clinical nurse reviewer

University of Massachusetts

<div>Overview:
<div><div><div><b>
Job Summary</b></div></div><div><div><div><div><div><div><br>
Under the general supervision of the Associate Director, Clinical Coordinator, or designee, the Nurse Reviewer II is responsible for providing administrative case management as part of the Community Case Management Program. This position is responsible for the authorization, coordination and facilitation of long term services and supports (LTSS) for program Members. As a member of a multidisciplinary team, the Nurse Reviewer II is responsible for assessing, planning, organizing, reviewing and evaluating the care needs of Members requiring community-based services. This position fosters and promotes continuity of care and cooperative partnerships by liaising with nursing providers, state agency staff, acute care hospitals and other programs/organizations involved in the provision of services.</div></div></div></div></div></div></div><br>
<div></div>
Responsibilities:
<div><div><div><b>
Major Responsibilities</b></div></div><div><div><div><div><div><div><br>
<ul><li>
Serve as the clinical manager for an assigned caseload of Members.</li></ul></div><div><br>
<ul><li>
Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of Members requiring health care services, to include outpatient and home based therapy services.</li></ul></div><div><br>
<ul><li>
Conduct on-site reviews and assessments of Member&rsquo;s community long term care needs to determine medical necessity and clinical eligibility for Community Case Management and Continuous Skilled Nursing Services Determine and authorize services for Members in accordance with program guidelines and regulations, meeting all established deadlines.</li></ul></div><div><br>
<ul><li>
Prepare and implement Member service records.</li></ul></div><div><br>
<ul><li>
Coordinate, facilitate and monitor the delivery of services to members.</li></ul></div><div><br>
<ul><li>
Review and document all relevant information into data system applications in accordance with program guidelines and regulations.</li></ul></div><div><br>
<ul><li>
Conduct routine and ad-hoc evaluations and re-evaluations of Members&rsquo; services.</li></ul></div><div><br>
<ul><li>
Contact and engage providers, state agency offices, and Members to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination.</li></ul></div><div><br>
<ul><li>
Evaluate and document the appropriateness of Members&rsquo; services and make modifications, as required.</li></ul></div><div><br>
<ul><li>
Maintain individual records documenting all Member encounters and contacts; write clinical summaries.</li></ul></div><div><br>
<ul><li>
Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals and other programs/organizations involved in the provision of services.</li></ul></div><div><br>
<ul><li>
Prepare and respond to inquiries related to appeals on clinical determinations.</li></ul></div><div><br>
<ul><li>
Maintain positive working relationships with peers, leadership, Members, relevant informal supports, provider organizations, and state agencies.</li></ul></div><div><br>
<ul><li>
Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations.</li></ul></div><div><br>
<ul><li>
Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.</li></ul></div><div><br>
<ul><li>
Participates in training and onboarding of new clinical staff</li></ul></div><div><br>
<ul><li>
Comply with established departmental policies, procedures and objectives.</li></ul></div><div><br>
<ul><li>
Perform other duties as required.</li></ul></div></div></div></div></div></div></div><br>
<div></div>
Qualifications:
<div><div><div><b>
Required Qualifications</b></div></div><div><div><div><div><div><div><br>
<ul><li>
RN licensed to practice in Massachusetts</li></ul></div><div><br>
5-7 years of work experience with at least 3 recent years providing direct service or case management to the pediatric, young adult, or adult medically complex population<br>
<ul><li>
</li></ul></div><br>
<div><ul><li>Ability to travel statewide to Member homes and service providers places of business</li></ul></div><div><br>
<ul><li>
Experience with Office Application and database</li></ul></div><div><br>
<ul><li>
Valid Driver&rsquo;s license required</li></ul></div></div></div></div></div></div></div><div></div><div><div><div><b><br>
Preferred Qualifications</b></div></div><div><div><div><div><div><div><br>
<ul><li>
Experience with home care</li></ul></div><div><br>
<ul><li>
Knowledge of applicable state regulations</li></ul></div><div><br>
<ul><li>
Experience with prior authorization and/or eligibility determinations</li></ul></div><div><br>
<ul><li>
Experience with the care of medically complex individuals</li></ul></div></div></div></div></div></div></div><br>
<div></div>
Additional Information:
<div><div><div><b>
Supervision</b></div></div><div><div><div><div><div><b><br>
Supervision Received</b></div></div><div><div><div><div><br>
Supervision received from Clinical Coordinator</div></div></div></div></div></div></div><div></div><div><div><div><div><div><b><br>
Supervision Exercised</b></div></div><div><div><div><div><br>
None</div></div></div></div></div></div></div></div><div></div><div><div><div><b><br>
Environmental Working Conditions</b></div></div><div><div><div><div><div><div><br>
Remote/desk work with statewide travel required</div></div></div></div></div></div></div></div><div></div>

