• Medical Claim Review Nurse…

    Molina Healthcare (Rochester, NY)
    …of payment decisions. + Serves as a clinical resource for Utilization Management , Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals. ... SKILLS & ABILITIES:** + Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years… more
    Molina Healthcare (09/06/25)
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  • Care Facilitator- Per Diem- Canton-Potsdam…

    Rochester Regional Health (Rochester, NY)
    …Support - American Heart Association (AHA)American Heart Association (AHA)American Heart Association (AHA), RN - Registered Nurse - New York State Education ... Management Data base to support the clinical review process. + Concurrently monitors resources utilization ,...required + Licensed in New York State as a Registered Nurse + For hires after 10/28/2024,… more
    Rochester Regional Health (07/25/25)
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  • Manager, Healthcare Services

    Molina Healthcare (Buffalo, NY)
    …integrated) performing one or more of the following activities: care review / utilization management (prior authorizations, inpatient/outpatient medical ... identifying opportunities for improvement. **JOB QUALIFICATIONS** **Required Education** + Registered Nurse or equivalent combination of Licensed Vocational… more
    Molina Healthcare (09/27/25)
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  • Appeals and Grievances Clinical Specialist…

    Healthfirst (NY)
    …practice with experience in appeals & grievances, claims processing, utilization review or utilization management /case management . + Demonstrated ... for each Specialist against expectations + Prepare cases for Medical Director Review ensuring that all pertinent information (ie case summary, contract information,… more
    Healthfirst (10/02/25)
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  • Registered Nurse Care Manager…

    Catholic Health (Kenmore, NY)
    …Yes Work Schedule: Days with Weekend and Holiday Rotation Hours: 0800-1800 Summary: The Registered Nurse ( RN ) Care Manager-Transition of Care, as an active ... BS Education, or BS in Health related field + Registered Nurse , licensed (unrestricted) in New York...and/or community health nursing + Preferred prior insurance /managed care/ utilization review experience in the role of… more
    Catholic Health (09/03/25)
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  • Care Review Clinician, Prior Authorization

    Molina Healthcare (Albany, NY)
    …**JOB QUALIFICATIONS** **Required Education** Any of the following: Completion of an accredited Registered Nurse ( RN ), Licensed Vocational Nurse (LVN) ... clinic experience. **Required License, Certification, Association** Active, unrestricted State Registered Nursing ( RN ), Licensed Vocational Nurse...Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and… more
    Molina Healthcare (09/18/25)
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  • Registered Nurse Case Manager II…

    Rochester Regional Health (Rochester, NY)
    Job Title: Registered Nurse Case Manager IIDepartment: Home Care Location: West Monroe Hours Per Week: 40Schedule: Days SUMMARY:The RN Case Manager is ... + Practices according to Agency and community standards + Participates in utilization review and/or continuous quality improvement activities as requested. +… more
    Rochester Regional Health (09/23/25)
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  • Case Manager (Inpatient Units)

    Ellis Medicine (Schenectady, NY)
    …for appropriate Level of Care and status on all patients through collaboration with Utilization Review RN + Contacts the attending physician for additional ... RN Case Manager has responsibility for case management of assigned patients on a designated unit(s). This...the Case Manager include, but are not limited to, utilization review , case management , care… more
    Ellis Medicine (09/11/25)
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  • Care Review Clinician ( RN )

    Molina Healthcare (Buffalo, NY)
    …authorization, managed care, or equivalent combination of relevant education and experience. * Registered Nurse ( RN ). License must be active and unrestricted ... with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. **Required Qualifications** * At… more
    Molina Healthcare (10/02/25)
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  • Case Manager - RN

    Calvary Hospital (Bronx, NY)
    …Flex Spending, Transit Check. + Free On-Site Parking Requirements Participates in the Utilization Review , Discharge Planning, Risk Management , and Quality ... unencumbered NYS licensure. + Five (5) or more years experience in either Utilization Management , Quality Assessment and Improvement, Risk Management , and/or… more
    Calvary Hospital (09/11/25)
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