clinical review nurse

Clever Care Health Plan

<div>
 Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California&rsquo;s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.
 <br/>
 <br/>
 Who Are We? ✨
 <br/>
 <br/>
 Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members&rsquo; culture and values.
 <br/>
 <br/>
 Why Join Us? 🏆
 <br/>
 <br/>
 We&rsquo;re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you&rsquo;ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.
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 <br/>
 <strong>
  Job Summary
  <br/>
  <br/>
 </strong>
 The Clinical Review Nurse evaluates medical records and clinical documentation to support the resolution of claims, member grievances, appeals, and quality-of-care concerns. Using clinical judgment and appropriate application of CMS regulations, Medicare Advantage requirements, and evidence-based guidelines, this role conducts retrospective clinical reviews and prepares complete, accurate, and audit-ready case files for Medical Director review and determination.
 <br/>
 <br/>
 Claims are defined as:
 <br/>
 <br/>
 <ul>
  <li>
   Initial payment determinations for covered Part C and Part D services
  </li>
  <li>
   Post-service claims requiring clinical review to support payment accuracy and benefit application
  </li>
  <li>
   Claims requiring medical necessity, level-of-care, or appropriateness-of-care assessment
  </li>
  <li>
   Claims involving retrospective review of medical records or clinical documentation
  </li>
  <li>
   Provider payment disputes requiring clinical validation (non-appeal)
  </li>
  <li>
   High-dollar, complex, or high-risk claims requiring clinical review prior to final determination
  </li>
  <li>
   Claims requiring coordination with Medical Management, Claims Operations, or Medical Director review
   <br/>
   <br/>
  </li>
 </ul>
 Appeals and Grievances are defined as:
 <br/>
 <br/>
 <ul>
  <li>
   Organization Determinations / Coverage Requests (pre-service)
  </li>
  <li>
   Part C reconsiderations (standard &amp; expedited)
  </li>
  <li>
   Part D redeterminations/coverage determinations (if applicable)
  </li>
  <li>
   Payment disputes/claim appeals (if in scope)
  </li>
  <li>
   Quality of Care grievances
  </li>
  <li>
   Appeal withdrawals/dismissals &amp; validity checks (authorized rep, timeliness, etc.)
   <br/>
   <br/>
  </li>
 </ul>
 The Clinical Review Nurse applies clinical acumen to assess medical necessity, appropriateness of care, and quality of services rendered; documents findings in designated medical management systems; and collaborates with non-clinical staff to ensure timely, compliant, and defensible case resolution.
 <br/>
 <br/>
 <strong>
  Essential Functions &amp; Job Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Provide clinical review support for claims, claim appeals, grievances, provider disputes, and quality of care grievances, including retrospective review of medical records and claims.
  </li>
  <li>
   Conduct clinical reviews to assess medical necessity, appropriateness of care, and quality of services rendered, using clinical judgment and applicable CMS guidelines, Medicare manuals, and plan policies.
  </li>
  <li>
   Prepare clear, concise clinical summaries and recommendations for Medical Director review, including identification of key clinical facts, regulatory considerations, and applicable coverage or clinical criteria.
  </li>
  <li>
   Support the preparation and review of Quality of Care (QOC) grievance cases for Medical Director evaluation, including identification of potential care issues, documentation gaps, and quality concerns.
  </li>
  <li>
   Apply nationally recognized clinical decision support tools and guidelines (e.g., InterQual, MCG, NCDs/LCDs, specialty society guidance) as applicable to clinical reviews.
  </li>
  <li>
   Review and interpret medical coding and billing information (CPT, HCPCS, ICD-10-CM/PCS, DRG, Revenue Codes) to support accurate clinical assessment.
  </li>
  <li>
   Identify missing or insufficient clinical documentation and coordinate with providers or internal departments to obtain additional information.
  </li>
  <li>
   Enter, maintain, and validate clinical documentation and review outcomes in medical management and case tracking systems.
  </li>
  <li>
   Ensure cases are prepared and routed within required CMS and contractual turnaround timeframes; maintain awareness of standard vs expedited timeframes and tolling requirements when records are pending.
  </li>
  <li>
   Escalates risks to prevent late determinations; escalates cases at risk of noncompliance same day when barriers arise (missing records, invalid auth rep, misrouted cases).
