Utilization Review Coordinator jobs in Queens Village, NY
Utilization Review Coordinator conducts utilization reviews to determine if patients are receiving care appropriate to illness or condition. Monitors patient charts and records to evaluate care concurrent with the patients treatment. Being a Utilization Review Coordinator reviews treatment plans and status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Additionally, Utilization Review Coordinator consults with physicians as needed. May require a bachelor's degree. Typically reports to a supervisor. Typically requires Registered Nurse(RN). The Utilization Review Coordinator contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature. To be a Utilization Review Coordinator typically requires 4 to 7 years of related experience. (Copyright 2024 Salary.com)
Recently Added Utilization Review Coordinator jobs
Clinical Review Nurses
- Mitchell Martin
-
Fresh Meadows, NY
CONTRACTOR,FULL_TIME
-
A Day treatment facility located in Flushing, NY is looking for an Clinical Review Nurses.
Type: Contract
Schedule: M-F 8:30am-5:30pm -1 Hour Break, as well as two 15-minute breaks
Location: Flushing, NY
JOB PURPOSE:
The Clinical Review Nurse is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance standards.
Responsible for determining the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines with state, federal, Managed Long-Term Care, and PACE regulations.
The Clinical Review Nurse will manage his/her own caseload and is accountable for investigating and resolving participant or provider-initiated appeal cases, including clinical claim appeals from participating and non-participating providers.
The position works closely with the Medical Director.
RESPONSIBILITIES:
Performs clinical/medical reviews of previously denied cases in which a formal appeals request has been made.
Interacts with clients providers, participants, and internal service & care delivery teams to obtain necessary information and communicating appeal determinations timely.
The Clinical Review Nurse works closely with the A&G Specialists to ensure accurate entry of a case for tracking purposes.
Works independently, prioritizes case deliverables, and stays current on changes in the healthcare system that may affect clinical decisions.
Excellent knowledge of all relevant PACE and applicable Federal and State regulatory requirements and guidelines, knowledge of policies and procedures, and individual judgment and experience to assess the appropriateness of services, items provided, length of stay and level of care.
Collects relevant medical information and applies the appropriate evidence-based guidelines and medical policy for denied services associated with appeal cases.
Follows documentation guidelines for clear and concise decision-making within EMR appeals tracking platform.
Maintains appeal cases in a complete, accurate, and organized fashion for audit readiness.
Collaborates with regional medical directors and upon direction, communicate appropriately with the regulator/team liaison.
Meets required decision-making timeframes, including promptly triggering escalation for cases requiring physician review.
Applies appropriate criteria on PAR and Non-PAR (contracted and non-contracted) provider claim appeal cases.
Reviews medically appropriate clinical guidelines and other appropriate criteria with Chief Medical Officer/ Medical Director on denial decisions.
The end- to-end process requires the Clinical Review Nurse to independently:
Research issues
Reference and understand CenterLight internal policies and procedures to frame decisions
Interpret PACE/CMS regulations
Resolve cases and make critical decisions
Update file documentation such as EMR, case notes and case summary
Manage all duties within regulatory timeframes
Prepares cases for Medical Director Review or External Physician Advisor ensuring that all pertinent information (i.e., case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented in the Appeal Summary Review Sheet as part of the case
Prepares cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process.
Prepares and presents cases in conjunction with the Medical Director and IDT team for Administrative Law Judge pre-hearings meetings.
Represents and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.
Serves as a clinical resource for Medical staff, IDT, and Participant/Provider Inquiries/Appeals.
Identifies and reports quality of care issues.
Communicates effectively to hand-off and pick-up work from colleagues as necessary.
Additional duties as assigned
QUALIFICATIONS:
Education: Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred.
Licensure: Nursing
Experience:
3-5 years' clinical nursing experience, with 1-3 years in a managed care healthcare setting with experience clinical practice with experience in appeals & grievances or claims processing
Knowledgeable about Medicare (CMS) PACE and Medicaid MLTC regulations Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
Other:
Requires excellent verbal and communications skills
Requires excellent organizational skills
Requires good PC skills and ability to manage applicable software. Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email
Requires good interpersonal skills and the ability to work with all levels of employees
Please email: (url removed) - 22 Days Ago
Senior Manager – RCM / Maintenance Management Review
- Metropolitan Transportation Authority
-
Jamaica, NY
FULL_TIME
- Description Position at Long Island Rail Road Job InformationTitle: Senior Manager, RCM/Maintenance Management Review Department: Maintenance of Equipment Post Date: 04/23/2024 Close Date: 05/06/2024 ...