Nurse Rev II-Case Mgt

HMSA

<div>
 <strong>
  Employment Type
  <br/>
  <br/>
 </strong>
 Full-time
 <br/>
 <br/>
 <strong>
  Exempt or Non-Exempt
  <br/>
  <br/>
 </strong>
 Exempt
 <br/>
 <br/>
 <strong>
  Job Summary
  <br/>
  <br/>
 </strong>
 <strong>
  Hybrid Work Environment - Must reside in Hawaii
  <br/>
  <br/>
 </strong>
 <strong>
  Pay Range:
 </strong>
 $59,000 to $116,000
 <br/>
 <br/>
 <strong>
  Note
 </strong>
 : Individuals typically begin between the minimum to middle of the pay range
 <br/>
 <br/>
 Under minimal supervision, conducts detailed analysis and review of precertification requests, post-service and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally accepted clinical guidelines to determine appropriateness of care for all HMSA lines of business.
 <br/>
 <br/>
 <strong>
  Minimum Qualifications
 </strong>
 <br/>
 <br/>
 <ul>
  <li>
   Associates degree in Nursing.
  </li>
  <li>
   Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
  </li>
  <li>
   Two years clinical, case management or utilization management related experience.
  </li>
  <li>
   Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
  </li>
  <li>
   Strong organizational skills
  </li>
  <li>
   Good communication skills both verbally and written
  </li>
  <li>
   Analytical skills
  </li>
  <li>
   Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
  </li>
  <li>
   Currently licensed in Hawaii as an RN or LPN
  </li>
  <ul>
   <li>
    (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)
    <br/>
   </li>
  </ul>
 </ul>
 <strong>
  Duties And Responsibilities
 </strong>
 <br/>
 <br/>
 <ul>
  <li>
   Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
  </li>
  <ul>
   <li>
    Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
   </li>
   <li>
    Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
   </li>
   <li>
    Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
   </li>
   <li>
    Review various types of services, including but not limited to:
   </li>
   <li>
    Transplants
   </li>
   <li>
    Air Ambulance
   </li>
   <li>
    Chemotherapy
   </li>
   <li>
    Clinical trials
   </li>
   <li>
    Genetic testing
   </li>
   <li>
    Cancer treatments/radiation therapy
   </li>
   <li>
    Experimental/Investigational Services/Devices
   </li>
   <li>
    New Technology
   </li>
  </ul>
  <li>
   Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
  </li>
  <ul>
   <li>
    Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
   </li>
   <li>
    Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
   </li>
   <li>
    Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
   </li>
   <li>
    Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
   </li>
  </ul>
  <li>
   Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
  </li>
  <li>
   Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
  </li>
  <li>
   Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
  </li>
  <li>
   Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
  </li>
  <li>
   Performs all other miscellaneous responsibilities and duties as assigned or directed.
   <br/>
   <br/>
  </li>
 </ul>
</div>


