- Molina Healthcare (Yonkers, NY)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... schedule) Looking for a RN with experience with appeals, claims review , and medical coding....clinical/ medical reviews of retrospective medical claim reviews, medical claims and… more
- Centene Corporation (New York, NY)
- …license; and a NYS Driver's License or Identification card.** **Position Purpose:** The Utilization Review Nurse I provides first level clinical review for ... and medical necessity using appropriate criteria, referring those requests that fail review to the medical director for second level review and… more
- Elevance Health (Woodbridge, NJ)
- …and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to payment. Researches new healthcare-related questions ... **Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon Payment Integrity SIU**...Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Clinical Fraud Investigator II** is responsible… more
- Travelers Insurance Company (New York, NY)
- …Utilize evaluation documentation tools in accordance with department guidelines. + Proactively review Claim File Analysis (CFA) for adherence to quality ... evaluating, reserving, negotiating and resolving assigned serious and complex Specialty claims . Provides quality claim handling throughout the claim… more
- BronxCare Health System (Bronx, NY)
- …(according to the NPSG), intake screening of patient, pre-visit planning (if applicable), review of medical record to determine visit requirements such as HEIDS ... Overview Licensed Practical Nurse : Under the direct supervision of a physician...analysis, implementation of and compliance with risk management and claims activities, support of and participation in Continuous Quality… more
- Elevance Health (Woodbridge, NJ)
- **Telephonic Nurse Case Manager II** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Elevance Health (Woodbridge, NJ)
- **Telephonic RN Nurse Case Manager I** **Sign On Bonus: $3000** **Location: This role enables associates to work virtually full-time, with the exception of required ... in different states; therefore Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager I** is responsible for performing care management within… more
- Constructive Partnerships Unlimited (Brooklyn, NY)
- …in the management of medications. POSITION DUTIES 1. Maintain effective communication on medical issues with VP of Nursing, Nurse Administrator, Registered ... Nurse (RN), and Medical Coordinators2. Maintains medical records, including obtaining/filing all necessary reports and maintaining database of individuals… more
- Constructive Partnerships Unlimited (Brooklyn, NY)
- …and SCIP-R. 12. Reports all incidents to the Residence Manager, and reports all medical issues/ injuries to the registered nurse and follows protocols for ... individuals and arranges transportation as necessary. Upon instructions of the Nurse , accompanies individuals on medical appointments and/or visits hospital… more
- Molina Healthcare (Yonkers, NY)
- …retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as ... Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial… more
- Brighton Health Plan Solutions, LLC (Westbury, NY)
- About The Role MagnaCare provides Utilization Review / Case Management/ Medical Management/ Claims Review services to its clients. Care Coordinators ... data collection & data entry, and effectively communicating with Nurse Case Reviewers/Managers, employers and claimants in regard to... claims a plus. + Strong skills in medical record review . + Familiarity with … more
- Elevance Health (Woodbridge, NJ)
- …experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing ... the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims...you will make an impact:** + Analyzes and audits claims by integrating medical chart coding principles,… more
- City of New York (New York, NY)
- …compensability of treatment as it relates to the claimant's work injury and assist with medical case management of claims . Review and process high value and ... Compensation Division are responsible for all medically related issues for medical management of workers' compensation claims . Responsibilities include: Consult… more
- Mount Sinai Health System (New York, NY)
- …for reviewing, summarizing, analyzing, presenting and monitoring safety events, claims management, loss prevention and reduction, patient safety related quality ... + Current New York State license as a Registered Professional Nurse or other licensed/certified clinical professional strongly preferred; foreign healthcare… more
- BronxCare Health System (Bronx, NY)
- …projects and committees as determined by Director. Qualifications CERTIFICATION/LICENSURE : Registered Nurse or physician or a foreign medical graduate preferred ... collection, analysis, implementation of and compliance with risk management and claims activities, support of and participation in Continuous Quality Improvement… more