- 1 Day Ago
HR Coordinator
- 1st Class Care Services Inc
-
Flushing, NY
FULL_TIME
- Flushing Office hiring Human Resources and Coordinator, The candidate must be fluent in English and Chinese must with good communication skills, Please send your resume to info.firstclasscare@gmail.co...
- Just Posted
Clinical Coordinator
- Breaking Ground
-
Jamaica, NY
FULL_TIME
- Reporting to the Assistant Program Director, Transitional Housing the Clinical Coordinator, Transitional Housing supervises Case Managers and ensures the utilization of Harm Reduction and Housing Firs...
- Just Posted
Subcontractor Coordinator
- Sawh Voltcomm Construction LLC
-
Jamaica, NY
FULL_TIME
- We are seeking a dedicated Subcontractor Coordinator to join our team and help us continue to uphold our reputation for high-quality construction solutions. As a Subcontractor Coordinator, you will be...
- Just Posted
Resource Coordinator
- The Child Center Of NY, Inc.
-
Forest, NY
FULL_TIME
- The Child Center of NY strengthens children and families with skills, opportunities, and emotional support to build healthy, successful lives. Founded in 1953 as a children’s counseling center in Quee...
- Just Posted
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0 Utilization Review Coordinator jobs found in Queens Village, NY area
Peer Coordinator II
- Catholic Charities of Brooklyn and Queens
-
Jamaica, NY
- Job Description Job Description For over 117 years, Catholic Charities Brooklyn and Queens has been providing quality so...
- 5/8/2024 12:00:00 AM
Care Management Coordinator
- Northwell Health
-
Great Neck, NY
- Job Description Job Description Coordinates and participates in activities related to Care Management services to family...
- 5/8/2024 12:00:00 AM
Civil Engineer - Senior
- Blue Signal Search
-
New York, NY
- Our client is renowned for their innovative and comprehensive approach to complex construction, engineering, and archite...
- 5/7/2024 12:00:00 AM
Civil Engineer
- NV5
-
Parsippany, NJ
- Overview: NV5 (NASDAQ: NVEE) is a provider of engineering and consulting services to public and private sector clients, ...
- 5/6/2024 12:00:00 AM
Senior Civil Engineer
- Blue Signal Search
-
Hempstead, NY
- Our client is renowned for their innovative and comprehensive approach to complex construction, engineering, and archite...
- 5/5/2024 12:00:00 AM
Senior Civil Engineer
- Blue Signal Search
-
Westbury, NY
- Our client is renowned for their innovative and comprehensive approach to complex construction, engineering, and archite...
- 5/5/2024 12:00:00 AM
Senior Civil Engineer
- Blue Signal Search
-
Garden City, NY
- Our client is renowned for their innovative and comprehensive approach to complex construction, engineering, and archite...
- 5/5/2024 12:00:00 AM
Project Coordinator
- Actalent
-
New York, NY
- We are hiring for entry level construction project coordinators! This is an exciting opportunity for entry level Assista...
- 5/4/2024 12:00:00 AM
About Queens Village, New York
Queens Village is a mostly residential middle class neighborhood in the eastern part of the New York City borough of Queens. The Queens Village Post Office serves the ZIP codes of 11427 (Hollis Hills and Bellaire), 11428 (central Queens Village), and 11429 (Southern Queens Village south of the LIRR Main Line). The neighborhood is part of Queens Community Board 13.
Shopping in the community is located along Braddock Avenue, Hillside Avenue, Hempstead Avenue, and Jamaica Avenue (NY 25), as well as on Springfield Boulevard. Located just east of Queens Village, in Nassau County, is the Belmont Par...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Utilization Review Coordinator jobs
$93,739 to $116,116
Queens Village, New York area prices
were up 1.5% from a year ago
were up 1.5% from a year ago
What does an Utilization Review Coordinator do?
Utilization Review Coordinator in Fort Lauderdale, FL
Some review coordinator positions require that professionals have training and experience within a more specific field.
January 10, 2020
Utilization Review Coordinator in Asheville, NC
Schick Shadel Hospital is seeking a part-time (20 hours per week) Utilization Review Coordinator (UR Coordinator) to help oversee and perform the process of utilization review to ensure appropriate reimbursement by third party payers.
January 04, 2020
Utilization Review Coordinator in Jacksonville, FL
Excellent benefits, pay, small on-site employee gym, wonderful co-workers and managersFull Review.
January 04, 2020