clinical appeals reviewer

Tanaq Health

<div>
 
 Description
 
 
 
 
 Overview
 
 
 
 Tanaq Support Services (TSS) delivers professional, scientific, and technical services and information technology (IT) solutions to federal agencies in health, agriculture, technology, and other government services. TSS is a subsidiary of the St. George Tanaq Corporation, an Alaskan Native Corporation (ANC) committed to serving Federal customers while also giving back to the Tanaq native community and shareholders.
 
 
 
 About The Role
 
 
 
 We are seeking a
 
 Clinical Appeals Reviewer
 
 to support a contract with our federal client. The Clinical Appeals Professional performs complex (senior-level) work. Provides dissatisfied parties with the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. Qualified candidates must be licensed health care professionals capable of rendering independent clinical judgment, including but not limited to Registered Nurses (RN), Physical Therapists (PT), Occupational Therapists (OT), and Respiratory Therapists (RT).
 
 
 This is a remote position that can be based anywhere in the United States. Must be able to work on a rotating schedule on weekends and holidays.
 
 
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Reviews medical records/case files, writes reconsideration decision letters that are clear, concise, and impartial, and support the determination made, and documents the review.
 </li>
 <li>
 Makes sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy.
 </li>
 <li>
 Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
 </li>
 <li>
 Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
 </li>
 <li>
 Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
 </li>
 <li>
 Stays abreast of changes in regulations, medical and healthcare practices, policies, and procedures.
 </li>
 <li>
 Participates in case-specific verbal discussions.
 </li>
 <li>
 Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
 </li>
 <li>
 Plans responses to statistical analysis challenges with assistance from statisticians.
 </li>
 <li>
 Attends meetings and participates in workgroups at management's direction.
 </li>
 <li>
 Conducts quality reviews, as needed.
 </li>
 <li>
 Serves as a subject matter expert.
 </li>
 <li>
 Mentors and/or trains staff.
 </li>
 <li>
 May conduct quality reviews and audits.
 </li>
 <li>
 Participates in special projects and performs other duties as assigned.
 
 
 </li>
 </ul>
 
 Requirements
 
 
 
 
 Required Skills and Experience
 
 
 
 <ul>
 <li>
 Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles.
 </li>
 <li>
 Healthcare Professional with experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience.
 </li>
 <li>
 Demonstrated experience writing or making medical necessity decisions.
 </li>
 <li>
 Proficiency in research techniques, medical terminology, and analyzing and interpreting policies, along with knowledge of state and federal laws and regulations.
 </li>
 <li>
 Must have experience and working knowledge of the Medicare program, including coverage and payment rules.
 </li>
 <li>
 Experience with Medicare regulations, claims processing, and the medical review process, as well as applicable laws, rules, and regulations.
 </li>
 <li>
 Prioritize and organize work tasks to handle multitasking and meet deadlines.
 </li>
 <li>
 Ability to prepare correspondence and documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency.
 </li>
 <li>
 Practice logic and reasoning to identify problems, verify facts, and reach valid conclusions.
 </li>
 <li>
 Experience in making decisions that support business objectives and goals.
 </li>
 <li>
 Ability to identify and resolve problems or refer issues appropriately.
 </li>
 <li>
 Communicate effectively verbally and in writing.
 </li>
 <li>
 Adapt to the needs of internal and external customers.
 </li>
 <li>
 Show integrity and ethical behavior, respect confidentiality, business ethics, and organizational standards.
 </li>
 <li>
 Ensure compliance with company policies, procedures, and guidelines, including cybersecurity, regulatory, contractual, and accreditation entities.
 </li>
 <li>
 Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred.
 </li>
 <li>
 Must have resided in the United States for a minimum of three (3) years out of the last five (5) years. This is a contractual requirement.
 </li>
 <li>
 Must possess a valid driver's license with a clear and satisfactory driving record.
 </li>
 <li>
 Ability to obtain and maintain public trust clearance and customer approval.
 </li>
 <li>
 Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.
 
