Review. Managed Care… more
- Cardinal Health (Albany, NY)
- …the appropriate system. + Manages and resolves complex insurance claims, including appeals and denials, to ensure timely and accurate reimbursement. + Processes ... regulations, or third party policy. + Updates patient files for insurance information, Medicare status, and other changes as necessary or required. + Keeps email… more
- Calvary Hospital (Bronx, NY)
- …to facilitate reimbursement for services provided by the Hospital. Oversees the appeals process for those cases for which reimbursement has been denied. Conducts ... interface with the Finance Office regarding pertinent insurance information, eg Medicare , Medicaid, Blue Cross, and Commercial Insurance. Performs other related… more