UNKNOWN

FEED

The incumbent works closely with multiple leaders in the organization to monitor and drive internal and external production teams to ensure consistent output, high quality and to maintain compliance on all levels. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798.

YEAR

Healthfirst

Manager, Clinical Appeals & Grievances

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Within the case management role will within the scope of licensure assess, develop, implement coordinate, monitor, and evaluate care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their specific health needs. Within the medical management role will collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical transplant issues.

Elevance Health

Transplant Nurse II

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Carrot is regularly featured in media reporting on issues related to the future of work, women in leadership, and healthcare innovation, including MSNBC, The Economist, Bloomberg, The Wall Street Journal, CNBC, National Public Radio, Harvard Business Review, and more. Carrot''s comprehensive clinical program delivers industry-leading cost savings for plan sponsors and award-winning experiences and improved outcomes for millions of people worldwide.

HOUR

Carrot Fertility Inc

Telemedicine Registered Nurse RN

We're growing our network of clinical reviewers and are actively seeking Pediatric Neurologist (must be actively practicing) who are passionate about quality, accountability, and patient outcomes. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care.

DOMA Technologies

Pediatric Neurologist needed (actively practicing) for PRN peer review work

We're growing our network of clinical reviewers and are actively seeking a Board Certified Gastroenterologist ( must be actively practicing ), who are passionate about quality, accountability, and patient outcomes. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care.

Board Certified Gastroenterologist needed for peer review work

The Recruiter will strategically source, engage, and onboard physicians across a broad range of specialties-spanning primary care fields such as Family Medicine, Internal Medicine, and Pediatrics, as well as highly specialized disciplines including Neurosurgery, Allergy & Immunology, and Genetics. Negotiates market-specific rates with providers to ensure quality and cost-effectiveness, while delivering compelling value propositions that align provider capabilities with organizational needs.

Acentra Health

EAP Provider Network Recruiter

This individual will provide integral Medical Information & Medical Capabilities support across Nuvation Bio’s pipeline which includes serving as the medical reviewer on the MLR committee, leading the development of Medical Information deliverables, and overseeing the Independent Medical Education (IME) grant review process. Alongside Director Medical Capabilities, manage Medical Information metrics, quality indicators, and inquiry trends, and contribute to process improvements, SOP development, training initiatives, and operational excellence activities.

Nuvation Bio, Inc.

Senior Manager, Medical Information and Medical Capabilities

JobScore

In a landscape crowded with contradictory advice, isolating apps, and one-size-fits-all solutions, Weight Watchers offers a proven path forward that is rooted in research, grounded in empathy and designed to help every member feel better in their body and live a longer, healthier life. Weight Watchers is the global leader in science-backed weight management, offering an integrated support system built for the GLP-1 era that combines scientific expertise, medication, cutting-edge technology, and human connection.

<p>WW offers a scientifically proven program for weight loss and wellness, with Digital, in-person and Virtual Workshops, and Personal Coaching solutions to help meet your goals. For more than 55 years, WW has helped millions lose weight with the latest nutritional and behavior change science.</p>
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Weight Watchers

Manager, Global Performance Creative

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WEEK

Performs face-to-face visits with patients that need assessment of physical, mental, and emotional barriers that prohibit self-care, prompt medical management assistance in the community, and initiation of referrals to social work by using nursing clinical judgment. ·Monitors the electronic health records (EHR) daily or as needed, for assigned patients, and complete clinical documentation pertaining to hospitalization for submission to insurance companies (Initial, Concurrent or Retroactive).

MetaSense Inc

RN Case Manager

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We are sharing a specialised consulting opportunity for experienced Senior Hospitalist Clinical Reviewers with strong expertise in inpatient care, clinical quality, documentation review, medical auditing, quality assurance, and complex clinical judgement to contribute to an advanced AI training and clinical evaluation project. The work requires senior-level hospitalist judgement, strong written communication, and the ability to explain nuanced clinical decisions clearly and consistently.

