clinical nurse reviewer

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

ForHealth Consulting at UMass Chan Medical School

<div>
 <strong>
  Position Summary
  <br/>
  <br/>
 </strong>
 ForHealth Consulting at UMass Chan Medical School is seeking a detail-oriented
 <strong>
  Nurse Reviewer II
 </strong>
 with experience caring for individuals with complex medical needs to join our Community Case Management Program. In this role, you will manage a caseload of members, ensuring they receive the long-term services and supports (LTSS) they need to thrive in the community. This position combines the flexibility of remote work with meaningful field interactions through home and site visits.
 <br/>
 <br/>
 Youll play a key role on a multidisciplinary team - assessing, planning, coordinating, and authorizing care for individuals with complex medical needs, while collaborating closely with providers, state agencies, and other healthcare partners to ensure continuity and quality of care.
 <br/>
 <br/>
 <strong>
  Major Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Serve as the clinical manager for an assigned caseload of Members.
  </li>
  <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>
  <li>
   Conduct on-site reviews and assessments of Members 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>
  <li>
   Prepare and implement Member service records.
  </li>
  <li>
   Coordinate, facilitate and monitor the delivery of services to members.
  </li>
  <li>
   Review and document all relevant information into data system applications in accordance with program guidelines and regulations.
  </li>
  <li>
   Conduct routine and ad-hoc evaluations and re-evaluations of Members services.
  </li>
  <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>
  <li>
   Evaluate and document the appropriateness of Members services and make modifications, as required.
  </li>
  <li>
   Maintain individual records documenting all Member encounters and contacts; write clinical summaries.
  </li>
  <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>
  <li>
   Prepare and respond to inquiries related to appeals on clinical determinations.
  </li>
  <li>
   Maintain positive working relationships with peers, leadership, Members, relevant informal supports, provider organizations, and state agencies.
  </li>
  <li>
   Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations.
  </li>
  <li>
   Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
  </li>
  <li>
   Participates in training and onboarding of new clinical staff
  </li>
  <li>
   Comply with established departmental policies, procedures and objectives.
  </li>
  <li>
   Perform other duties as required.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Required Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   RN licensed to practice in Massachusetts
  </li>
  <li>
   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
  </li>
  <li>
   Ability to travel statewide to Member homes and service providers places of business
  </li>
  <li>
   Experience with Office Application and database
  </li>
  <li>
   Valid Drivers license required
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Experience with home care
  </li>
  <li>
   Knowledge of applicable state regulations
  </li>
  <li>
   Experience with prior authorization and/or eligibility determinations
  </li>
  <li>
   Experience with the care of medically complex individuals
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Why Join Us
  <br/>
  <br/>
 </strong>
 At ForHealth Consulting, part of
 <strong>
  UMass Chan Medical School
 </strong>
 , we are dedicated to advancing health and well-being across Massachusetts communities. Youll be part of a mission-driven organization that values collaboration, innovation, and compassion in care management.
 <br/>
 <br/>
 The University of Massachusetts Chan Medical School welcomes all qualified applicants and complies with all state and federal anti-discrimination laws.
 <br/>
 <br/>
</div>


Nurse Rev II-Case Mgt (Home Based with Client Visits)

Hines & Associates, Inc.