Nurse Reviewer - Clinical Review Unit

MultiCare Health System

<p></p><div><p><b>Where Kids and Families are Always First
</b></p><p>MultiCare Mary Bridge Children&rsquo;s Hospital is the state-designated Level II Pediatric Trauma Center and the only pediatric hospital in Washington&rsquo;s South Sound Region dedicated to a comprehensive network of health services for children and adolescents. Our vision is to be the highest quality and safest place for children to receive care, where every child has a medical home and is supported by nationally recognized services and experience. Mary Bridge Children&rsquo;s multi-disciplinary approach to care includes pediatric experts for emergency services, inpatient care, and outpatient specialty clinics, all specializing in kids and their unique needs.
</p><p><b>FTE:</b> 0.5 <b>Shift:</b> Days <b>Schedule:</b> Monday - Friday</p><p></p><p><b>
Position Summary</b></p>
The Surgical Clinical Reviewer works with the Manager of the Pediatric Surgery Program to implement and monitor the quality of care of pediatric patients receiving surgical services; serves as a resource for multidisciplinary team members; provides data abstraction into the ACS NSQIP-P database; participates in teams and evaluates performance improvement; develops effective working relationships with members of the Children&rsquo;s Surgery Department and ancillary hospital employees.<p><b>
Responsibilities:</b></p><ul><li>
Navigate the electronic medical record and abstract patient data in the ACS NSQIP-P database.</li><li>
Communicate with MB providers and hospital staff across the care continuum.</li><li>
Analyze and present data to providers, hospital teams and leadership.</li><li>
Contact patients and families to obtain post-operative follow-up as per ACS NSQIP-P guidelines.</li></ul><p></p><p><b>
Requirements:</b></p><ul><li>
Bachelor's degree in Nursing (required); Master degree in Nursing (preferred)</li><li>
Registered Nurse license (RN) in Washington State or multi-state licensure endorsement (MSL)</li><li>
BLS - Basic Life Support (includes RQI) - American Heart Association or American Red Cross</li><li>
Minimum five (5) years of professional/technical nursing experience required</li><li>
Minimum two (2) years of experience in data abstraction or quality improvement</li></ul><p></p><p><b>
Why Mary Bridge Children's?</b></p><ul><li><p><b>
Mission-driven:</b> Partnering for healing and a healthy future for the patients and communities we serve</p></li><li><p><b>
Award-winning: </b>Named &lsquo;Top Children&rsquo;s Hospital&rsquo; for five years by the Leapfrog Group; physicians consistently named on &lsquo;Top Doctors&rsquo; lists by Seattle Magazine, Seattle Met and the Tacoma News Tribune</p></li><li><p><b>
Growing:</b> New pediatric hospital facility and medical office building opening in 2026</p></li><li><p><b>
Leading research: </b>MultiCare Institute for Research &amp; Innovation partners with our pediatric providers, offering ground-breaking research and clinical trials</p></li><li><p><b>
Employee-centric: </b>MultiCare is consistently ranked among &ldquo;America&rsquo;s Best Employers by State&rdquo; by Forbes</p></li><li><p><b>
Lifestyle: </b>Live and work in the Pacific Northwest surrounded by breathtaking mountain, forest and water views</p></li><li><p><b>
Explore </b>our services at marybridge.org</p></li></ul><p></p><p><b>
Pay and Benefit Expectations</b></p>
We provide a comprehensive benefits package, including competitive salary, medical, dental and retirement benefits and paid time off. As required by various pay transparency laws, we share a competitive range of compensation for candidates hired into each position. The pay scale is $54.17 - $88.37 USD. However, pay is influenced by factors specific to applicants, including but not limited to: skill set, level of experience, and certification(s) and/or education. If this position is associated with a union contract, pay will be reflective of the appropriate step on the pay scale to which the applicant&rsquo;s years of experience align.<p></p><p>
Associated benefit information can be viewed here.</p></div>

