- 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
- Molina Healthcare (Buffalo, 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 (Buffalo, 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
- 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
- Independent Health (Buffalo, NY)
- …statistics. + Perform validation of diagnosis and procedure coding by reviewing medical record documentation and/or provider claims data. Ensure coding ... policies/contracts. + Responsible for all reconsideration clinical appeals to include review of records, consultation with Medical Director, response to… more