  </li>
  <li>
   Respond accurately and timely to Medical Directors, Claims, Appeals and Grievances staff, and other internal stakeholders regarding clinical findings.
  </li>
  <li>
   Assist with CTM-related clinical case review and provide clinical input to support compliant complaint resolution.
  </li>
  <li>
   Participate in audit readiness activities, including case file review, universe validation, and response to regulatory or oversight entity requests.
  </li>
  <li>
   Audit clinical reviews to ensure compliance with Claims, Appeals and Grievances, and medical management policies and procedures.
  </li>
  <li>
   Provide clinical guidance and act as a clinical resource to non-clinical staff.
  </li>
  <li>
   Participate in special projects related to Claims, Appeals and Grievances operations, quality improvement, or regulatory compliance.
  </li>
  <li>
   Participate in required training and assist with onboarding and education of new or existing staff as needed.
  </li>
  <li>
   Ensures all case documentation supports CMS audit and legal defensibility, including record inventory, clinical criteria citations, decision rationale, and accurate system time stamps.
  </li>
  <li>
   Differentiates and prioritizes standard vs expedited requests and applies tolling/extension rules as applicable per policy.
  </li>
  <li>
   Maintains HIPAA compliance and secure handling of PHI in all systems and remote work environments.
  </li>
  <li>
   Other duties as assigned.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Qualifications
  <br/>
  <br/>
 </strong>
 <strong>
  Qualifications
  <br/>
  <br/>
 </strong>
 <strong>
  Education &amp; Experience
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Graduate from an accredited school of nursing
  </li>
  <li>
   Active, unrestricted RN or LVN/LPN license
  </li>
  <li>
   Must hold a current CCS or CPC certificate; both are preferred
  </li>
  <li>
   Three (3) or more years of Appeals and Grievances and/or Utilization Management experience within a Health Plan, IPA, MSO, or managed care environment
  </li>
  <li>
   Demonstrated experience supporting Medicare Advantage Appeals and Grievances, including clinical appeal review and Medical Director case preparation
  </li>
  <li>
   Two (2) or more years of direct clinical nursing experience
  </li>
  <li>
   Knowledge of Medicare Advantage regulations related to claims, appeals, grievances, and quality of care reviews
  </li>
  <li>
   Experience applying clinical decision support tools (e.g., InterQual, MCG, NCDs/LCDs) and evidence-based guidelines
  </li>
  <li>
   Familiarity with medical coding and billing concepts (CPT, HCPCS, ICD-10, DRG, Revenue Codes)
  </li>
  <li>
   Knowledge of regulatory timelines to ensure compliance with CMS and state requirements
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Skills
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Strong clinical judgment and analytical skills
  </li>
  <li>
   Strong organizational skills with the ability to manage multiple cases and deadlines
  </li>
  <li>
   Excellent written and verbal communication skills, including clinical summary preparation
  </li>
  <li>
   Strong attention to detail and documentation accuracy
  </li>
  <li>
   Proficiency with Windows-based applications and Microsoft Office (Word, Excel, PowerPoint)
  </li>
  <li>
   Ability to adapt to new systems and regulatory requirements
  </li>
  <li>
   Excellent typing and documentation skills
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Wage Range:
 </strong>
 $38.46 to $48.00 per hour DOE and License
 <br/>
 <br/>
 <strong>
  Physical &amp; Working Environment.
  <br/>
  <br/>
 </strong>
 Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:
 <br/>
 <br/>
 <ul>
  <li>
   Must be able to travel when needed or required
  </li>
  <li>
   Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (notetaking)
  </li>
  <li>
   Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
   <br/>
   <br/>
  </li>
 </ul>
 Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.
 <br/>
 <br/>
 Work is performed in an office environment and/or remotely. When working remotely, the workspace must be HIPAA compliant:
 <br/>
 <br/>
 <ul>
  <li>
   HIPAA/PHI handling, minimum necessary access
  </li>
  <li>
   Secure remote work expectations (private workspace, locking screens, secure network, no printing unless authorized, etc.)
   <br/>
   <br/>
  </li>
 </ul>
 The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.
 <br/>
 <br/>
 <em>
  Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
  <br/>
  <br/>
 </em>
 <em>
  Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate&rsquo;s state residency.
 </em>
</div>