Registered Nurse (RN) - Surgical Clinical Reviewer

PruittHealth

<div>
 <strong>
  RN experienced with OASIS and certified ICD 10 Reviewer
 </strong>
 <strong>
  - HOME HEALTH SERVICES
  <br/>
  <br/>
 </strong>
 <strong>
  Must have ICD-10 Certification
  <br/>
  <br/>
 </strong>
 <strong>
  Join the PruittHealth @Home family, where we deliver quality care where the patients choose to be!
 </strong>
 We know that home is where the heart is, and thanks to our PruittHealth @Home caregivers, home is where the healing happens too. PruittHealth @Home is committed to our patients and to your home health career. If you&rsquo;re looking for a home, rather than a job, then now is the time to join one of the leading providers of post-acute care.
 <br/>
 <br/>
 <strong>
  PruittHealth @Home will help you conquer your career goals.
 </strong>
 O ur Home Health team is searching for compassionate caregivers who are committed to serving our patients in the comfort of their own home. In return, we are committed to supporting your nursing career through top-of-market pay, flexible schedules, preceptorship, and more.
 <br/>
 <br/>
 <strong>
  Investing In Our Employee-Partners With Benefits
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Top-of-market pay
  </li>
  <li>
   Annual merit increases
  </li>
  <li>
   Premium Pay Days (1.5x pay for holidays)
  </li>
  <li>
   Paid time off
  </li>
  <li>
   Employee Referral Bonus Program
  </li>
  <li>
   Preceptorship Program and hands-on training
  </li>
  <li>
   Competitive mileage reimbursement rates
  </li>
  <li>
   Comprehensive health plans
  </li>
  <li>
   401(k) and profit-sharing plans
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Complete evaluations, assessments, and treatments in accordance with policy and the individualized care plan
  </li>
  <li>
   Complete all documentation and records in a timely and accurate manner
  </li>
  <li>
   Follow established policies and procedures as related to the scope of practice
  </li>
  <li>
   Maintain continuity of patient care in a home care setting
   <br/>
   <br/>
  </li>
 </ul>
 To apply please email Britany.Kerr@pruitthealth.com
 <br/>
 <br/>
 <strong>
  Licensure, Certification, And Educational Requirements
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Current, active, and unrestricted Registered Nurse (RN) licensure in the state of practice
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Family Makes Us Stronger.
 </strong>
 Our family, your family, one family. Committed to loving, giving, and caring. United in making a difference.
 <br/>
 <br/>
 We are eager to connect with you!
 <em>
  <strong>
   Apply Now
  </strong>
 </em>
 to get started at PruittHealth!
 <br/>
 <br/>
 <em>
  As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.
  <br/>
  <br/>
 </em>
 <strong>
  For Florida Job Postings Only
  <br/>
  <br/>
 </strong>
 For more information regarding Florida&rsquo;s Care Provider Background Screening Clearinghouse Education and Awareness, please visit https://info.flclearinghouse.com
 <br/>
 <br/>
 <strong>
  Job
  <br/>
  <br/>
 </strong>
 Administrative
 <br/>
 <br/>
 <strong>
  Primary Location
  <br/>
  <br/>
 </strong>
 Georgia-NORCROSS
 <br/>
 <br/>
 <strong>
  Schedule
  <br/>
  <br/>
 </strong>
 Full-time
 <br/>
 <br/>
 <strong>
  Shift
  <br/>
  <br/>
 </strong>
 1st Shift
 <br/>
 <br/>
 <strong>
  Job Posting
  <br/>
  <br/>
 </strong>
 Mar 16, 2026, 8:11:19 AM
 <br/>
 <br/>
 <strong>
  Work Locations
  <br/>
  <br/>
 </strong>
 PruittHealth Home Health - Home Office
</div>


