- Excellus BlueCross BlueShield (Rochester, NY)
- …depending on customer and departmental needs. + Plans, implements, and documents utilization management activities which incorporate a thorough understanding of ... productivity and gain efficiencies for performance improvement opportunities in the Utilization Management Department. + Assists in updating departmental… more
- MVP Health Care (Rochester, NY)
- Hospital Case Manager - Registered Nurse ( RN ) Rochester, NY, USA Req #2611 Monday, May 19, 2025 At MVP Health Care, we're on a mission to create a healthier ... bring:** + Current New York State Licensure as a Registered Nurse required with at least 4...at least 4 years of recent clinical and Care Management experience. + Certification in Case Manager (CCM) is… more
- Molina Healthcare (Rochester, NY)
- …Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG ... guidelines. **Preferred License, Certification, Association** Active, unrestricted Utilization Management Certification (CPHM). MULTI STATE / COMPACT LICENSURE… more
- Fresenius Medical Center (Rochester, NY)
- …auditing activities. + Accountable for completion of the Annual Standing Order Review and Internal Classification of Disease (ICD) coding. + Manages clinic ... financials including efficient utilization of supplies or equipment and regular profits and...of supplies or equipment and regular profits and loss review . + Responsible for all required network reporting and… more
- Catholic Health (Buffalo, NY)
- …(2) years acute care RN experience required + Preferred prior insurance /managed care/ utilization review experience in the role of a Case Manager or Disease ... and families in the hospital setting. Utilizing foundational case management and discharge planning principles, the RN ...BS Education, or BS in Health related field + Registered Nurse , licensed (unrestricted) in New York… more
- Excellus BlueCross BlueShield (Rochester, NY)
- …and quality health care services. Examples may include: Utilization Management , Quality, Behavioral Health, Pharmacy, Registered Dietitian and Respiratory ... varied clinical expertise (ex. Social Work, Behavioral Health, Respiratory Therapy, Registered Dietitian, Registered Nurse , Medical Director, Pharmacist,… more
- Rochester Regional Health (Rochester, NY)
- …LICENSES / CERTIFICATIONS: BLS - Basic Life Support - American Heart Association (AHA), RN - Registered Nurse - New York State Education Department ... navigation for patients, including triage management , algorithm management , utilization management and resource...after admission-within the first 12 to 24 hours. Applies utilization review criteria to assess and document… more
- Rochester Regional Health (Rochester, NY)
- …LICENSES / CERTIFICATIONS: BLS - Basic Life Support - American Heart Association (AHA), RN - Registered Nurse - New York State Education Department ... Management Data base to support the clinical review process. + Concurrently monitors resources utilization ,...Certification/Licensure + Licensed in New York State as a Registered Nurse Required Years of Experience +… more
- Rochester Regional Health (Rochester, NY)
- …LICENSES / CERTIFICATIONS: BLS - Basic Life Support - American Heart Association (AHA), RN - Registered Nurse - New York State Education Department ... navigation for patients, including triage management , algorithm management , utilization management and resource...after admission-within the first 12 to 24 hours. Applies utilization review criteria to assess and document… more
- Catholic Health (Kenmore, NY)
- …and Holiday Rotation Hours: 0800-1600 with rotation to 0900-1700, 1000-1800. Summary: The Registered Nurse ( RN ) Care Manager-Transition of Care, as an ... BS Education, or BS in Health related field + Registered Nurse , licensed (unrestricted) in New York...and/or community health nursing + Preferred prior insurance /managed care/ utilization review experience in the role of… more
- Elderwood (Buffalo, NY)
- …operation of the RN Care Management Team 4. Participate in the utilization review process and evaluate to determine if the member's condition and needs ... visit, telephonic, or written interaction. 10. Participate in Disease Management , Utilization Management (as required)..., or Administrator Qualifications * Current New York State Registered Nurse License and a valid NYS… more
- Molina Healthcare (Rochester, NY)
- **JOB DESCRIPTION** Opportunity for experienced Utilization Review RN in United States who has a compact, multi-state license. This team reviews the prior ... authorization requests for transplants; the ideal candidate will have experience either in utilization review or case management for transplants. Preference… more
- Molina Healthcare (Rochester, NY)
- …Medical, or ER unit. **Preferred License, Certification, Association** Active, unrestricted Utilization Management Certification (CPHM). To all current Molina ... acute care/medical experience. **Required License, Certification, Association** Active, unrestricted State Registered Nursing ( RN ) license in good standing. Must… more
- Excellus BlueCross BlueShield (Buffalo, NY)
- …calls in timely manner and provides support for the Case Management (CM) and Registered Nurse ( RN ) reviewers and manages the denial process. + Leads ... rounds. + Provision of clinical oversight and leadership to Utilization Management /Case Management (UM/CM) staff...the UM/ CM staff. + Participates in clinical peer review recruitment and supervision. + Collaborates with Provider Relations… more
- MVP Health Care (Rochester, NY)
- …you'll bring:** + Current New York State Licensure as a Registered Nurse required. + Certification in Case Management required within 24 months after ... key responsibilities:** + Utilize the essentials of an integrated utilization management and case management ...with an established interdisciplinary team. + The role requires review of a comprehensive assessment and development of a… more
- Villa of Hope (Rochester, NY)
- …JOB SUMMARY: Under the general direction of the Nurse Manager, the Intake Coordinator- RN is a Registered Nurse who will assist in supervising Clinical ... director of LHTC and administrative team, including billing and utilization review . + Triages potential admissions and...or leaving against medical advice. MINIMUM QUALIFICATIONS: + NYS Registered Nurse license + Bachelor degree preferred… more
- Kaleida Health (Williamsville, NY)
- …care Nursing Experience required. 2 years of experience in any combination of case management , home care and utilization review preferred. Knowledge of and ... members of the interdisciplinary team to coordinate care, facilitate utilization and resource management and discharge planning...(BLS) required upon hire. Current NYS registration as a Registered Professional Nurse / RN Permit and… more
- University of Rochester (Rochester, NY)
- …- Quality Assurance and Process Improvement (QA/PI) experience preferred LICENSES AND CERTIFICATIONS - RN - Registered Nurse - State Licensure and/or Compact ... primary internal contact for national and state registry data management questions, issues or concerns, but not limited to...State Licensure Current licensure as a Registered Nurse in NYS upon hire required… more
- Molina Healthcare (Rochester, NY)
- …years Training & Education **Preferred License, Certification, Association** Active and unrestricted Registered Nurse ( RN ) license and Certified Coding ... assurance, or recovery auditing, ideally in a DRG/ Clinical Validation * 3+ years of Utilization Review and/or Medical Claims Review experience. * 3+ years… more
- STG International (West Seneca, NY)
- …in quality improvement, care management , risk management , peer review , utilization review , clinical outcomes, and health enhancement activities. ... Performance Improvement Team (QPIT) strategic initiatives. + Participate in review and improvement of clinical success in of areas...of the clinic's day-to-day activity, in conjunction with the Registered Nurse ( RN )/CBOC Manager and… more