- Molina Healthcare (Syracuse, NY)
- …appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct...denied cases in which a formal appeals request has been made or upon request by… more
- Evolent (Albany, NY)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Evolent Appeals Nurse 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… more
- 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
- Catholic Health (Buffalo, NY)
- …potential Summary: This position is accountable for carrying out and documenting the appeals process for denied claims denied due to reasons including, but not ... third party payers in scenarios related to denials and appeals . This position educates all members of the patient...level of care denial trends. Responsibilities: EDUCATION + Registered Nurse with a current New York State license +… more
- Centene Corporation (New York, NY)
- …**Position Purpose:** Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical ... + Communicates with members, providers, facilities, and other departments regarding appeals requests + Generates appropriate appeals resolution communication and… more
- BronxCare Health System (Bronx, NY)
- Overview Appeals associate will be responsible for coordinating and monitoring the administrative and non-clinical servicesfor the clinical appeals team. These ... date. Responsibilities -Print Medical records- Admission notes, Progress notes, Nurse progress notes, Medical order, Lab results (15 to...results (15 to 20 cases per day) pertaining to Appeals and mail them out to the corresponding Payor… more
- WMCHealth (Valhalla, NY)
- Asst Utilization Coordinator - Appeals Company: Westchester Medical Center City/State: Valhalla, NY Category: Nursing/Nursing Management Department: Clinical Care ... by the New York State Department of Education, as a registered professional nurse . Training and Experience: three years of experience where the primary function of… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …the use of medical and health care services for members. The SN CHA Nurse may also perform other technical and administrative tasks essential to the efficient ... areas, including but not limited to UM and CM, Fair Hearings and Appeals /Grievances, within three months of working in position. * Demonstrates ability to handle… more
- Crouse Hospital (Syracuse, NY)
- …department, including Utilization Management, Discharge Planning and Denials and Appeals functions. + Assessing workflow related to readmission prevention, length ... and contractual agreements. Manager, Care Coordination Requirements: + Licensed as a Registered Nurse in New York State + Bachelor's degree + Five (5) years previous… more
- Molina Healthcare (New York, NY)
- …responsibilities will include specialized medical necessity reviews and/or appeals and supporting market performance. Performance activities include physician ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- Mount Sinai Health System (Long Island City, NY)
- …will direct and manage departmental activities involved in utilization review, appeals management and discharge planning to facilitate the case management process ... Requirements** 5 years of Case Management and 6 years of clinical nurse experience. Previous supervisory experience in Case Management or a related field.… 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 ... Administration of BH QM/UM and performance improvement activities, including grievances and appeals . + Attendance at regular (at least quarterly) Plan leadership and… more
- Mount Sinai Health System (New York, NY)
- …collaboratively with physicians and managed care companies on concurrent denial appeals + Communicates clinical information to the payor, as needed, coordinating ... assessment, communication and monitoring of discharge planning process (The clinical nurse initiates the discharge planning process on admission). + Obtains… more
- Mount Sinai Health System (New York, NY)
- …collaboratively with physicians and managed care companies on concurrent denial appeals e. Communicates clinical information to the payor, as needed, coordinating ... assessment, communication and monitoring of discharge planning process (The clinical nurse initiates the discharge planning process on admission). b. Obtains… 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
- Mount Sinai Health System (New York, NY)
- …degree preferred + 5 years of Case Management and 6 years as a clinical nurse . + Previous supervisory experience in case management or a related field. + Name: ... ensure appropriateness of admissions and proper reimbursement. 11. Ensures Discharge Appeals functions are carried out within contractual, federal and state… more
- Guthrie (Corning, NY)
- …in basket monitoring, overdue results, referrals, provider orders and support the nurse navigator role. Experience: A minimum of 2 years' experience in nursing, ... state in which the position resides. Licenses: Licensed Practical Nurse in the state of position. Essential Functions: Patient...of coverage of ordered medications. * *Coordinate and complete appeals for denials as needed * *Monitor and Review… more
- Elderwood (Waverly, NY)
- Salary $38 - $53.30 / hourly Overview Are you a Registered Nurse (RN) with Medicare experience? Do you consider yourself an expert in assessment and reimbursement ... for pre and post-pay record reviews, ADR requests and appeals processes. + Manages NYS RUGs III case mix...RN - MDS Coordinator - Qualifications: + Licensed Professional Nurse (RN licensure preferred) with current license in state… more
- Mount Sinai Health System (New York, NY)
- …hospital personnel as needed. The Nursing Clinical Manager collaborates with Appeals Management, Managed Care Contracting and other institutional departments to ... management experience and 5 -7 years of experience as a clinical nurse . Licensing and Certification Requirements (if applicable) License: RN (current) and… more
- Premier Medical Group of the Hudson Valley (Poughkeepsie, NY)
- GI Prescription/ Infusion Nurse (LPN) The LPN functions under the supervision and guidance of the Registered Nurse and Physician, participating in the ... Prescription Que, sends in prescription refills, completes prior authorizations, works thru appeals and denials, assists patients with copay assistance and free drug… more