Registered Nurse RN OASIS and ICD 10 Reviewer

RemoteFocus

<p><b>Job Overview</b><br/>We are seeking a dedicated and detail-oriented Clinical Chart Reviewer (HomeCare) to join our dynamic healthcare team. In this vital role, you will meticulously review patient charts and clinical documentation to ensure accuracy, completeness, and compliance with regulatory standards. Your expertise will support quality assurance initiatives, enhance patient care documentation, and uphold the highest standards of clinical integrity. This position offers an exciting opportunity to contribute to improving healthcare outcomes through precise chart analysis and collaborative teamwork.</p><p><b>Responsibilities</b></p><ul><li>Conduct comprehensive reviews of patient medical records, clinical notes, and homecare documentation to verify accuracy and completeness</li><li>Ensure all documentation aligns with regulatory guidelines, payer requirements, and organizational policies</li><li>Identify discrepancies or gaps in clinical records and collaborate with healthcare providers for clarification or correction</li><li>Maintain detailed logs of review findings, including any issues identified and actions taken</li><li>Support quality improvement initiatives by providing insights based on chart reviews and documentation trends</li><li>Stay current with evolving healthcare regulations, documentation standards, and best practices in homecare settings</li><li>Assist in training staff on proper documentation procedures to promote consistency and compliance</li></ul><p><b>Requirements</b></p><ul><li>Proven experience in clinical chart review within a homecare or outpatient healthcare setting</li><li>Strong knowledge of healthcare regulations, coding standards, and documentation requirements (such as CMS guidelines)</li><li>Excellent attention to detail with the ability to identify errors or inconsistencies swiftly</li><li>Effective communication skills for collaborating with clinicians, administrators, and regulatory bodies</li><li>Ability to interpret medical records accurately and maintain confidentiality at all times</li><li>Proficiency in electronic health record (EHR) systems and data management tools</li><li>A proactive approach to problem-solving and continuous learning in a fast-paced environment</li></ul><p>Join us in making a meaningful difference by ensuring the highest quality of clinical documentation. We&rsquo;re committed to supporting your professional growth while fostering a vibrant team dedicated to excellence in homecare services!</p><p>Pay: $35.00 - $40.00 per hour</p><p>Work Location: Remote</p>

Clinical Chart Reviewer (HomeCare)

Acentra Health

<div>Company Overview:
<div>
Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.</div><div></div><div><br>
Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes &ndash; making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.</div>
Job Summary and Responsibilities:
<div><b>
Acentra Health is looking for a Clinical Reviewer - LPN/LVN or RN (remote U.S.) to join our growing team.</b></div><div><b><br>
Job Summary:</b></div><div></div><div><br>
The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements.</div><div></div><div><b><br>
***This position is remote within the United States, but applicants must be clinically licensed for the State of Indiana or have a compact license.***</b></div><div></div><div><b><br>
***Work Schedule: Five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays***</b></div><div><b><br>
Responsibilities:</b></div><ul><li>
Assures accuracy and timeliness of all applicable review type cases within contract requirements.</li><li>
Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.</li><li>
In collaboration with Supervisor, responsible for quality monitoring activities.</li><li>
Maintains current knowledge base related to review processes and clinical practices.</li><li>
Functions as providers' liaison for customer service issues and problem resolution.</li><li>
Performs all applicable review types as workload indicates.</li><li>
Fosters positive and professional relationships with internal and external customers.</li><li>
Attends training and scheduled meetings for current/updated information.</li><li>
Cross trains to provide flexible workforce to meet client/customer needs.</li><li>
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.</li></ul><div><i>
The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.</i></div>
Qualifications:
<div><b>
Required Qualifications:</b></div><ul><li>
Active, unrestricted LPN/LVN or RN license in the state of Indiana or a Compact state clinical license.</li><li>
Associate's degree (bachelor's preferred) or Practical/Professional nursing diploma from an accredited nursing school, college, or university.</li><li>
2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience.</li><li>
2+ years of medical necessity review experience.</li><li>
1+ years of InterQual criteria and/or Milliman Care Guidelines (MCG) experience.</li><li>
Knowledge of medical records, medical terminology, and disease processes.</li><li>
Strong clinical assessment and critical thinking skills.</li><li>
Excellent written and verbal communication skills.</li><li>
Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively.</li><li>
Flexibility and strong organizational skills.</li><li>
Ability to work five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays.</li></ul><div><b>
Preferred Qualifications:</b></div><ul><li>
3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment.</li><li>
Knowledge of current National Committee for Quality Assurance (NCQA) standards.</li><li>
Knowledge of Utilization Review Accreditation Commission (URAC) standards.</li><li>
Ability to work in a team environment.</li><li>
Proficient in Microsoft Office.</li><li>
Efficient time management, including the ability to prioritize tasks, and meet deadlines.</li><li>
Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance when assessing relevant issues.</li></ul><div><b>
Why us?</b></div><div></div><div><br>
We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.</div><div></div><div><b><br>
We do this through our people.</b></div><div></div><div><br>
You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.</div><div></div><div><b><br>
Benefits</b></div><div></div><div><br>
Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.</div><div></div><div><b><br>
Compensation</b></div><div></div><div><br>
The pay range for this position is listed below.</div><div></div><div><br>
&ldquo;Based on our compensation philosophy, an applicant&rsquo;s position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.&rdquo;</div><div></div><div><b><br>
Thank You!</b></div><div></div><div><br>
We know your time is valuable and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may be of interest. Best of luck in your search!</div><div></div><div><br>
~ The Acentra Health Talent Acquisition Team</div><div></div><div><br>
Visit us at https://careers.acentra.com/jobs</div><div></div><div><b><br>
EEO AA M/F/Vet/Disability</b></div><div></div><div><br>
Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.</div>
Pay Range: USD $28.37 - USD $39.19 /Hr.</div>

