• Physician Advisor

    Mohawk Valley Health System (Utica, NY)
    …specialist regarding correct level of care and reimbursement. Apply knowledge of utilization review , discharge planning, patient status changes, length of stay, ... range of medical/clinical knowledge. + Expertise in, or willing to learn utilization management , state/federal regulations, private payer contracts. + Dedication… more
    Mohawk Valley Health System (01/06/26)
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  • Clinical Pharmacy Specialist, Pharmacy Benefits…

    Northwell Health (New Hyde Park, NY)
    …for the development, implementation, and maintenance of drug formularies, clinical utilization management (UM) criteria, and evidence-based drug therapy ... plans + Experience in formulary management , P&T committee support, and/or utilization management (PA, ST, QL) criteria development + Experience with benefit… more
    Northwell Health (01/06/26)
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  • Field Medical Director- (MD/DO)

    Evolent (Albany, NY)
    …**What You'll Be Doing:** As a FMD, Radiology you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
    Evolent (12/26/25)
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  • Field Medical Director, Oncology

    Evolent (Albany, NY)
    …Doing:** As a Field Medical Director, Oncology, you will be a key member of the utilization management team. We can offer you a meaningful way to make a ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality… more
    Evolent (11/18/25)
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  • Strategic Pharmacy Analyst

    RxBenefits (New York, NY)
    …channel management , B/G classifications, specialty designations, rebate eligibility, utilization trend, Utilization Management (UM) implications, ... prospect member size, marketing agreements, broker commissions, and drug utilization . + Be the SME on dozens of medical...closed won groups into a client record for Account Management (AM) and Implementation including the initial gathering of… more
    RxBenefits (12/04/25)
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  • Medical Director, Behavioral Health (PST)

    Molina Healthcare (Syracuse, NY)
    …learn new programs. Preferred Qualifications * Experience with utilization /quality program management . * Managed care experience. * Peer review experience. * ... health oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs… more
    Molina Healthcare (01/06/26)
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  • Care Facilitator- Per Diem- Canton-Potsdam…

    Rochester Regional Health (Rochester, NY)
    …in the Care Management Data base to support the clinical review process. + Concurrently monitors resources utilization , performing continued stay reviews ... efficient utilization of resources. Carries out activities related to utilization management , discharge planning, care coordination and referral to other… more
    Rochester Regional Health (10/24/25)
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  • Case Manager (Inpatient Units)

    Ellis Medicine (Schenectady, NY)
    …services provided by the Case Manager include, but are not limited to, utilization review , case management , care transition, collaboration with physicians ... years of inpatient experience in a hospital environment preferred. + Previous case management , utilization review , and discharge planning experience highly… more
    Ellis Medicine (12/11/25)
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  • RN Clinical Appeals Nurse Remote

    Molina Healthcare (Syracuse, NY)
    …candidate with a RN licensure, Diagnosis-Related Group (DRG) experience, 2 years of Utilization Review and/or Medical Claims Review experience. Knowledge in ... officer on denial decisions. * Resolves escalated complaints regarding utilization management and long-term services and supports...the specific programs supported by the plan such as utilization review , medical claims review ,… more
    Molina Healthcare (01/02/26)
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  • Medical Director - Medicaid (remote)

    Humana (Albany, NY)
    …. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial ... daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, ...with prior experience participating in teams focusing on quality management , utilization management , case … more
    Humana (01/01/26)
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