<div>Description:
<p><b>
Nurses &ndash; are you looking for a change? Want to work no nights, no weekends, and no holidays? Be able to work from home 50% of the time once trained? Check out Hines &amp; Associates!</b></p><p><b>
ABOUT US:</b></p><p>
Hines is a nationwide, independent leader in personalized managed health care, focused on what&rsquo;s important to you&mdash;comprehensive services with the program excellence and cost containment that you demand. Hines &amp; Associates, Inc.&rsquo;s reputation as an industry leader is founded on over three decades of innovative and professional health care excellence. Serving all aspects of the industry, Hines is committed to conserving health care dollars while ensuring quality care through effective programs and personalized service.</p><p><b>
WHAT WE OFFER:</b></p><ul><li>
Competitive salary and benefits, including medical, dental, vision, long-term care, short-term disability, long-term disability, company paid and voluntary life insurance. Critical Illness, accident insurance and flexible spending also available!</li><li>
401k plan with company match, fully vested after 1 year.</li><li>
No weekends and nights!</li><li>
Paid Holidays</li><li>
Work-life balance.</li><li>
Remote/hybrid setting (once trained)</li></ul><p><b>
ROLE DESCRIPTION:</b></p><p>
This individual will utilize clinical knowledge and communication skills to obtain patient specific information regarding patient condition and proposed treatments and procedures to determine if illness and/or proposed services meet acceptable criteria sets and acceptable nursing practice guidelines for outpatient treatment or inpatient confinement. This individual will certify treatment for confinement when criteria and/or practice guidelines are met, in accordance with the health benefit plan, disability, workers compensation regulations and state and federal regulations. If these conditions do not appear to be met, this individual will defer decision to a second level reviewer. This individual interfaces with case managers and disease management nurses on active cases involved in other Hines&rsquo; programs.</p><p><b>
*****This is a Monday through Friday position, 9:30 AM to 6:00 PM.******</b></p><p><b>
RESPONSIBILITIES AND PERFORMANCE</b>:</p><ul><li>
Completes first level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review. General Medical-Surgical nursing is sufficient to be relevant to the clinical areas addressed in most initial clinical reviews. .</li><li>
Demonstrates ability to assess a patient&rsquo;s current medical status, including complications and untoward events, which may require additional intervention. Provides certification of medical, disability and workers compensation cases.</li><li>
Demonstrates a thorough understanding of criteria sets and their limitations including when a second level review is required.</li><li>
Evaluates appropriateness of current plan of care.</li><li>
Assesses aftercare needs, implements discharge planning and/or case management referral in a timely manner.</li><li>
Maintains knowledge of current advances and trends in medical care.</li><li>
Demonstrates knowledge of URAC guidelines, Hines policies and procedures, and standards of practice and their revisions. Able to attain and maintain the minimal quality assurance performance standards.</li><li>
Demonstrates assertiveness in completion of precertification and concurrent review within the guidelines of URAC, disability, workers compensation regulations, and state and federal requirements and according to the Hines policies and procedures.</li><li>
Performs onsite evaluations as needed or requested.</li><li>
Additional responsibilities as assigned.</li></ul><p>
PM21</p><p><b>
COMMUNICATION:</b></p><ul><li>
Communicates with hospital staff, physicians, other providers and Hines customer contacts in a competent, calm, effective and professional manner.</li><li>
Effectively communicates the need to refer to a higher-level review for questionable plans of treatment.</li><li>
Provides written documentation concerning the clinical information obtained regarding the patient&rsquo;s status, benefit and claim concerns, and validation of criteria.</li><li>
Communicates knowledge of policies and procedures, URAC guidelines, disability and workers compensation regulations, state and federal requirements, and standards of practice.</li></ul><p><b>
PERSONAL AND PROFESSIONAL:</b></p><ul><li>
Participates in self-evaluation by identifying areas of strength and limitations and offers and accepts constructive criticism.</li><li>
Creative and assertive.</li><li>
All First Level Reviewers are required to sign and honor a confidentiality statement at the time of hire and annually at the time of performance reviews.</li></ul>
Requirements:
<p><b>
QUALIFICATIONS:</b></p><ul><li>
Registered Nurse with valid, unrestricted, current nursing license in the state or territory of the United States where employed. For mental health/substance abuse, licensed medical professional with an unrestricted license in the state or in a state that has licensure reciprocation with the state of the office location the employee is working in may perform first level reviews. Accepted licensure includes but is not limited to RN, LMSW, LMHC.</li><li>
Must have Mental Health or Substance Abuse experience.</li><li>
Successful completion of UR nurse orientation program.</li><li>
Minimum of 3 years recent acute clinical practice required, 5 years preferred.</li><li>
Managed care, disability or workers compensation experience helpful but not mandatory.</li><li>
Customer service oriented.</li></ul><p>
*Hines welcomes diversity and as an equal opportunity employer all qualified applicants will be considered regardless of race, religion, color, national origin, sex, age, sexual orientation, gender identity, disability or protected veteran status.*</p></div>

Behavioral Health Utilization Review Registered Nurse

Palm Medical Centers

<div><b>Position Summary:</b><br>
The <b>Concurrent Review Nurse</b> is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements.<br>
<br>
<b>Key Responsibilities:</b><ul><li>
Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care.</li><li>
Evaluate clinical documentation against evidence-based criteria (e.g., InterQual&reg;, MCG) to determine medical necessity and appropriate level of care.</li><li>
Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning.</li><li>
Communicate utilization review decisions and recommendations to providers and payers.</li><li>
Document all reviews, decisions, and communications in accordance with regulatory and organizational standards.</li><li>
Identify cases requiring escalation or peer review and follow established procedures.</li><li>
Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA.</li><li>
Participate in quality improvement initiatives and departmental meetings</li></ul><b>
Qualifications:</b><br>
<br>
<b>Education &amp; Licensure:</b><ul><li>
Registered Nurse (RN) license, active and in good standing, required.</li><li>
Associate or Bachelor&rsquo;s degree in nursing (BSN preferred).</li></ul><b>
Experience:</b><ul><li>
Minimum 2 years of clinical experience (e.g., med-surg, critical care).</li><li>
At least 1 year of utilization review, case management, or managed care experience preferred.</li></ul><b>
Skills &amp; Competencies:</b><ul><li>
Knowledge of InterQual&reg;, MCG, or other clinical review guidelines.</li><li>
Familiarity with Medicare/Medicaid and commercial insurance regulations.</li><li>
Strong analytical and clinical judgment skills.</li><li>
Effective communication and negotiation skills.</li><li>
Proficient with electronic medical records (EMRs) and utilization review platforms.</li><li>
Detail-oriented with excellent organizational skills.</li></ul><b>
Work Environment:</b><ul><li>
Remote</li></ul><p><br>
Palm Primary Care is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.<br>
<br>
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Primary Care makes hiring decisions based solely on qualifications, merit, and business needs at the time.</p><p>
</p><p>9cbfR8Lziz</p></div>