Clinical Reviewer - LPN/LVN or RN

Atlantic Cove Medical Group

<p><b>Overview</b></p><p>The OASIS Review Nurse is a Registered Nurse responsible for reviewing and analyzing OASIS documentation for accuracy, completeness, consistency, and regulatory compliance. This role helps ensure proper ICD-10 coding and sequencing, supports documentation integrity, and collaborates with clinical staff to resolve discrepancies and improve assessment quality.</p><p>The ideal candidate has strong home health experience, a solid understanding of OASIS and ICD-10 requirements, and the ability to identify documentation trends that may affect reimbursement, utilization, and quality outcomes.</p><p><b>Responsibilities</b></p><ul><li>Review OASIS assessments prospectively to ensure completeness, accuracy, and compliance with federal and state regulations, as well as organizational policy.</li><li>Utilize OASIS variation and alert reports during chart review.</li><li>Ensure appropriate ICD-10 coding and sequencing based on the patient&rsquo;s clinical condition and comorbidities.</li><li>Collaborate with clinical staff to clarify documentation issues and facilitate appropriate corrections.</li><li>Review visit utilization for appropriateness based on patient condition and care guidelines; escalate concerns regarding underutilization or potential financial impact.</li><li>Identify and report problematic trends or recurring issues discovered through OASIS review.</li><li>Partner with managers and leadership to address trends affecting outcome and process measures.</li><li>Conduct OASIS inter-rater reliability visits with clinical staff.</li><li>Participate in quality improvement and corporate compliance activities as assigned.</li><li>Assist with additional chart audit activities as needed.</li><li>Maintain current professional and technical knowledge through ongoing education and professional development.</li></ul><p><b>Experience</b></p><ul><li>Current Registered Nurse (RN) license in the applicable state.</li><li>One to two years of clinical home health experience required.</li><li>Working knowledge of OASIS and ICD-10 coding required.</li><li>OASIS Certification (COS-C) preferred.</li><li>OASIS Home Health ICD-10 Coding Certification preferred.</li><li>Knowledge of federal regulations and state licensure requirements.</li><li>Proficiency with computer systems and clinical documentation platforms.</li><li>Current CPR certification required.</li><li>Valid driver&rsquo;s license, reliable automobile, and insurance in accordance with organizational requirements.</li><li>Strong coordination, communication, and organizational skills.</li><li>Detail-oriented with the ability to work independently and with minimal supervision.</li></ul><p>Pay: $61,000.00 - $65,000.00 per year</p><p>Work Location: In person</p>

OASIS REVIEW NURSE / Q/A NURSE

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