 
 </li>
 </ul>
 
 Education and Training
 
 
 
 <ul>
 <li>
 Associate's degree or 60 or more credit hours towards a Bachelor&rsquo;s degree from an accredited college or university in healthcare or related discipline.
 </li>
 <li>
 Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for an Associate&rsquo;s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)
 
 
 </li>
 </ul>
 
 Physical Requirements And Work Environment
 
 
 
 <ul>
 <li>
 Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting, and/or reaching.
 </li>
 <li>
 Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.
 </li>
 <li>
 May require the ability to operate a motor vehicle and travel by motor vehicle and commercial airline. May require overnight travel. Travel may be less than 5% annually.
 
 
 </li>
 </ul>
 
 Who We Are
 
 
 
 Tanaq Management Services (TMS) is a public health contractor, certified 8(a) business, owned by St. George Tanaq Corporation, an Alaska Native Corporation. (ANC). We listen to our stakeholders and leverage our science, technology, communication, and program expertise to understand and provide feedback as we develop solutions.
 
 
 
 Our Commitment to Non-Discrimination
 
 
 
 Tanaq is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to disability, status as a protected veteran or any other status protected by applicable federal, state, or local law. Tanaq complies with the Drug-free Workplace Act of 1988 and E-Verify.
 
 
 If you are an individual with a disability and need assistance completing any part of the application process, please email accommodation@tanaq.com to request a reasonable accommodation. This email is for accommodation requests only and cannot be used to inquire about the status of applications.
 
 
 
 Notice on Candidate AI Usage
 
 
 
 Tanaq is committed to ensuring a fair and competitive interview process for all candidates based on their experience, skills and education. To ensure the integrity of the interview process, the use of artificial intelligence (AI) tools to generate or assist with responses during phone, in person and virtual interviews is not allowed. However, candidates who require a reasonable accommodation that may involve AI are required to contact us prior to their interview at accommodation@tanaq.com.
 
 
 
 To Apply For This Positions, Visit
 
 
 
 https://recruiting.paylocity.com/Recruiting/Jobs/Details/4071254
</div>

Clinical Appeals Reviewer (Licensed Healthcare Professional)

TEEMA

<div>Claims Reviewer Opportunity
Join a dynamic team where your expertise in claims review can make a real difference! We're looking for a detail-oriented Claims Reviewer who can apply clinical and coding knowledge to ensure accurate claims processing. If you have a strong foundation in medical claims and are passionate about quality, we want to hear from you!
Position Highlights<ul><li>
Role: Conduct retrospective review of medical, surgical, and behavioral health claims.</li><li>
Focus: Evaluate claims for medical necessity, appropriateness, and adherence to program benefits.</li><li>
Collaboration: Work closely with medical directors, providers, peer reviewers, and various internal teams.</li></ul>
Key Responsibilities<ul><li>
Review and validate claims using established criteria and processing guidelines.</li><li>
Prepare cases for payment or further review.</li><li>
Identify opportunities for process improvement and flag quality or fraud concerns.</li><li>
Support peers and clinical/non-clinical staff with claims and coding inquiries.</li></ul>
What You Bring<ul><li>
Required:<ul><li>
High School Diploma or GED.</li><li>
2+ years of experience in medical claims review.</li><li>
Familiarity with medical claims processing and terminology.</li></ul></li><li>
Preferred:<ul><li>
Coding experience.</li><li>
Knowledge of behavioral health claims.</li></ul></li></ul>
Skills for Success<ul><li>
Strong technical skills in claims tools (e.g., CDST, Supercoder).</li><li>
Organizational and team-building abilities.</li><li>
Resilience in a fast-paced, high-intensity environment.</li><li>
Effective communication and problem-solving.</li></ul>
Additional Requirements<ul><li>
Must pass background, credit, and drug screening.</li><li>
Adherence to federal THC policies (medical card required if applicable).</li></ul>
Eligible Locations 
The position is remote, but you can only reside in the following states: AK, AR, AZ, CO, DC, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NC, ND, NE, NM, NV, OK, OR, SC, SD, TN, TX, UT, VA, WA, WI, WY.
Ready to bring your claims expertise to a rewarding role? Apply today to be part of our team!
#Workwolf #BCDC_Consulting</div>

Claims Reviewer

CareSource

<div>
 
 Job Summary
 
 
 
 The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations.
 