Concurrent Review Nurse

Tanaq Health

<div>
 <strong>
  Description
  <br/>
  <br/>
 </strong>
 <strong>
  Overview
  <br/>
  <br/>
 </strong>
 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.
 <br/>
 <br/>
 <strong>
  About The Role
  <br/>
  <br/>
 </strong>
 We are seeking a
 <strong>
  Clinical Appeals Reviewer
 </strong>
 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).
 <br/>
 <br/>
 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.
 <br/>
 <br/>
 <strong>
  Responsibilities
  <br/>
  <br/>
 </strong>
 <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.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Requirements
  <br/>
  <br/>
 </strong>
 <strong>
  Required Skills and Experience
  <br/>
  <br/>
 </strong>
 <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.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Education and Training
  <br/>
  <br/>
 </strong>
 <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.)
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Physical Requirements And Work Environment
  <br/>
  <br/>
 </strong>
 <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.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Who We Are
  <br/>
  <br/>
 </strong>
 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.
 <br/>
 <br/>
 <strong>
  Our Commitment to Non-Discrimination
  <br/>
  <br/>
 </strong>
 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.
 <br/>
 <br/>
 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.
 <br/>
 <br/>
 <strong>
  Notice on Candidate AI Usage
  <br/>
  <br/>
 </strong>
 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.
 <br/>
 <br/>
 <strong>
  To Apply For This Positions, Visit
  <br/>
  <br/>
 </strong>
 https://recruiting.paylocity.com/Recruiting/Jobs/Details/4071254
</div>


Clinical Appeals Reviewer (Licensed Healthcare Professional)

