- NewYork-Presbyterian Hospital (Brooklyn, NY)
- …admissions that requires risk identification and clinical reviews. A utilization nurse completes no less than 20 initial clinical reviews daily. Responsibilities ... also includes: *Completing 100% clinical reviews for managed care, Medicare and Medicaid admissions *Completing concurrent and retrospective reviews *Communicating… more
- Elevance Health (Latham, NY)
- ** Nurse Appeals - Medicare ** **Location:** Virtual: This role enables associates to work virtually full-time, with the exception of required in-person ... for employment, unless an accommodation is granted as required by law. The ** Nurse Appeals - Medicare ** is responsible for investigating and processing and… more
- Molina Healthcare (NY)
- …appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously ... _For this position we are seeking a (RN) Registered Nurse who must be licensed for the state of...internet connectivity of high speed required._ **Job Summary** Clinical Appeals is responsible for making appropriate and correct clinical… more
- Molina Healthcare (Albany, NY)
- …medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse ... medical director, and quality improvement staff. + Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements. + Reviews quality referred… more
- Humana (Albany, NY)
- …review by physician or nurse , with a focus on our 5+ million Medicare members. You will also facilitate the delivery of high quality, appropriate, and consistent ... to assist and facilitate new hires and remediation of medical directors performing Medicare utilization management processes and be the liaison for the Medicare … 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 ... BH QM/UM and performance improvement activities, including grievances and appeals . + Attendance at regular (at least quarterly) Plan...without restrictions and free of sanctions from Medicaid or Medicare required. + Minimum of five (5) years of… more
- Stony Brook University (Stony Brook, NY)
- …within thirty days. Documents over utilization of resources and services. + All Medicare cases are reviewed for level of care on admission. Reviews with the ... for admission. Follows the process for Code 44 on Medicare patients. Follow the process for Code 44 on...the hospital stay. + Assist with coverage for UR, Appeals and denials + Actively involved in performance improvement… more
- Catholic Health Services (West Islip, NY)
- …not limited to, Medical Staff, Quality/Risk Management, CH Utilization and Central Appeals , Managed Care and Revenue Cycle and Patient Access departments to ensure ... is required. Current knowledge of NY Department of Health and Centers of Medicare and Medicaid regulations is required. Knowledge of Joint Commission Standards, and… more
