- 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
- 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)
- … 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 (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
- 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
- Brighton Health Plan Solutions, LLC (New York, NY)
- …+ Inform callers that the Nurse Case Reviewer may obtain additional medical information for review and certification. + (In regard to discharge planning ... diploma or GED is preferred. + Strong skills in medical record review . + Excellent customer service...plus. + Previous experience in case management handling insurance claims a plus. + Ability to work in a… more