 
 
 Essential Functions
 
 
 
 <ul>
 <li>
 Responsible for the completion of clinical appeals and state hearings from all states
 </li>
 <li>
 Perform clinical reviews of member and provider appeals for medical, dental, behavioral health, pharmacy, and waiver services
 </li>
 <li>
 Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions
 </li>
 <li>
 Document clinical rationale clearly and accurately in alignment with organizational and regulatory standards
 </li>
 <li>
 Work closely with medical directors, and pharmacists to resolve complex cases.
 </li>
 <li>
 Communicate outcomes effectively to members, and providers.
 </li>
 <li>
 Review and complete all provider clinical appeals within required timeframes
 </li>
 <li>
 Review and complete member clinical appeals within required timeframes
 </li>
 <li>
 Communicate with state agencies and internal departments to prepare for State Hearings
 </li>
 <li>
 Apply CareSource Medical Policy and Milliman guidelines when processing clinical appeals
 </li>
 <li>
 Issue administrative denials appropriately
 </li>
 <li>
 Refer denials based on medical necessity to medical director
 </li>
 <li>
 Collaborate with the Quality Improvement and Clinical Operations teams to prepare all requests for Independent External Review
 </li>
 <li>
 Participate in training programs to maintain clinical and regulatory expertise.
 </li>
 <li>
 Perform any other job duties as requested
 
 
 </li>
 </ul>
 
 Education And Experience
 
 
 
 <ul>
 <li>
 Associate&rsquo;s Degree required
 </li>
 <li>
 Managed care, appeals, Medicare, and Medicaid experience preferred
 </li>
 <li>
 Prior clinical appeals, and/or Utilization review experience is strongly preferred
 
 
 </li>
 </ul>
 
 Competencies, Knowledge And Skills
 
 
 
 <ul>
 <li>
 Intermediate proficiency with Microsoft Office products and Facets
 </li>
 <li>
 Knowledge of NCQA, URAC, OAC, and MDCH regulations
 </li>
 <li>
 Strong clinical judgment
 </li>
 <li>
 Attention to detail
 </li>
 <li>
 Ability to navigate complex regulations while maintaining a commitment to high-quality care
 </li>
 <li>
 Strong written and oral communication skills
 </li>
 <li>
 Ability to work independently and within a team environment
 </li>
 <li>
 Critical listening and thinking skills
 </li>
 <li>
 Proper grammar usage
 </li>
 <li>
 Time management skills
 </li>
 <li>
 Proper phone etiquette
 </li>
 <li>
 Customer Service oriented
 </li>
 <li>
 Decision making/problem solving skills
 </li>
 <li>
 Knowledge of Medicaid, and Medicare,
 </li>
 <li>
 Flexibility
 </li>
 <li>
 Change resiliency
 
 
 </li>
 </ul>
 
 Licensure And Certification
 
 
 
 <ul>
 <li>
 Current, unrestricted license as a Registered Nurse (RN) is required
 </li>
 <li>
 Multi-state RN license is preferred
 </li>
 <li>
 MCG Certification is required or must be obtained within six (6) months of hire
 
 
 </li>
 </ul>
 
 Working Conditions
 
 
 
 <ul>
 <li>
 General office environment; may be required to sit or stand for extended periods of time
 </li>
 <li>
 Position requires the flexibility to work weekends, evenings, and/or holidays, as needed
 
 
 </li>
 </ul>
 
 Compensation Range
 
 
 
 $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate&rsquo;s education, training, and experience as well as the position&rsquo;s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee&rsquo;s total well-being and offer a substantial and comprehensive total rewards package.
 
