- 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
- Lincoln Financial Group (Trenton, NJ)
- …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 (Trenton, NJ)
- …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 (Trenton, NJ)
- …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
- NJM Insurance (Trenton, NJ)
- …Auto (PIP/Medpay) lines of business by performing prospective and retrospective Utilization Review of medical services/treatment requested or rendered by ... and/or evidence-based guidelines. Job Responsibilities: + Accurately and effectively evaluate the claim history and current medical records against NJM … 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
- Elevance Health (Woodbridge, NJ)
- ** Nurse and CPC - Clinical Fraud Investigator II -...control. + Review and conducts analysis of claims and medical records prior to payment. Researches ... + Performs in-depth investigations on identified providers as warranted. + Examines claims for compliance with relevant billing and processing guidelines and to… 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
- Elevance Health (Woodbridge, NJ)
- **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
- 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
- Evolent (Trenton, NJ)
- …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 (Trenton, NJ)
- …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
- 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
- Intermountain Health (Trenton, NJ)
- …Prior Authorization RN provides timely review of authorization requests and/or review of denials to ensure medical necessity, payer policies, appeals and ... reviews and submission of complex authorization requests using appropriate criteria, medical policy review and department expectations + Collaborate with… 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
- 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