Trillium Health Resources

<div><div><b>Pay Plan Title: </b>Registered Nurse</div><div><b>
Working Title: </b>Registered Nurse, UM &ndash; Physical Health</div><div><b>
FLSA Status: </b>Exempt</div><div><b>
Posting Salary Range: </b>$66,240 - $88,595</div><div><b>
Office Location: </b>Remote within North Carolina.</div><div></div><div><b><br>
POSTING DETAILS:</b></div><div></div><div><b><br>
Make an Impact</b></div><div></div><div><br>
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.</div><div></div><div><b><br>
Why Work for Us</b>?</div><div></div><div><br>
Trillium believes that empowering others begins with supporting our team. We offer our employees:</div><div></div><div><br>
<ul><li>
A collaborative, mission-driven work environment</li><li>
Competitive benefits and work-from-home options for most positions</li><li>
Opportunities for professional growth in a diverse inclusive culture</li></ul></div><div></div><div><br>
Every day, our work changes lives &ndash; from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.</div><div></div><div><br>
If you are looking for a unique opportunity to make a tangible impact on the lives of others, apply today!</div><div></div><div><b><br>
What We&rsquo;re Looking For</b></div><div></div><div><br>
Trillium Health Resources has a career opening for a Registered Nurse to join our Utilization Management team! The Registered Nurse, UM &ndash; Physical Health, is responsible for ensuring timely and accurate determination and notification of reviews and reconsiderations based on the review determination status. The Registered Nurse, UM &ndash; Physical Health, will generate approval, modifications, and denials communications, to include member and provider notification of review determination. This position also facilitates, coordinates, and approves medically necessary reviews that meet established criteria.</div><div></div><div><b><br>
On a typical day, you might:</b></div><div></div><div><br>
<ul><li>
Perform prospective/preservice, concurrent, post-service, and retrospective claims medical review processes. Utilizing considerable clinical judgement, independent analysis, critical-thinking skills, and detailed knowledge of clinical coverage policies, clinical practice guidelines, and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identify cases needing Medical Director review or input. Present cases to Medical Director for potential review or determinations when needed.</li><li>
Perform telephonic admission and concurrent review, and collaborate with on-site facility staff, physicians, providers, care management, the member, and significant others to develop and implement a successful discharge plan, if contracted by client.</li><li>
Maintain accurate records in the designated medical management system and/or claims systems.</li><li>
Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.</li></ul></div><div></div><div><b><br>
Employee Benefits:</b></div><div></div><div><br>
Trillium knows that work/life balance is essential. That&rsquo;s why we offer:</div><div></div><div><br>
<ul><li>
Typical working hours: 8:30 am &ndash; 5:00 pm; flexible work schedules with some roles with management approval.</li><li>
Work-from-home options available for most positions</li><li>
Health Insurance with no premium for employee coverage</li><li>
Flexible Spending Accounts</li><li>
24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year</li><li>
NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook</li><li>
401k with 5% employer match and immediate vesting</li><li>
Public Service Loan Forgiveness (PSLF) qualifying employer</li><li>
Quarterly stipend for remote work supplies</li></ul></div><div></div><div><b><br>
Qualifications</b></div><div></div><div><br>
Required:</div><div><ul><li>
Fully licensed by the North Carolina State Board of Nursing as an RN.</li><li>
Minimum two (2) years of Utilization Management/Review experience, to include clinical acute inpatient care (ER, ICU, Med-Surg), behavioral health, compliance, or evidence-based clinical decision support tools (ex: MCG/InterQual).</li><li>
Must have a valid driver&rsquo;s license.</li><li>
Must reside within North Carolina.</li><li>
Must be able to travel within catchment as required.</li></ul></div><div></div><div><br>
Preferred:</div><div><ul><li>
Clinical experience in a managed care organization, health plan or hospital setting.</li><li>
Utilization Management certification.</li></ul></div><div></div><div><b><br>
Deadline for Application:</b> Monday, May 18, 2026 at 11:59pm</div><div></div><div><b><br>
How to Apply</b></div><div></div><div><br>
To be considered, submit your application and resume through our ADP Career Center. Your resume must include:</div><div></div><div><br>
<ul><li>
Employer name, dates of service (month/year), average hours worked per week, and essential job duties</li><li>
Education details (degree type, date awarded, institution, field of study)</li><li>
Licensure/certification information, if applicable</li></ul></div><div></div><div><br>
After submission, your resume will be reviewed to ensure it meets the essential criteria for the position. You&rsquo;ll be notified by HR regarding your application status as appropriate. All applicants will receive a final update once the recruitment cycle closes.</div><div></div><div><br>
Join our Talent Community through ADP to stay informed about future opportunities. Be sure to keep your resume updated in your profile.</div><div></div><div><b><br>
Trillium Health Resources is an Equal Employment Opportunity (EEO) employer and a drug-free workplace. All candidates must pass a drug test as a condition of employment.</b></div><div></div><div><i><br>
#Innovation #Technology #Careers #NorthCarolina #BehavioralHealth</i></div></div>

Registered Nurse, UM – Physical Health

Staffing Solutions Organization LLC (SSO)

Staffing Solutions Organization LLC (SSO), an affiliate of Public Consulting Group LLC (PCG), is focused on delighting clients with world-class managed staffing and talent consulting services. SSO is committed to a diverse workforce, which is a reflection of our clients and the people they serve.
<br><br>
Nurse Reviewer – State of Illinois
<br><b>Location:</b> Remote with on site visits across Illinois
<br>We are currently seeking Nurses who reside in Central Illinois - preferably in McLean and Sangamon Counties.
<br><br>
Position Overview
<br>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.
<br><br>
Duties & Responsibilities
<br><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
<br><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
<br>Experience
<br><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>
Education
<br><ul>
<li>Bachelor’s degree preferred</li>
</ul>
Certification
<br><ul>
<li>Active Illinois Registered Professional Nurse (RN) license required.</li>
</ul>
Working Conditions
<br><ul>
<li>Remote work with 2–3 on site provider visits per week throughout the state of Illinois.</li>
</ul>
Benefits (Through SSO)
<br>SSO offers a competitive benefits package that supports your health, financial well being, and long term growth, including:
<br><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
<br>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.
<br><br>
Compensation for roles at Staffing Solutions Organization LLC (SSO) varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience. As required by applicable law, SSO provides a reasonable range of compensation for this role. In addition, SSO provides a range of benefits for this role.
<br><br>
Applicants must be authorized to work in the U.S. This position is not eligible for work authorization sponsorship (including H-1B sponsorship) by SSO and under the federal laws relating to the F-1 STEM EAD program, this position is not eligible to support a STEM EAD extension application.
<br><br>
All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, marital status, age, national origin, protected veteran status, or disability. Staffing Solutions Organization LLC is an E-Verify participant.

Nurse Reviewer

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