 
 
 Compensation Type
 
 
 
 Hourly
 
 
 
 Competencies
 
 
 
 <ul>
 <li>
 Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
 
 
 </li>
 </ul>
 This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
 
 
</div>

Clinical Appeals - R11356

Performant Financial Corporation

<div>ABOUT MACHINIFY:
In October 2025, Machinify acquired Performant and we are now part of the Machinify organization. Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, Machinify&rsquo;s AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We&rsquo;re reshaping healthcare payment through seamless intelligence.
ABOUT THE OPPORTUNITY:
Expected Hiring Range: $80-90k
The Medical Review Clinical Appeals Auditor (RN) is responsible for conducting Appeals reviews of new evidence presented by auditee&rsquo;s, disputing all or part of the findings from medical review audit work completed by the medical review clinical audit team members, as well as communicate and support the identification of potential training opportunities or enhancements to training and/or concept review guideline materials and tools. The Appeals Auditor is also responsible for consistently achieving or exceeding productivity goals and quality standards and serves as a subject matter expert, providing supplemental escalation support, and may perform special project activity as needed.
Key Responsibilities<ul><li>
Performs clinical reviews on medical records to maintain subject matter expertise.</li><li>
Conducts Appeals reviews on medical review audit work completed by the medical review clinical and documentation audit team members, as new evidence is presented by auditees.</li><li>
Objectively and accurately documents Appeals results in accordance with department quality policies and procedures, scoring and reporting all Appeals results and routes the result appropriately within audit platform based upon how the Appeal review resulted in a full or partial upholding of the audit finding or with a full or partial overturn.</li><li>
Reviews audit documentation and conducts research, analyzes claims data, applies knowledge of client SOW, applicable concept guidelines, policies, and regulations as necessary to determine if audit result is accurate and includes complete details to support findings.</li><li>
Provides correction to narrative rationale to correspond with audit determination and flags patterns of concern to audit leadership for real-time intervention, preventing an accumulation of improper findings.</li><li>
Contributes to the continuous improvement feedback process and suggests any edits to documentation, enhancements review guidelines, and reporting as may be necessary in accordance with department process and audit leadership direction.</li><li>
May support findings during the appeals process, if needed.</li><li>
May perform primary audit activity as assigned by management.</li><li>
Monitors, tracks, and reports on all work conducted in accordance with Appeals process and management direction.</li><li>
May prepare reports for management that includes a variety of data and trends at the individual, department, and client program level, as well as date range or concept based/trended, or other characteristic that will provide valuable business insights.</li><li>
Consults with internal resources as necessary.</li><li>
Become subject matter expert for assigned business segment(s).</li><li>
Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation, and business trends.</li><li>
Participates in and contributes to applicable department meetings.</li><li>
Successfully completes, retains, applies, and adheres to content in required training as assigned that includes but not limited to information security, anti-harassment and other compliance and policy/procedures training applicable for position.</li><li>
Proactively contributes to continuous improvement of activities and sets positive example.</li><li>
Contributes collaboratively to identifying opportunities for improvement of audit results and continuous improvement initiatives.</li><li>
May support training material/tools and best practices development.</li><li>
May identify/make recommendations to management for supplemental team/concept type training.</li><li>
May support training activities for new audit staff or provide supplemental training for existing staff as needed.</li><li>
Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results.</li><li>
Receives feedback and adjusts work priority as necessary.</li><li>
Serves as positive role model and example for other audit staff and conducts work in accordance with company policies, government regulations and law.</li><li>
Performs job duties with high level of professionalism and maintains confidentiality.</li><li>
Perform other incidental and related duties as required and assigned to meet business needs.</li></ul>
Knowledge, Skills and Abilities Needed<ul><li>
Demonstrated ability to perform claim payment audits with high quality and production results, as well as successful application of skills to conduct quality assurance review of audit work completed by others.</li><li>
Must be able to manage multiple assignments effectively, create documentation outlining findings, Appeals review results and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members.</li><li>
Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding may be necessary.</li><li>
Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules and regulations, may be necessary.</li><li>
Experience with utilization management systems or clinical decision-making tools such as Millimen Care Guidelines (MCG) or InterQual.</li><li>
Working knowledge of encoder may be necessary.</li><li>
