- CDPHP (Albany, NY)
- …who share these values and invites you to be a part of that experience. The Utilization Review (UR) Nurse is responsible for the clinical review ... of acute care experience is required as a Registered Nurse . + Minimum of two (2) years Utilization...Utilization Management experience is preferred. + Knowledge of coding/ claims processing is preferred. + Experience working with Microsoft… more
- Centene Corporation (New York, NY)
- …benefits including a fresh perspective on workplace flexibility. **Position Purpose:** The Utilization Review Nurse I provides first level clinical ... requiring authorization. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care… more
- Molina Healthcare (Albany, NY)
- …1-3 years Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and ... outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously denied cases… more
- Northern Rivers Family Services (Troy, NY)
- …county and community partners, and participate in any quality audit and utilization review + Provide on-site/community based/home visits, medication evaluations, ... an NPI. Claims processing functions also require the NPI of nurse practitioners and physicians. + Federal Drug Enforcement Administration (DEA)number - issued by… 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 ... in different states; therefore, Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager II** is responsible for care management within the… more
- Molina Healthcare (Rochester, NY)
- …experience, including hospital acute care/medical experience (STRONGLY DESIRED)** + **Registered Nurse with Claims and CIC coding experience (STRONGLY DESIRED)** ... **_For this position we are seeking a (RN) Registered Nurse who must be licensed for the state of...Payment Integrity strategies through both pre-payment and post payment claims reviews, aligning with industry and corporate standards as… more
- Molina Healthcare (Albany, NY)
- …the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the ... and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource… more
- Excellus BlueCross BlueShield (Buffalo, NY)
- …timely manner and provides support for the Case Management (CM) and Registered Nurse (RN) reviewers and manages the denial process. + Leads interdisciplinary complex ... management rounds. + Provision of clinical oversight and leadership to Utilization Management/Case Management (UM/CM) staff working with the children's population. +… more
- Arnot Health (Elmira, NY)
- …Bachelor's in nursing preferred. Must have proficient writing skills.Experience in Utilization Review and InterQual required. CARDIOPULMONARY RESUSCITATION (CPR) ... Case Managers! MAIN FUNCTION: The Case Management (denial/prior auth) will review and appeal as appropriate for concurrent and retrospective authorization and… more
- Veterans Affairs, Veterans Health Administration (Castle Point, NY)
- …coordinated care delivery model. Coordinates with the patient care team to review clinic appointment availability utilization to ensure that clinic schedules ... the Medicare Rate. This position includes payment reconciling for Community Care medical claims submitted for payment due to outsourcing of treatment for VA Hudson… more