- Evolent (Albany, NY)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of ... a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and… more
- Cognizant (Albany, NY)
- …to Friday - Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced level work related to clinical ... . Maintain working knowledge of applicable health insurers' internal claims, appeals , and retro-authorization as well as timely filing deadlines and processes.… more
- Molina Healthcare (Albany, NY)
- …will work on set schedule) Looking for a RN with experience with appeals , claims review, and medical coding. **Job Summary** Utilizing clinical knowledge and ... resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/ Appeals . + Provides training and support to clinical peers. +… more
- Sharecare (Albany, NY)
- …enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited to medical, ... 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status +...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… 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 ... and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends… more
- MVP Health Care (Schenectady, NY)
- …you'll bring:** + Current New York State Licensure as a Registered Nurse required. + Certification in Case Management required within 24 months after ... maintain cost-effectiveness and manage Medical Loss Ratio (MLR). + Appeals & Denials: Participate in the appeals ...+ Appeals & Denials: Participate in the appeals process for denied services and ensure timely resolution.… more
- Ellis Medicine (Schenectady, NY)
- …The Discharge Planner's primary function is to work with the Social Worker, Nurse Case Manager, or Utilization Management Nurse to facilitate patient discharge ... in utilization management activities under the direction of a registered nurse and/or social worker. Responsibilities include maintaining case files, updating… more