• Utilization Management…

    Humana (Albany, NY)
    **Become a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the ... communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work...action. Humana is seeking a Part C Grievance & Appeals (G&A) Nurse who will assist in… more
    Humana (11/12/25)
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  • Medical Review Nurse (RN)

    Molina Healthcare (Buffalo, NY)
    …decisions. + Serves as a clinical resource for utilization management , CMOs, physicians and member/provider inquiries/ appeals . + Provides training and ... ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS)… more
    Molina Healthcare (10/18/25)
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  • RN/Case Manager-MSH-Case Management…

    Mount Sinai Health System (New York, NY)
    …are not limited to: a. Reviews all new admissions to identify patients where utilization review, discharge planning, and/or case management will be needed using ... **Job Description** **RN/Case Manager MSH Case Management FT Days** The Case Manager (CM) will...length of stay (LOS), improved efficiency, quality and resource utilization . Assignment will be by units/clinical areas of practice… more
    Mount Sinai Health System (10/29/25)
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  • Medical Director (NV)

    Molina Healthcare (Buffalo, NY)
    …of health care services provided to plan members. * Supports plan utilization management program and accompanying action plan(s), which includes strategies ... the most appropriate care at the most effective setting. *Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and… more
    Molina Healthcare (10/31/25)
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  • Medical Director (AZ)

    Molina Healthcare (NY)
    … and effective resource management . + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...analysts to produce tools to report, monitor and improve Utilization Management . + Actively participates in regulatory,… more
    Molina Healthcare (10/17/25)
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  • RN/Case Manager (Inpatient)-Mount Sinai…

    Mount Sinai Health System (New York, NY)
    …are not limited to: 1. Reviews all new admissions to identify patients where utilization review, discharge planning, and/or case management will be needed using ... (CM) will be responsible for all aspects of case management for an assigned group of inpatients to determine...length of stay (LOS), improved efficiency, quality and resource utilization . Assignment will be by units/clinical areas of practice… more
    Mount Sinai Health System (11/05/25)
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  • Care Facilitator

    Rochester Regional Health (Rochester, NY)
    …New York State as a Registered Nurse PREFERRED QUALIFICATIONS: + Case Management or Utilization Management experience + Bachelor's Degree EDUCATION: ... efficient utilization of resources. Carries out activities related to utilization management , discharge planning, care coordination and referral to other… more
    Rochester Regional Health (10/31/25)
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  • Case Manager, Medicaid Long Term Support Program

    MVP Health Care (Tarrytown, NY)
    …every interaction **Your key responsibilities:** + Utilize the essentials of an integrated utilization management and case management model that includes ... **Qualifications you'll bring:** + Current New York State Licensure as a Registered Nurse required. + Certification in Case Management required within 24 months… more
    MVP Health Care (11/12/25)
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  • Family Health Advocate - Remote

    Sharecare (Albany, NY)
    …open enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited ... 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management ...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
    Sharecare (10/14/25)
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  • Director of Care Coordination (RN)

    Catholic Health Services (West Islip, NY)
    …Management : + Works collaboratively with, but not limited to, Medical Staff, Quality/Risk Management , CH Utilization and Central Appeals , Managed Care and ... hospital care management leadership role is required. + Experience in utilization management , working with managed care organizations, and discharge planning… more
    Catholic Health Services (10/16/25)
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