- Molina Healthcare (New York, NY)
- …appeals outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously ... **JOB DESCRIPTION** **Job Summary** Clinical Appeals is responsible for making appropriate and correct...denied cases in which a formal appeals request has been made or upon request by… more
- Evolent (Trenton, NJ)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Evolent Appeals Nurse 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… more
- Evolent (Trenton, NJ)
- …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
- Centene Corporation (New York, NY)
- …**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
- Hackensack Meridian Health (Neptune City, NJ)
- …transform healthcare and serve as a leader of positive change. The **Registered Nurse ** Non-Acute functions as a caregiver for a specific patient population in order ... assisting the LPNs, MDs, and NPs with their inboxes, medication appeals , prescription/lab/imaging ordering, etc. The office is open Monday-Friday 8:30am-5:00pm, no… more
- Trinity Health (Langhorne, PA)
- …to the clinical review and level of care. Management of all review and appeals utilizing a modified approach based on specific needs of the patient population. ... Facilitates achievement of efficient resource consumption, and acceptable clinical outcomes, through integration and implementation of utilization management. **Our Commitment to Diversity and Inclusion** Trinity Health is one of the largest not-for-profit,… more
- Molina Healthcare (New York, NY)
- …responsibilities will include specialized medical necessity reviews and/or appeals and supporting market performance. Performance activities include physician ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… 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 + 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). + Obtains… 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
- Mount Sinai Health System (New York, NY)
- …degree preferred + 5 years of Case Management and 6 years as a clinical nurse . + Previous supervisory experience in case management or a related field. + Name: ... ensure appropriateness of admissions and proper reimbursement. 11. Ensures Discharge Appeals functions are carried out within contractual, federal and state… more
- Sharecare (Trenton, NJ)
- …enrollment / new hire plan selection, claims issues, ID card issues, grievances/ appeals , utilization management (UM) status, including but not limited to medical, ... 3rd parties for: + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status +...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Mount Sinai Health System (New York, NY)
- …hospital personnel as needed. The Nursing Clinical Manager collaborates with Appeals Management, Managed Care Contracting and other institutional departments to ... management experience and 5 -7 years of experience as a clinical nurse . Licensing and Certification Requirements (if applicable) License: RN (current) and… more