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Job Title: Case Manager, Appeals/Retrospective Review
Job Location: NY: New York City
Pay Rate: Open
Job Length: full time
Start Date: 2008-02-28

Company Name: GHI
Contact: Human Resources
Phone: email only please
Fax: email only please

Description: Case Manager, Appeals/Retrospective Review COMPANY: GHI LOCATION: 34th Street

HOURS: Monday Thru Friday 9:00 a.m. to 5:00 p.m.

DEPT:

Description of Duties * Reviews pertinent clinical information/medical records utilizing the appropriate clinical protocols to support internal appeals and retrospective reviews. * Supports the external appeal process for GHI and its vendors by collaborating with NYSID, GHI vendors and NYSID vendors. * Enters case documentation in max Mc and generates notifications of determinations in accordance with state, federal and accrediting body standards. * Contacts members and/or providers to obtain additional clinical information as needed to render utilization review determinations. * Confers with internal and external Medical Consultants on retrospective reviews, internal and external appeals. * Reviews/reconciles Daily Claims Exception Report. * Maintains appropriate databases on reviews and appeals. * Assists with compiling the Schedule M Report.

Requirements * Current license to practice nursing in New York State. * Baccalaureate Degree in Nursing preferred. * Minimum of 2 years acute medical/surgical experience. * Knowledge of claims preferred. * Excellent oral and written communication skills required. * Excellent organizational skills required. * Ability to multi-task. * Computer proficiency required. * Familiarity with Managed Care Law, Department of Labor Law and URAC UM Standards preferred.

Please refer to Job code ghi-1635 when responding to this ad.

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