- Stony Brook University (Stony Brook, NY)
- …Case Manager** is a valuable member of our team, who provides clinical services to our patient population. Qualified candidates will demonstrate superior patient ... required. **Qualifications** **Required** : A Bachelor's degree or a nurse working on their degree with an RN license...their work and follow up with cases. **Preferred:** CM, UM , Quality, Coding, Risk or MCG Certification Working knowledge… more
- CenterWell (Albany, NY)
- …our caring community and help us put health first** The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical ... **Required Qualifications** + Must be a licensed Registered Compact Nurse license (RN) with no disciplinary action and ability...Lung or Critical Care Nursing experience required + Prior clinical experience preferably in an acute care, skilled or… more
- Molina Healthcare (Buffalo, NY)
- **JOB DESCRIPTION** **Job Summary** The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals requests ... regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and… more
- Humana (Albany, NY)
- …community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills to support the coordination, ... from medical records sent from Behavioral Health Facilities to obtain sufficient clinical information. The Utilization Management Behavioral Health Nurse 2 work… more
- Molina Healthcare (Syracuse, NY)
- …**Job Summary** The RN Care Review Clinician provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...intensive care unit, or in a telemetry type setting. UM medical review experience highly preferred. Work Hours: Monday… more
- Humana (Albany, NY)
- …a part of our caring community and help us put health first** The Telephonic Nurse Case Manager will be a member of the In-Home Case Management Team, providing a ... beneficiary's capacity for self- care, to cost-effectively achieve desired clinical outcomes and to enhance quality of medical care....and to enhance quality of medical care. The **Telephonic Nurse Case Manager** will collect and document data to… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …drivers. Essential Accountabilities: Level I + Handles physical health member clinical management programs. + Maintains knowledge of current Case Management Society ... or external referral sources. Applies case management criteria and professional clinical judgment to determine a member's appropriateness for case management… more
- Highmark Health (Albany, NY)
- …experience, or provider operations and/or health insurance experience + 1 year in a clinical setting **Preferred** + 5 years in UM /CM/QA/Managed Care + 1 year ... over a specified panel of members that range in health status/severity and clinical needs; and assesses health management needs of the assigned member panel and… more
- Molina Healthcare (NY)
- …national, state, and local laws and regulatory requirements affecting the medical and clinical staff. + Marketplace UM reviews + MD licenses required for ... appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership… more
- Molina Healthcare (NY)
- **JOB DESCRIPTION** The Care Review Clinician (RN) provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...a candidate with a RN licensure that has previous UM and Inpatient Hospital experience. Candidates with MCO experience… more
- Centene Corporation (New York, NY)
- …the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, ... Purpose:** Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises… more
- Datavant (Albany, NY)
- …recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully. Ideal candidate should be a Licensed ... Practical Nurse or Registered Nurse well versed in...denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines. **You will:** +… more
- Molina Healthcare (NY)
- For this position we are seeking a (RN) Registered Nurse who must be licensed for the state they reside This role will be doing Utilization review for our Ohio ... Medicaid population, looking for clinicians with strong inpatient clinical experience WORK SCHEDULE: Tuesday to Saturday - 8 AM to 5 PM Wednesday to Sunday - 8 AM to… more
- Bassett Healthcare (Cooperstown, NY)
- …p ositive results + Works collaboratively with unit staff (charge nurse , staff nurse ) unit manager, and support team ( UM , MSW, SW, etc) to progress each ... scheduling, onboarding, training, coordination, support, and evaluation of the Unit Clinical Care Coordinators, Logistics Center Clinical Care Coordinators… more
- Molina Healthcare (NY)
- For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is a Remote position, home office with internet connectivity of high ... review, and medical coding. JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that… more
- Trinity Health (Troy, NY)
- …**Description:** If you are an RN and looking for a position in the Observation/ Clinical Decision Unit to meet your schedule, this could be your opportunity. 10-12 ... on M/S units. Will work closely with Hospitalist and CM/ UM assigned to unit. Here at St. Peter's Health...planning and meetings the needs of patients in the Observation/ Clinical Decision Unit for fast paced, frequent patient turn… more
- Molina Healthcare (NY)
- JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically ... necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...the Molina care model. * Adheres to utilization management ( UM ) policies and procedures. Required Qualifications * At least… more
- Molina Healthcare (Buffalo, NY)
- JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically ... necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...the Molina care model. * Adheres to utilization management ( UM ) policies and procedures. Required Qualifications * At least… more
- MVP Health Care (Tarrytown, NY)
- …ensure timely resolution. + Training & Support: Educate staff and providers on UM protocols, documentation standards, and clinical guidelines. + Contribute to ... + Current New York State Licensure as a Registered Nurse required. + Certification in Case Management required within...after hire. + At least 3 years of recent clinical and Case Management experience. Experience working in a… more
- Molina Healthcare (Buffalo, NY)
- …at the most effective setting. *Evaluates effectiveness of utilization management ( UM ) practices - actively monitoring for over and under-utilization. * Educates ... and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical … more
