- Sharecare (Albany, NY)
- …/ new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical, ... parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex pharmacy inquiries + Complex spending… more
- Healthfirst (NY)
- …+ The Medical Peer Reviewer will: + Maintain productivity standards. + Collaborate with Utilization Management and Care Management and medical departments as ... in Internal Medicine or Family Practice + Previous, relevant experience in utilization management and clinical practice + Knowledge of Medicare, Medicaid,… more
- Humana (Albany, NY)
- …+ Demonstrate adaptability and willingness to learn evolving workflows, tools, and utilization management practices **Work Schedule Monday - Friday w/standard ... Delivery Systems, health insurance, or other healthcare providers. + Utilization management experience in a medical management review organization,… more
- Highmark Health (Albany, NY)
- …of internal clinical and value-based evaluation committees that drive formulary and utilization management functions. + Participate in product specific Pharmacy ... value of implemented initiatives. + Lead product based pharmacy trend management discussions with internal partners including senior executives. + Support… more
- Centene Corporation (New York, NY)
- …preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. **License/Certification:** + LPN - ... 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, national organization offering competitive… more
- Molina Healthcare (Albany, NY)
- …and cost-effective member care. The candidate must have Medicare Appeals and/or Utilization Management knowledge. Work hours are Monday-Friday 8:00am- 5:00pm ... teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. **Required Qualifications** * At least 2… more
- Catholic Health Services (Smithtown, NY)
- …patients across the acute care continuum. + Performs required activities for utilization management , PRI assessment and completion, transition planning, and ... clinical medical/surgical or specialty experience required. + 2-3 years' Utilization Management , Performance Improvement, Transition Planning and/or Care… more
- Trinity Health (Syracuse, NY)
- …in terms of quality, safety, service, affordability, and technology. Oversees drug utilization management efforts; manages the pharmaceutical supply chain; and ... including new services/programs, revenue enhancement, expense reduction, managed care utilization systems, and strategies. Responsible for ensuring performance excellence… more
- Molina Healthcare (Albany, NY)
- …reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees. + Participates as needed in joint ... proficient, self-directed, autonomous and experience working from home. Care Management & Waiver Service Auditing experience is highly preferred. Work… more
- Evolent (Albany, NY)
- …billing and various sites of care/service + Familiarity with value-based care and utilization management + Understanding of data systems and the critical ... member-centric products. This role plays a critical part in both **Medical Cost Management ** and **Product Management ** , leveraging advanced analytics to solve… more
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