- Excellus BlueCross BlueShield (Rochester, NY)
- …case planning and research, conducting onsite or desk audits, clinical reviews of medical records to ensure correct billing of services and appropriateness of care, ... Level I + Functions as a clinical reviewer of medical records, researching and investigating complex medical ...and concise manner. + Analyzes proactive detection reports and claims data to identify red flags/aberrant billing patterns. +… more
- Independent Health (Buffalo, NY)
- …statistics. + Perform validation of diagnosis and procedure coding by reviewing medical record documentation and/or provider claims data. Ensure coding ... policies/contracts. + Responsible for all reconsideration clinical appeals to include review of records, consultation with Medical Director, response to… more
- Trinity Health (Albany, NY)
- …degree is strongly preferred). Master's degree preferred. Certification (CPHRM) is preferred. Registered Nurse preferred. Ideally, the candidate will have 3-5 ... for the overall patient safety and clinical risk management functions related to review and response to reported events. Responds to crisis situations that have… more
- BronxCare Health System (Bronx, NY)
- …and committees as determined by Director. Qualifications CERTIFICATION/LICENSURE : Registered Nurse or physician or a foreign medical graduate preferred . ... collection, analysis, implementation of and compliance with risk management and claims activities, support of and participation in Continuous Quality Improvement… more
- Catholic Health Services (Melville, NY)
- …The ProFee CDS will focus on pre-visit provider support, post-visit provider review , and collaboration and education with providers. Pre-visit provider support - ... indicators + Validation of data-driven suspect diagnoses Post-visit provider review - Perform post-visit reviews focused on what is...other chronic conditions that are addressed as part of medical decision making and the treatment plan + Assesses… more
- Mount Sinai Health System (New York, NY)
- …The Senior Risk Manager supports the Risk Management staff on how best to review risk management data, conduct Root Cause Analysis, and comply with risk management ... to develop educational plans for instructing staff about the medical center's activities and the daily administration of its...to the Risk Management staff on how best to review risk management data, conduct Root Cause Analysis, and… more
- Elevance Health (Latham, NY)
- **Telephonic Nurse Case Manager II** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Catholic Health Services (Roslyn, NY)
- …actions plans + Responsible for professional liability discovery + Attends claims litigation meeting + Coordinates, investigates, trends and disseminates safety ... and Privacy programs including risk assessments and rounding + Conduct medical record reviews to identify potential regulatory concerns, quality issues, and… more