Utilization Review Nurse Jobs in Buffalo, New York

31 jobs

Utilization Review RN - Managed Care Buffalo, NY Your Job Summary: The Utilization Review Nurse is responsible for utilization management and utilization review for prospective, concurrent, or retrospective review. The UR Nurse will performs reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guideline...

The Utilization Management (UM) Clinician performs clinical reviews to assess medical necessity of a broad range of outpatient and inpatient services, while maintaining compliance with all regulatory requirements. Interfaces with medical directors, and both internal and external stakeholders, with regard to coverage for services, contract benefits and alternate resources available. This position i...

GRADE: 307 POSITION SUMMARY Facilitates the effective utilization of health care resources to optimize member health care outcomes. Enhance access to care and service while maintaining maximum quality and service value. Reviews requests for referrals, prior authorizations and claims adjustments to determine whether health care services that have been provided, are being provided, or are proposed...

RN Care Manager-Erie & Niagara Counties Centers Plan for Healthy Living (CPHL) is a Managed Care Organization that provides complex utilization management, care management and quality management services for its members through a program of clinical support and intensive interventions designed to keep its enrollees safely maintained in the home. These activities are designed to provide the member...

Description: There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. A passion for excellence you wont find anywhere else. We ask tough questions. We push ourselves and each other to find smarter solutions. The result is a culture of performance that's driving the health care industry forward. Nursing here isn't for everybody. Instead of seeing a...

Roswell Park Cancer Institute is seeking a full-time Director Case Management. The Director coordinates and administers Institute programs for utilization review and case management; ensures compliance with The Joint Commission (TJC), New York State Department of Health (NYSDOH), Center for Medicare and Medicaid Services (CMS) and other regulatory agencies as they apply to the Institute utilizatio...

Women & Children's Hospital of Buffalo, a Kaleida Health facility and teaching hospital for the University at Buffalo School of Medicine and Biomedical Sciences, is the regional center for comprehensive and state-of-the-art pediatric, neonatal, perinatal and obstetrical services in Western New York and beyond. Join us as we move to the Buffalo Niagara Medical Campus, opening the new John R. Oishei...

This position supports American Health Holding (AHH). Telecommuters must have a separate dedicated area for HIPAA compliance. The hours for these positions are 11:30 AM and ending at 8:00 PM ET. This position is work at home from any location Minimum internet requirements for a telecommuting position include: • A separate wired Internet connection • Minimum download speed of 6MB • Minimum up...

Position: Medicaid Compliance LPN Reports to: Chief Compliance Officer Pay grade: hourly, non-exempt status Job Summary: Under the direction of a Licensed RN, performs utilization review in accordance with all state and federal mandated regulations. Reviews enrollee records and, using approved criteria and enrollee benefit information, ensures appropriate and cost‐effective healthcare services ...

JOB SUMMARY: The Medical CM Clinician position is responsible for conducting case management and any related utilization management and quality activities in accordance to HI policies and procedures. The position responsibilities include the management of assigned cases to ensure costs are contained and quality of care is maintained as the patient accesses care and services in the continuum of car...

Company Introduction: Landmark Health is a high growth, entrepreneurial organization committed to improving healthcare for the patients with the most intense and complex medical needs. Landmark partners with health plans across the country to bring high-quality, compassionate medical care our nation’s sickest members, wherever they reside and whenever they need it. By integrating technology, a h...

Job Summary Office based telephonic medical case management with emphasis on early intervention, return to work planning, coordination of quality medical care on claims involving disability and medical treatment as well as in-house medical reviews as applicable to claim handling laws and regulations. Responsible for helping to ensure injured parties receive appropriate treatment directly related t...

Company Introduction: Landmark Health is a high growth, entrepreneurial organization committed to improving healthcare for the patients with the most intense and complex medical needs. Landmark partners with health plans across the country to bring high-quality, compassionate medical care our nation’s sickest members, wherever they reside and whenever they need it. By integrating technology, a h...

This position is responsible for engaging provider offices in corporate driven initiatives focused on ICD-9 and ICD-10 coding and billing. Responsibilities include, but not limited to, reviewing medical records and educating providers on clinical initiatives to achieve provider incentive metrics. Primary Responsibility Work with internal business partners specifically with the CRMO clinical coding...

Under the direction of management, this position is responsible for identifying potential/actual fraud/abuse through comprehensive medical record and claims review of all HealthNow contracted providers. Concomitant responsibilities include initiation and completion of provider audits, post-audit provider education and evaluation to ensure corporate and regulatory compliance. Integral to the role i...

Director of Patient Services JOB SUMMARY: The Director of Patient Services, often called the Director of Nursing, is a registered professional nurse who is approved by the Board of Directors to organize and direct the Agency’s service program. He/She functions under the direction of the CEO/Administrator and the Board of Directors, and reports directly to the CEO/Administrator. QUALIFICATIONS: ...

Director of Patient Services JOB SUMMARY: The Director of Patient Services, often called the Director of Nursing, is a registered professional nurse who is approved by the Board of Directors to organize and direct the Agency’s service program. He/She functions under the direction of the CEO/Administrator and the Board of Directors, and reports directly to the CEO/Administrator. QUALIFICATIONS: ...

The Medical Services Care Coordinator is responsible for coordinating, integrating, and monitoring the use of medical and health care services for members, ensuring compliance with internal land external standards set by regulatory and accrediting entities. Refers appropriate cases to the Medical Director for review, identifies billing trends and refers possible medical fraud to the Special Invest...

Description McKesson is in the business of better health and we touch the lives of patients in virtually every aspect of healthcare. McKesson Technology Solutions provides software, services and consulting to hospitals, physician offices, imaging centers, home health care agencies and payors. We also provide interactive connectivity services that streamline clinical, financial and administrative ...

McKesson is in the business of better health and we touch the lives of patients in virtually every aspect of healthcare. McKesson Technology Solutions provides software, services and consulting to hospitals, physician offices, imaging centers, home health care agencies and payors. We also provide interactive connectivity services that streamline clinical, financial and administrative communication...