- 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
- Mount Sinai Health System (New York, NY)
- …for appeals , On / Off-site Insurance reviews + Implements first step of appeals process to assist Appeals Nurse and Enter Denial information in ... department protocol (IPRO Discharge Appeals / Insurance requests) + Support Appeals Nurse / Manager by confirming status of denials + Tracking status of… more
- Centene Corporation (New York, NY)
- …Friday.** **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)
- …the analysis and preparation of responses to payor denials and develop strong appeals for the purpose of securing reimbursement for acute care services provided to ... identification of patterns and trends identified during the course of appeals preparation. Conduct departmental performance improvement audits, analyze findings and… more
- Catholic Health (Buffalo, NY)
- …role of management and oversight of team Summary: The Clinical Denials and Appeals , Clinical Supervisor is responsible for the people, carrying out and documenting ... the appeals process for denied claims denied due to reasons...operational analysis, information systems or related field + Registered Nurse with a four (4) year degree and Unrestricted… more
- Northwell Health (Melville, NY)
- …current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect patient's severity of illness ... of job entry date. Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed. Preferred… more
- Molina Healthcare (Rochester, 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
- 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
- Independent Health (Buffalo, NY)
- …the collection and review of medical records specific to quality complaints/grievances and appeals as indicated in support of a high performing health plan and ... network. The Clinical Reviewer will investigate quality complaints/grievances and appeals , document research of initial coverage determinations, and lead… 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
- 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
- Molina Healthcare (Syracuse, 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
- Guthrie (Binghamton, NY)
- …in basket monitoring, overdue results, referrals, provider orders and support the nurse navigator role. Experience: A minimum of 2 years' experience preferred in ... 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
- 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
- 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 (Cheektowaga, NY)
- Salary $38 - $49.50 per hour 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
- Bassett Healthcare (Cooperstown, NY)
- …and financial indicators including LOS, excess days, resource utilization, denials and appeals , swing bed statistics. + Uses data to drive decisions and ... Licensure/Certifications: + Current NYS licensure as a Registered Professional Nurse , if applying as a nurse , required...Registered Professional Nurse , if applying as a nurse , required + Case Management certification, preferred + Case… more
- Rochester Regional Health (Rochester, NY)
- …hospital and payors, ensuring accurate communication of clinical information, supporting appeals , and optimizing benefit use. + Collaborates with care teams to ... care experience + Licensed in New York State as a Registered Nurse PREFERRED QUALIFICATIONS: + Case Management or Utilization Management experience + Bachelor's… more
- Memorial Sloan-Kettering Cancer Center (New York, NY)
- …+ Work with insurance carriers and MSKCC billing departments to initiate appeals and acquire authorizations for treatment **Key Qualifications:** + Current NYS ... Registered Nurse License/Registration and BSN preferred + At least 2-3 years of clinical hospital nursing experience + Managed care/UR/CM experience strongly… more