Reimbursement policy and/or claims software analyst experience may be necessary.</li><li>
Familiarity with interpreting electronic medical records (EHR)</li><li>
Basic understanding of accounting principles for accounts payable and receivable as it relates to medical billing.</li><li>
Demonstrated ability to consistently apply sound judgment and good effective decision making.</li><li>
Understands Medical Review Audit and Quality Assurance objectives, activities, and key drivers in achieving operational goals.</li><li>
Ability to efficiently and effectively run reports, analyze information, identify meaningful trends, and identify potential solutions.</li><li>
Strong communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal external.</li><li>
Demonstrated ability to collaborate effectively in a variety of settings and topics.</li><li>
Excellent editing and proofreading skills.</li><li>
Ability to independently organization, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively.</li><li>
Excellent time management and delivers results balancing multiple priorities.</li><li>
Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data.</li><li>
Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues.</li><li>
Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures.</li><li>
Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.</li><li>
Ability to create documentation outlining findings and/or documenting suggestions.</li><li>
Strong general computer skills, including, but not limited to Desktop and MS Office applications (Intermediate-to-Advanced Excel Skills), application reporting tools, and case management system/tools to review and document findings.</li><li>
Advanced technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools.</li><li>
Ability to be flexible and thrive in a high pace environment with changing priorities.</li><li>
Adaptable to applying skills to diverse operational activities to support business needs.</li><li>
Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives.</li><li>
Serves as a positive role model; and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams.</li><li>
Capability of working in a fast-paced environment, flexibility with assignments and the ability to adapt in a changing environment.</li></ul>
Required and Preferred Qualifications<ul><li>
Active unrestricted RN license in good standing and diversified nursing experience providing direct care in an inpatient or outpatient setting, is required.</li><li>
At least 5+ years relevant experience in a provider or payer environment demonstrating breadth and depth of auditing knowledge/skills for the position. Less than 5 years may be considered for internal candidates based upon demonstrated skills and results.</li><li>
Not currently sanctioned or excluded from the Medicare program by OIG.</li><li>
Must have strong technical aptitude and intermediate to advanced skills using Excel.</li><li>
One or more years of experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, bundled payment methodologies and/or medical billing experience for an Insurance Company or hospital or other appropriate medical provider may be required.</li><li>
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions.</li><li>
Prior experience in role with responsibility for conducting primary audit, utilization management or prior-authorization work, or review of audit work performed by others (QA function, appeals function, lead, supervisory role, etc.)</li><li>
Prior experience in payer edit development and/or reimbursement policy a plus.</li><li>
Prior experience working in remote setting is strongly preferred. Must be comfortable solving minor/intermediate technical issues, with or without immediate remote assistance.</li></ul>
WHAT WE OFFER:
Machinify offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually. For more information about our benefits package, please refer to our benefits page on our website or discuss with your Talent Acquisition contact during an interview.
Physical Requirements &amp; Additional Notices:
If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required. Proof of such may be required prior to an offer being made. It is the Employee&rsquo;s responsibility to maintain this Internet access at their home office location.
The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.<ul><li>
Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.</li><li>
Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).</li><li>
Regularly sit/stand 8 or more hours per day.</li><li>
Occasionally lift/carry/push/pull up to 10lbs.</li></ul>
Machinify is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position:<ul><li>
Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.</li><li>
Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.</li><li>
Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.</li><li>
Other requirements may apply.</li></ul>
All employees and contractors for Machinify may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times. Violations to Machinify's policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.
Machinify is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Machinify will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you believe a reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Machinify&rsquo;s Human Resources team to discuss further.
Our diversity makes Machinify unique and strengthens us as an organization to help us better serve our clients. Machinify is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.
THIRD PARTY RECRUITMENT AGENCY SUBMISSIONS ARE NOT ACCEPTED UNLESS EXPLICITY AGREED TO IN WRITING</div>

