- Molina Healthcare (Rochester, 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
- Lincoln Financial Group (Albany, NY)
- …for conducting initial and ongoing interviews with claimants, obtaining, and reviewing medical records and making timely and ethical claim determinations. You'll ... 74082 **The Role at a Glance** As an **LTD Claims Specialist** , you will manage a workload of...and consulting physicians to make appropriate, ethical, and timely claim determinations + Reviewing complex medical records… more
- Lincoln Financial Group (Albany, NY)
- …for conducting initial and ongoing interviews with claimants, obtaining, and reviewing medical records and making timely and ethical claim determinations. You'll ... through phone and e-mail to gather information regarding the Short Term Disability claim . + Collaborating with fellow case managers, nurse case managers and… more
- Lincoln Financial Group (Albany, NY)
- …organization. This position will be responsible for reviewing, analyzing, and interpreting medical information available for disability claims . In this role you ... a clinical resource for Group Protection benefit specialists and claim professionals. You will evaluate medical information...this role you will provide coaching and guidance to claims regarding medical management **What you'll be… more
- Northern Rivers Family Services (Queensbury, NY)
- …an NPI. Claims processing functions also require the NPI of nurse practitioners and physicians. + Federal Drug Enforcement Administration (DEA)number - issued by ... Nurse -Psychiatric NP Job Details Job Location Queensbury-Bay-PCFC -...and education to staff + Prescribe medications, monitor, and review of drug regimen for enrolled individuals + Participate… more
- Travelers Insurance Company (Melville, 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
- CP Unlimited (Carmel, NY)
- Registered Nurse Type of Position Full time Search Location(s) Carmel, NY, Fishkill, NY, Garrison, NY, Poughkeepsie, 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 to individuals who… more
- Elevance Health (Latham, NY)
- …messages in a timely fashion. + Knowledge of health insurance/benefits, medical management process, care management, and utilization review management ... ** Nurse Case Manager I - NICU** **Location:** **This...management plan and modifies, as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- BronxCare Health System (Bronx, NY)
- …(according to the NPSG), intake screening of patient, pre-visit planning (if applicable), review of medical record to determine visit requirements such as HEIDS ... Overview Licensed Practical Nurse : Under the direct supervision of a physician...analysis, implementation of and compliance with risk management and claims activities, support of and participation in Continuous Quality… more
- Elevance Health (Latham, NY)
- **Telephonic Nurse Case Manager II** **Location: This is a virtual position. Candidates must reside within 50 miles of an Elevance Health Pulse Point location.** ... hours of receipt and meet the criteria._** The **Telephonic Nurse Case Manager II** is responsible for care management...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… 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
- Constructive Partnerships Unlimited (Brooklyn, NY)
- …and SCIP-R. 12. Reports all incidents to the Residence Manager, and reports all medical issues/ injuries to the registered nurse and follows protocols for ... individuals and arranges transportation as necessary. Upon instructions of the Nurse , accompanies individuals on medical appointments and/or visits hospital… more
- Brighton Health Plan Solutions, LLC (Westbury, NY)
- …and guidelines. + Provides clinical support for all areas of Clinical Services. + Review medical files and make coverage and medical necessity determinations ... expert for care management and population health; reviews and evaluates cases with review nurses; ensures medical care provided meets the standards for… more
- Molina Healthcare (New York, NY)
- … claims with corresponding medical records to determine accuracy of claims payments. + Review of applicable policies, CPT guidelines, and provider ... policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or… more
- Molina Healthcare (Yonkers, 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
- Independent Health (Buffalo, NY)
- …UM pre-service, concurrent and retrospective review , services not currently on medical review as outlined by trend and cost containment activities, and ... of clinical care management processes, member benefit structures and applications, and claims processing. + Knowledge of medical necessity criteria development, … more
- BronxCare Health System (Bronx, NY)
- …(according to the NPSG), intake screening of patient, pre-visit planning (if applicable), review of medical record to determine visit requirements such as HEIDS ... Overview Under the direct supervision of a Registered Nurse or Physician, participate in providing patient care...for patients. Record patient's personal care and physical findings. Review discharge instructions with the patients and confirms that… more
- Evolent (Albany, NY)
- …other clinicians who review the appeal, the claims department to review provider post-service claims for medical necessity, and managers for ... behind it. **What You'll Be Doing:** The Evolent Appeals Nurse team offers candidates the opportunity to make a...and accomplishments. **What You Will Be Doing:** Communicates with medical office personnel to obtain pertinent clinical history and… more
- United Therapeutics (Albany, NY)
- …reimbursement support, patient support programs, field reimbursement managers, patient navigators and nurse educators + Review Needs Assessment Forms related to ... and biotech industry, including FDA advertising and promotion, False Claims Act, Anti-Kickback Statute, OIG Guidance, the PhRMA Code,...+ Serve as the Legal representative on the Company's medical communications review , including review … more
- CP Unlimited (Fishkill, NY)
- …Job Brief Provides supervision, training and guidance to the nurse case managers. Shift Worked: Varied Weekly Hours: 37.5 FLSA ... and regulations. Provides technical assistance and resources, as needed, on medical /nursing practices and participates in the development and monitoring of programs… more