7 jobs found in Buffalo, NY

JOB DESCRIPTION Job Summary The Delegation Oversight Nurse provides support for delegation oversight quality improvement activities. Responsible for overseeing delegated activities to ensure compliance with the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), state Medicaid entity requirements and all other standards and requirements pertaining to delegation agreements. Contributes to overarching strategy to provide quality and cost-effective member care. This position will support our Corporate Compliance business. The candidate must have an unrestricted LVN licensure. Candidates must be technologically proficient, self-directed, autonomous and experience working from home. Care Management & Waiver Service Auditing experience is highly preferred. Work hours: Monday - Friday 8:00am – 4:00pm Remote position Essential Job Duties Coordinates, conducts and documents pre-delegation and annual assessments as necessary...

JOB DESCRIPTION  Job Summary The Care Manager RN provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. This position will be supporting our Complex Pediatric Care Management program. The ideal candidate will bring expertise in pediatric conditions such as asthma, diabetes, and ADHD. Skilled in closing HEDIS and preventive care gaps through proactive outreach and coordination with members and providers. Experience integrating medical and behavioral health needs in care planning, along with an understanding of clinical guidelines, social determinants of health, and health equity principles is also beneficial. Case management and managed care experience is preferred. Remote position based in New York A New...

Job Description Job Summary The Medical Review Nurse provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care.  This position will be supporting our Appeals and Grievances department. We are seeking a Registered Nurse with previous Appeals experience. The candidate must have strong organizational skills, proficient knowledge of MS Excel, able to work on multiple screens simultaneously and be computer literate to keep up with the work. The team works in a very fast and productive environment. Further details to be discussed during our interview process. Remote position with location preference in MI, IL or WI Work hours: Monday- Friday: 8:30am -5:00pm EST. There is Saturday on call and holiday rotation....

JOB DESCRIPTION  Job Summary The Care Manager (RN) provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. This position will be supporting our Complex Adult Medical Care Management program. The ideal candidate will bring strong expertise in chronic disease management, with familiarity in evidence-based practices for conditions commonly seen; such as hypertension, diabetes, asthma, COPD, and chronic kidney disease/ESRD. Skilled in closing HEDIS, preventive care gaps through proactive outreach and coordination with members/providers. Experience integrating medical and behavioral health needs in care planning, understanding of clinical guidelines, social determinants of health, and health equity principles is...

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