• Care Review Clinician , PA (RN)

    Molina Healthcare (Rochester, NY)
    …Experience** Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual ... / MCG guidelines. **Preferred License, Certification, Association** Active, unrestricted Utilization Management Certification (CPHM). **MULTI STATE / COMPACT LICENSURE**… more
    Molina Healthcare (10/26/25)
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  • Care Review Clinician (RN)

    Molina Healthcare (Buffalo, NY)
    …on set schedule) Looking for a RN with experience with appeals, claims review , and medical coding. JOB DESCRIPTION Job SummaryProvides support for clinical member ... services review assessment processes. Responsible for verifying that services are...to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications *… more
    Molina Healthcare (11/23/25)
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  • Care Review Clinician (RN)

    Molina Healthcare (Syracuse, NY)
    JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary ... with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At least 2… more
    Molina Healthcare (11/21/25)
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  • Integrated Outpatient Senior Clinician

    FLACRA (Penn Yan, NY)
    …within the timelines outlined by FLACRA. + Participates in quality initiatives and utilization review activities as requested. + Strives to understand and meet ... Integrated Outpatient Senior Clinician FLACRA Penn Yan, NY (Onsite) Full-Time $34.00/Hour...plus. Valid NYS driver's License. Job Summary:The integrated senior clinician is a clinician with demonstrated leadership… more
    FLACRA (11/11/25)
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  • Payment Integrity Clinician

    Highmark Health (Albany, NY)
    …of the claim rejection and the proper action to complete the retrospective claim review with the goal of proper and timely payment to provider and member ... Payment Integrity strategies on a pre-payment and retrospective claims review basis. Review process includes a ...data to assure appropriate level of payment and resource utilization . It is also used to identify issues which… more
    Highmark Health (11/14/25)
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  • Medical Management Clinician Associate

    Elevance Health (Latham, NY)
    …or equivalent. + Requires a minimum of 2 years of clinical experience and/or utilization review experience. + Current active, valid and unrestricted LPN/LVN or ... The **Medical Management Clinician Associate** is responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information… more
    Elevance Health (11/21/25)
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  • Denials Prevention Specialist, Clinician…

    Datavant (Albany, NY)
    …healthcare. The purpose of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for medical ... author appeal letter Identification of referrals to the medical director for review + Select appropriate preferred and contracted providers + Provide proper… more
    Datavant (11/12/25)
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  • Social Worker - Inpatient Behavioral Health

    Garnet Health (Harris, NY)
    …Case Manager for the detox patient on the medical floor assuring discharge planning, utilization review , and insurance approval. Join the Garnet Health team and ... organize/prioritize accordingly, and implement evidence based care. Social Work Clinician /Case Manager - primary role is to provide psychiatric/detox emergency… more
    Garnet Health (11/25/25)
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  • Nurse Case Manager: Full Time, DAYS

    Albany Medical Center (Albany, NY)
    …a changing environment. + Basic knowledge of computer systems with skills applicable to utilization review process. + RN - Registered Nurse - State Licensure ... works proactively with the Quality Improvement Teams, patient care standards, and utilization management to coordinate the appropriate use of resources to achieve… more
    Albany Medical Center (11/25/25)
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  • Professional, Behavioral Health

    MVP Health Care (Schenectady, NY)
    …Workplace** . The Behavioral Health (BH) Professional is responsible for conducting utilization review for mental health and substance use treatment decisions. ... you'll bring:** + Master's prepared and licensed mental health clinician (LMSW, LCSW, LMHC, etc.) or Licensed Registered Nurse...with at least 2 years being ASD related + Utilization or Case Management experience in a managed care… more
    MVP Health Care (11/29/25)
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