Medical Review Clinical Appeals Auditor (RN)

Pantherx Specialty Llc

<div>7,000 Diseases - 500 Treatments - 1 Rare Pharmacy
PANTHERx is the nation&rsquo;s largest rare disease pharmacy, and we put the patient experience at the top of everything that we do.
If you are looking for a career in the healthcare field that embraces authentic dedication to patient care, you don&rsquo;t need to look beyond PANTHERx. In every line of service, in every position and area of expertise, PANTHERx associates are driven to provide the highest quality outcomes for our patients.
We are seeking team members who:
Are inspired and compassionate problem solvers;
Produce high quality work;
Thrive in the excitement of the ever-challenging environment of modern medicine; and
Are committed to achieving superior health outcomes for people living with rare and devastating diseases.
At PANTHERx, we know our employees are the driving force in what we do. We cultivate talent and encourage growth within PANTHERx so that our associates can continue to explore their interests and expand their careers. Guided by our mission to provide uncompromising quality every day, we continue our strategic growth to further reach those affected by rare diseases.
Join the PANTHERx team, and define your own RxARE future in healthcare!
Location: Pittsburgh, PA; Hybrid 
Classification: Non-Exempt
Status: Full Time
Reports to: Manager, Clinical Programs
Purpose:
The Clinical Authorization and Appeals Specialist provides support and education to health care providers for prescribed treatment therapies. This role serves as a single point of contact for health care providers to coordinate alignment of documentation with prior authorization and appeals criteria. This role submits timely prior authorizations requests, appeals, initiatives to increase patient adherence, and closes collaboration with both internal and external stakeholders.
Responsibilities:<ul><li>
Educates health care providers regarding prior authorization and appeals criteria for prescribed therapies.</li><li>
Assesses clinical documentation provided and assist the health care provider with alignment to specific plan criteria.</li><li>
Creates initiatives to increase patient adherence and optimize patient care.</li><li>
Possess a broad and deep understanding of assigned disease states, products, and clinical programs.</li><li>
Closes collaboration with program team members as well as external stakeholders.</li><li>
Performs appropriate and accurate documentation of cases using call management software.</li><li>
Demonstrates appropriate judgment skills to be able to make independent clinical decisions.</li><li>
Fosters teamwork by trusting and supporting each other while encouraging collaboration at all levels of the organization. Embraces diversity and demonstrates the ability to work together.</li><li>
Provides superior customer service to internal and external clients, customers, and patients.</li><li>
Assumes accountability for own professional practice in achieving patient outcomes.</li><li>
Completes all other duties as assigned.</li></ul>
Required Qualifications:<ul><li>
Associate degree or bachelor&rsquo;s degree from an accredited nursing school as a Registered Nurse (RN).</li><li>
Must have demonstrated competence in community health or patient care setting, providing direct patient care with patients for 1-3 years.</li><li>
Strong writing and grammar skills.</li><li>
Strong organizational skills and a thorough knowledge of computers (Microsoft Office and Windows) are required.</li><li>
Demonstrated ability to work independently and meet goals.</li></ul>
Preferred Qualifications:<ul><li>
1-3 years of specialty pharmacy experience</li></ul>
Work Environment:
PANTHERx Rare Pharmacy offers flexibility only to eligible employees to work hybrid or remotely without compromising work performance, productivity, or team collaboration. This role routinely uses standard office equipment such as computers and phones.
Physical Demands:
While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands and fingers, handle or feel; and reach with hands and arms. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential function of the job.
Benefits:
Hybrid, remote and flexible on-site work schedules are available, based on the position. PANTHERx Rare Pharmacy also affords an excellent benefit package, including but not limited to medical, dental, vision, health savings and flexible spending accounts, 401K with employer matching, employer-paid life insurance and short/long term disability coverage, and an Employee Assistance Program! Generous paid time off is also available to all full-time employees, as well as limited paid time off for part-time employees. Of course we offer paid holidays too!
Equal Opportunity:
PANTHERx Rare Pharmacy is an equal opportunity employer, and does not discriminate in recruiting, hiring, promotions or any term or condition of employment based on race, age, religion, gender, ethnicity, sexual orientation, gender identity, disability, protected veteran's status, or any other characteristic protected by federal, state or local laws.</div>

