- Molina Healthcare (New York, NY)
- …Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years of experience in ... clinical/ medical reviews of retrospective medical claim reviews, medical claims and...Claims Auditing, Medical Necessity Review and Coding experience +… more
- Travelers Insurance Company (New York, NY)
- …Utilize evaluation documentation tools in accordance with department guidelines. + Proactively review Claim File Analysis (CFA) for adherence to quality ... evaluating, reserving, negotiating and resolving assigned serious and complex Specialty claims . Provides quality claim handling throughout the claim… more
- Molina Healthcare (New York, NY)
- …Managed Care Experience in the specific programs supported by the plan such as Utilization Review , Medical Claims Review , Long Term Service and Support, ... the likelihood of a formal appeal being submitted. + Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge,… more
- Mount Sinai Health System (New York, NY)
- …practices; routes requests to medical leadership when appropriate + Documents authorization review for medical and pharmacy claims . + Prepares case ... related documents required to modify and/or add necessary services. + Performs continuing review of medical records; analyzing data trends and implementing best… more
- Molina Healthcare (New York, NY)
- …retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as ... Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review , and manages the denial… more
- Elevance Health (Woodbridge, NJ)
- …experience preferred. + Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing ... the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims...you will make an impact:** + Analyzes and audits claims by integrating medical chart coding principles,… more
- City of New York (New York, NY)
- …compensability of treatment as it relates to the claimant's work injury and assist with medical case management of claims . Review and process high value and ... Compensation Division are responsible for all medically related issues for medical management of workers' compensation claims . Responsibilities include: Consult… more
- Mount Sinai Health System (New York, NY)
- …for reviewing, summarizing, analyzing, presenting and monitoring safety events, claims management, loss prevention and reduction, patient safety related quality ... + Current New York State license as a Registered Professional Nurse or other licensed/certified clinical professional strongly preferred; foreign healthcare… more
- VNS Health (Manhattan, NY)
- …incidents, quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of service or clinical quality. ... and the day to day management of clinical appeals review processes within Appeals & Grievances Department. + Manages...all levels including but not limited to, Provider Relations, Claims , Medical Director, third party administrator, pharmacy… more
- VNS Health (Manhattan, NY)
- …Improvement Organizations. + Collaborates with professionals, health plan departments such as Claims and Medical Management, and the third party administrator ... Health insurance plan for you and your loved ones, Medical , Dental, Vision, Life and Disability + Employer-matched retirement...of the plan's fiduciary responsibilities. Prepares records for physician review as needed. + Conducts review of… more
- Evolent (Trenton, NJ)
- …and write clearly. + Reviews adverse determinations against criteria and medical policies + Creates adverse determination notifications that meet all accreditation, ... + Appropriately identifies and refers quality issues to the Senior Director of Medical Management or Medical Director. + Appropriately identifies potential cases… more
- CVS Health (Trenton, NJ)
- …Direct and oversee complex reviews. Ensure timely and accurate reporting of review findings and coordinate with investigative to take appropriate action. Conducts ... detection, investigation, or auditing In-depth knowledge of healthcare systems, claims processing, and regulatory requirements related to healthcare fraud.… more