24-MAG

Remote

Manatal

You'll handle clinical grievances, appeals and external reviews for members receiving outpatient and community-based care: home health, long-term services and supports, outpatient procedures, DME and similar services. 2+ years working directly in grievance and appeals at a health plan, managed care organization or payer, where you personally investigated cases and drafted the determination.

We stand for PERSEVERANCE, as we refuse to quit when the journey gets tough. Your gold is our mission, and we search day and night to find it.

Phaxis

RN Grievance & Appeals Specialist (Contract, Remote)

HaleyMarketing

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. The CM is also responsible for care management for medically fragile children and supporting the coordination of services related to inpatient, homecare, specialty medications, and DME according to UM requirements set forth by the "office of Health Insurance Programs Principles for Medically Fragile Children.

Metroplus Health Plan Inc

Children's Care Manager (RN)

Research, review, and analyze new medical procedures, technology, equipment, and corresponding CPT/HCPCS (Healthcare Common Procedure Coding System) codes; gather input from providers; recommend coverage and reimbursement levels consistent with state and federal policies. Demonstrate expertise in ICD-10-CM/PCS coding to act as a resource for the education of provider, nursing, and healthcare staff, as well as new employees.

EmblemHealth Inc

Lead Coding Analyst (RN or LPN) - Remote

Led by an experienced and proven team, we live by our values and are always on the hunt for motivated people with diverse experiences and backgrounds to help us improve the care journey for patients, clinicians, and caregivers by creating software that provides seamless, intuitive, and user-friendly experiences. As a CDI Risk Adjustment Nurse, you will provide clinical documentation and risk adjustment review for Tendo's QDI Services customers, working in real time with physicians and advanced practice providers to ensure documentation accurately reflects patient acuity and quality of care.

Tendo Systems Inc

CDI Risk Adjustment Nurse

The manager works with the DRG Clinical Educator, DRG Managers, and cross-functional partners to turn audit findings into training, process changes, and measurable quality improvement. The DRG QA/Training Manager leads the quality assurance and training team supporting Machinify's DRG Clinical Validation function, including MS-DRG and APR-DRG validation.

Machinify

DRG QA/Training Manager

This position plays a key role in auditing the work of both new hires and current staff while conducting training to ensure team members are equipped with the knowledge and skills needed to succeed. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise.

DRG QA and Trainer

Own scoping for agentic deployments in new verticals: Work closely with GTM representing product in early phases of customer journey, define scope, flag what's feasible in the near term with our agentic workflows, and translate ambiguous customer requests into crisp requirements with measurable success criteria. Turn plan priorities (HEDIS and Stars measures, care gap targets, member experience, compliance requirements) into program designs: target populations, outreach sequencing, channel mix, agent and nurse handoffs, and escalation logic.

Clinical Reviewer Jobs in New York

Manager, Clinical Appeals & Grievances Healthfirst

Transplant Nurse II Elevance Health

Telemedicine Registered Nurse RN Carrot Fertility Inc

Pediatric Neurologist needed (actively practicing) for PRN peer review work DOMA Technologies

Board Certified Gastroenterologist needed for peer review work DOMA Technologies

EAP Provider Network Recruiter Acentra Health

Senior Manager, Medical Information and Medical Capabilities Nuvation Bio, Inc.

Manager, Global Performance Creative Weight Watchers

RN Case Manager MetaSense Inc

Remote 24-MAG

RN Grievance & Appeals Specialist (Contract, Remote) Phaxis

Children's Care Manager (RN) Metroplus Health Plan Inc

Lead Coding Analyst (RN or LPN) - Remote EmblemHealth Inc

CDI Risk Adjustment Nurse Tendo Systems Inc

DRG QA/Training Manager Machinify

DRG QA and Trainer Machinify

Head of Strategic Deployments & Operations Arbiter AI

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