Clinical Authorization and Appeals Specialist

Tender Touch Rehab Services LLC

<div>
 
 Job Description:
 
 
 Need to be proficient in basic writing skills to email clients.
 
 
 Comfortable on the computer to&nbsp;review and compile medical records on the computer.&nbsp;
 
 
 Should be able&nbsp;to follow instructions set by the Claims Dept Manager for logging the requests of claims and /or appeals from the facility, and update the spreadsheet database&nbsp;with all necessary details as per the set standards of the department.
 
 
 Ensure&nbsp;all the medical records from Net-Health and SharePoint have been organized and provided to the reviewer for review.
 
 
 Maintain tracking of requests, submissions, denials, appeals, etc., as per department standards.
 
 
 
 
 
 Qualifications
 
 
 &bull;	College Graduate
 
 
 &bull;	Yearning to work in a fast-paced job
 
 
 &bull;	Have ability to communicate clearly and courteously
 
 
 &bull;	Have skills in writing professional emails
 
 
 &bull;	Have experience or willingness to learn to use Microsoft Excel and similar programs
 
 
 &bull;	Be thorough and pay attention to details
 
 
 &bull;	Be efficient and productive&nbsp;
 
 
 &bull;	Be a fast Learner
 
 
 
 
 
 Job Responsibilities
 
 
 1.	In charge of emails. Communication and action as needed based on the email
 
 
 2.	Respond to facility requests in a reasonable time frame&nbsp;
 
 
 3.	Communicate effectively
 
 
 4.	Submit records online/ Mail them physically&nbsp;
 
 
 5.	Be able to pull necessary reports when requested&nbsp;
 
 
 6.	Pull Medical records from Net Health
 
 
 7.	Organize and use PDF Xchange&nbsp;
 
 
 8.	Maintain a clean and accurate Spread Sheet&nbsp;
 
 
 9.	Organize the medical records as per the Checklist provided&nbsp;
 
 
 
 
 
 Physical Demands&nbsp;
 
 
 Extended sitting and being on the computer. Work will be in the office with accommodations for&nbsp;working from home occasionally.
 
 
 
 
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Clinical Assistant

Staffing Solutions Organization LLC

<div>
 
 
 Ensure Quality Care Across Illinois&mdash;One Review at a Time.
 
 
 
 
 
 
 
 Nurse Reviewer &ndash; Illinois
 
 
 
 
 Location:
 
 Remote with on‑site visits across Illinois
 
 
 
 
 
 
 Position Overview
 
 
 
 The Nurse Reviewer conducts provider compliance reviews to ensure adherence to state regulations, quality standards, and program requirements. This role includes conducting onsite visits, evaluating documentation, and determining provider compliance. The Nurse Reviewer works independently, exercises sound judgment, and provides recommendations that guide provider improvement and support statewide oversight efforts.
 
