- Molina Healthcare (Syracuse, NY)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... **Job Duties** + Performs clinical/ medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which… more
- Independent Health (Buffalo, NY)
- …collaboration. **Overview** The Utilization Review Nurse (URN) performs clinical review to determine the medical necessity of requested services. The URN ... Degree in Nursing required; Bachelor's degree preferred. Current, active, unrestricted, and licensed registered nurse ( RN ) required. + Two (2) years of… more
- CP Unlimited (Carmel, NY)
- Registered Nurse Type of Position Full...semiannual basis or as indicated. + Coordinate with the Medical Case Manager Counselors (MCMC) to ensure medical ... NY, Yonkers, NY Apply Now (https://phe.tbe.taleo.net/phe03/ats/careers/v2/applyRequisition?org=CPOFNYS&cws=45&rid=6353) Job Brief The Registered Nurse shall provide health related services… more
- FlexStaff (Poughkeepsie, NY)
- **Req Number** 153761 FlexStaff is looking for a Registered Nurse Case Manager. Coordinate the delivery of health care services for persons receiving services as ... semiannual basis or as indicated. 3. Coordinate with the Medical Case Manager Counselors (MCMC) to ensure medical...the timeframe assigned C. REQUIREMENTS: 1. Maintain current NYS Registered Nurse license - Graduation from an… more
- Public Consulting Group (Albany, NY)
- …sector. To learn more, visit www.publicconsultinggroup.com . PCG is currently seeking a qualified Registered Nurse to perform as a Case Manager. The Case Manager ... Proven working experience in case management, including as a nurse , medical , mental health care manager or...plans. + Current license, certification or registration as a Registered Nurse or Social Worker **Working Conditions**… more
- Molina Healthcare (Albany, NY)
- …to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. ... nursing experience with broad clinical knowledge. + Five years experience conducting medical review and coding/billing audits involving professional and facility… more
- Molina Healthcare (Syracuse, NY)
- …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse ( RN ) performs clinical/ medical reviews of… more
- Guardian Life (Albany, NY)
- …providing comprehensive medical reviews and analysis of long-term disability claims . The RN Clinical Consultant identifies restrictions, limitations and ... duration impacting functional capacity based on medical data, to assist the Claim Managers...The RN Clinical Consultant reviews long-term disability claims to determine the impact of claimants' medical… more
- MetLife (Oriskany, NY)
- …quarterly meetings with the Vocational resource and Account team member. * Participate in claim review meetings as requested by the customer. * Utilize tools ... for meetings Key Responsibilities: * Independently assess, analyze and render appropriate claim decisions pursuant to certificates on all claims . * Compare… more
- Guthrie (Binghamton, NY)
- …cases. Assists departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals. ... services regarding admissions, case management, discharge planning and utilization review . Responsibilites: Reviews admissions and service requests within assigned… more
- Trinity Health (Syracuse, NY)
- …meeting regulatory requirements for reporting to the FDA pursuant to the Safe Medical Device Act. **PROPERTY LOSS PREVENTION AND CLAIMS REPORTING:** Collaborates ... standing and walking. **WORK CONTACT GROUP:** All services, employees, medical staff, patients, visitors, vendors, various regulatory and professional agencies.… more
- Brighton Health Plan Solutions, LLC (New York, NY)
- …assurance standards and MagnaCare policies and procedures. Essential Qualifications + Currently licensed Registered Nurse in the state of NY, or the ability to ... About The Role Brighton Health Plan Solutions (BHPS) provides Utilization Review / Medical and Case Management services for Group Health and Workers' Compensation… more
- Excellus BlueCross BlueShield (Buffalo, NY)
- …peer-to-peer calls in timely manner and provides support for the Case Management (CM) and Registered Nurse ( RN ) reviewers and manages the denial process. + ... claims and appeals and resolves grievances related to medical quality of care, as needed. + Ensures that...standards and issue. + Ensures that other Behavioral Health medical directors reviewing pediatric cases review those… more
- Sedgwick (Albany, NY)
- …accredited college or university preferred. Current Certified Rehabilitation Counselor (CRC) or Registered Nurse ( RN ) license required. Current license, ... clinical evaluations on claims that require additional review based on medical condition, client requirement,... management of claims , including comprehension of medical terminology and substantiating claim decisions. **ADDITIONAL… more
- Lincoln Financial (Albany, NY)
- …as indicated **What we're looking for** * 4 Year/Bachelor's Degree in Nursing * Registered Nurse License - Current, unrestricted license in the state where the ... organization. This position will be responsible for reviewing, analyzing, and interpreting medical information available for disability claims . In this role you… more
- Healthfirst (NY)
- …quality of care, monitor progress, and recommend changes + Reviews billing codes, medical records, and claims submission processes to ensure accuracy + Attends ... Degree from an accredited institution + Clinical license: LPN, RN , LMSW or LCSW + Multiple years of HEDIS...for both Medicaid and Medicare lines of business + Medical record review experience directly working on… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …long term care insurance claims processing. + Must have the ability to review and interpret medical records and assessments for the purpose of determining ... required by the Company. + Evaluates Insured's condition through review of field assessments, medical records, etc....+ Reviews and audits the Insured's benefit file and claim payment to encourage timely submission of claims… more
- Constructive Partnerships Unlimited (Brooklyn, NY)
- …the Residence Manager, and reports all medical issues/ injuries to the registered nurse and follows protocols for notification. 13. Performs variety of ... reports and maintaining database of consumer health information after review and signed by the RN . +...+ Performs all other duties as assigned by the registered nurse . II. POSITION REQUIREMENTS A. Qualifications… more
- BronxCare Health System (Bronx, NY)
- …Licensed Practical Nurse : Under the direct supervision of a physician and/ or Registered Nurse , participates in the application of the nursing process to an ... (according to the NPSG), intake screening of patient, pre-visit planning (if applicable), review of medical record to determine visit requirements such as HEIDS… more
- Otsuka America Pharmaceutical Inc. (Albany, NY)
- …to travel up to 25%.** **Educational Qualifications** Required: + Bachelor's Degree or Registered Nurse ( RN ). Minimum of 10 years industry experience ... and guidance, ICH/GCP, and Otsuka SOPs.** **Contribute to the development and review of all critical clinical study documents, including clinical protocols, informed… more