 
 
 
 
 
 Duties &amp; Responsibilities
 
 
 <ul>
 <li>
 Build and maintain effective relationships with providers and users to support high‑quality customer service.
 </li>
 <li>
 Evaluate providers for compliance with applicable state and program regulations.
 </li>
 <li>
 Coordinate and schedule on‑site provider visits; clearly communicate visit requirements.
 </li>
 <li>
 Conduct compliance interviews with providers and gather all necessary information.
 </li>
 <li>
 Review provider documentation, policies, and business practices for regulatory alignment.
 </li>
 <li>
 Collect, organize, and submit documentation supporting compliance findings.
 </li>
 <li>
 Utilize technology and web‑based systems to convert paper documentation to electronic format.
 </li>
 <li>
 Conduct in‑person assessments of provider sites to evaluate compliance with oversight requirements.
 </li>
 <li>
 Summarize on‑site visit findings accurately and professionally.
 </li>
 <li>
 Exercise independent judgment to evaluate compliance and make final determinations based on documented evidence.
 </li>
 <li>
 Identify deficiencies and recommend appropriate next steps to support provider improvement.
 </li>
 <li>
 Analyze trends in non‑compliance and identify gaps in provider business processes.
 </li>
 <li>
 Provide timely recommendations and updates to the Supervisor.
 </li>
 <li>
 Maintain HIPAA standards and confidentiality at all times.
 </li>
 <li>
 Perform other duties as assigned.
 </li>
 </ul>
 
 
 
 
 
 Required Skills
 
 
 <ul>
 <li>
 Strong interpersonal skills with the ability to relate well to staff and providers.
 </li>
 <li>
 Active listening and effective communication skills.
 </li>
 <li>
 Proficiency in MS Word, Excel, Outlook, and web‑based applications.
 </li>
 <li>
 Process‑oriented and results‑driven work approach.
 </li>
 <li>
 Ability to foster teamwork and collaborate across levels of management and staff.
 </li>
 <li>
 Ability to work independently and within a team environment.
 </li>
 <li>
 Excellent written and verbal communication skills and customer‑service techniques.
 </li>
 <li>
 High accuracy, strong attention to detail, and commitment to quality.
 </li>
 <li>
 Proven ability to meet deadlines and follow strict standards.
 </li>
 <li>
 Ability to travel regularly to provider sites across Illinois.
 </li>
 </ul>
 
 
 
 
 
 Qualifications
 
 
 
 
 Education
 
 
 <ul>
 <li>
 Bachelor&rsquo;s degree in any field (Nursing preferred)
 </li>
 </ul>
 
 
 Experience
 
 
 <ul>
 <li>
 Minimum
 
 2 years of clinical experience
 
 working with critical care providers, public health providers, or providers serving children, older adults, individuals with traumatic brain injury, or individuals with developmental disabilities.
 </li>
 <li>
 Minimum
 
 1 year of experience
 
 conducting quality assurance reviews.
 </li>
 </ul>
 
 
 Certification
 
 
 <ul>
 <li>
 Active Illinois Registered Professional Nurse (RN) license required.
 </li>
 </ul>
 
 
 
 
 
 Working Conditions
 
 
 <ul>
 <li>
 Remote work with
 
 2&ndash;3 on‑site provider visits per week
 
 throughout the state of Illinois.
 </li>
 </ul>
 
 
 
 
 
 Benefits (Through SSO)
 
 
 
 SSO offers a competitive benefits package that supports your health, financial well‑being, and long‑term growth, including:
 
 <ul>
 <li>
 Medical, dental, and vision insurance
 </li>
 <li>
 401(k) with discretionary employer match
 </li>
 <li>
 Paid time off and holidays
 </li>
 <li>
 Flexible spending accounts
 </li>
 <li>
 Additional employee perks
 </li>
 </ul>
 
 
 
 
 
 Keyword Search Terms
 
 
 
 Nurse Reviewer, RN Reviewer, Provider Management Specialist, Compliance Nurse, Healthcare Quality Review, Provider Compliance, Medicaid Compliance, Clinical Reviewer, Illinois RN, Site Visit Nurse, Healthcare Auditor, Public Health Nursing, QA Nurse, Provider Monitoring.
 
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Nurse Reviewer

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