Grievance and Appeals Clinical Review Nurse (RN/LVN)

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

Hospital Sisters Health System

<p></p><div><p><b>Pay Range:</b></p>
$35.92 - $53.88<div><div><div><div><div><div><div><p>
A successful candidate's actual pay rate will be based on several factors including relevant experience, skills, training, certifications and education.</p></div></div></div></div></div></div></div><p></p>
HSHS Medical Staff Services is looking for a Clinical Review Specialist to join their team. This Registered Nurse (RN) will coordinate Medical Staff Professional Practice Evaluations and outcomes. A strong candidate will have a minimum of 3 years hospital experience.
<br>
<br>
This is a hybrid remote position - 3 days in office and 2 days remote per week<br>
<br>
Position Specifics:<br>
<ul><li>Department: Medical Staff Services</li><li>Core Function: Corporate Services</li><li>Schedule: Full time, 40 hrs/wk, Monday-Friday 7:30am- 4:00pm (flexible)</li><li>Facility: St. Vincent Hospital</li><li>Location: Green Bay, WI</li></ul><b>
Education Qualifications</b><ul><li>
Associate degree in nursing required.
</li><li>A Bachelor&rsquo;s degree in Nursing or related medical field is preferred.
</li></ul><b>Experience Qualifications</b><ul><li>
3 years nursing experience in acute care, critical care or emergency room required.
</li><li>2 years Quality/Process Improvement, Peer Review, Clinical informatics or Quality Assurance experience preferred.
</li></ul><b>Certifications, Licenses and Registrations</b><ul><li>
Licensed as a Registered Nurse (RN) in the state of practice is required. Wisconsin: RNs may practice with a valid multi-state RN license as outlined in the Nurse Licensure Compact rules.
</li><li>Certified Professional in Healthcare Quality (CPHQ) Preferred
</li></ul><p>Scheduled Weekly Hours:</p>
40<p>
Throughout communities in Illinois and Wisconsin, 13 hospitals, numerous community-based health centers and clinics, our 13,000+ colleagues have built a culture based on our solid core values of respect, care, competence, and joy. These are the ideals we believe in, work by, and live each day.</p><p></p><p>
Built upon more than 145 years of service to the communities we serve, we now look to the future and our place in it as a health care system that strives to continually improve processes, procedures, and outcomes with the latest and most advanced technologies and treatments.</p><p></p><p>
Regardless of how far our passion for excellence carries us, our focus will always remain on the most important person in our entire organization: The patient.</p><p></p><p><b>
Benefits: </b>HSHS provides a benefits package designed to support the overall well-being of our colleagues including their physical, emotional, financial, spiritual, and work health.<b> Colleagues budgeted to work at least 32 hours per pay period are eligible for HSHS benefits.</b></p><ul><li><p>
Comprehensive and affordable health coverage includes medical, prescription, dental and vision coverage for full-time and part-time colleagues.</p></li><li><p>
Paid Time Off (PTO) combines vacation, sick, and personal days into one balance to allow you the flexibility to use your time off as you need.</p></li><li><p>
Retirement benefits including HSHS<br>
contributions.</p></li><li><p>
Education Assistance benefits include up to $5,250 of educational assistance each calendar year and tuition discounts to select colleges with no waiting period.</p></li><li><p>
Adoption Assistance provides financial support up to $7,500 for colleagues growing their families through adoption to reimburse application and legal fees, transportation, and more!</p></li><li><p>
Other benefits include: Wellness program with incentives, employer-paid life insurance and short-term and long-term disability coverage, flexible spending accounts, employee assistance program, ID theft coverage, colleague rewards and recognition program, discount program, and more!</p></li></ul><p></p><p>
Benefits</p><p></p><p>
HSHS and affiliates is an Equal Opportunity Employer (EOE).</p><p></p><p>
HSHS is proud to be an equal opportunity workplace dedicated to pursuing and hiring a diverse workforce.</p></div>

Clinical Review Specialist (RN)

Molina Healthcare

JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.
<br><br>
Essential Job Duties
<br><br>
<ul>
<li>Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.</li>
<li>Analyzes clinical service requests from members or providers against evidence based clinical guidelines.</li>
<li>Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.</li>
<li>Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.</li>
<li>Processes requests within required timelines.</li>
<li>Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.</li>
<li>Requests additional information from members or providers as needed.</li>
<li>Makes appropriate referrals to other clinical programs.</li>
<li>Collaborates with multidisciplinary teams to promote the Molina care model.</li>
<li>Adheres to utilization management (UM) policies and procedures.</li>
</ul>
Required Qualifications
<br><br>
<ul>
<li>At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.</li>
<li>Registered Nurse (RN). License must be active and unrestricted in state of practice.</li>
<li>Ability to prioritize and manage multiple deadlines.</li>
<li>Excellent organizational, problem-solving and critical-thinking skills.</li>
<li>Strong written and verbal communication skills.</li>
<li>Microsoft Office suite/applicable software program(s) proficiency.</li>
</ul>
Preferred Qualifications
<br><br>
<ul>
<li>Certified Professional in Healthcare Management (CPHM).</li>
<li>Recent hospital experience in an intensive care unit (ICU) or emergency room.</li>
</ul>
<b>To all current Molina employees:</b> If you are interested in applying for this position, please apply through the Internal Job Board.
<br><br>
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
<br><b>Pay Range:</b> $23.76 - $51.49 / HOURLY
<br><ul>
<li>Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.</li>
</ul>


Care Review Clinician (RN)

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

Medi-Weightloss Clinics of Stamford & Wilton CT

<p><i><b>Position: </b></i><i>Nurse Practitioner/Physician Assistant</i><br/><i><b>Company: </b></i><i>Medi-Weightloss of Stamford &amp; Wilton Connecticut</i></p><p><i><b>About Us:</b></i><br/>Are you a passionate healthcare professional who values healthy living, quality of life, and work-life balance? Medi-Weightloss is thrilled to invite an exceptional Nurse Practitioner or Physician Assistant to join our dynamic team in a Part-Time/ PRN role, serving our clinic. This is a unique opportunity to provide top-tier medical care while enjoying the vibrancy of two diverse communities. If you're committed to excellence and compassionate patient care, we encourage you to apply.</p><p><i><b>Clinical Responsibilities:</b></i></p><ul><li>Obtain and review patient's medical and psychosocial history information relevant to patient care.</li><li>Conduct physical examinations according to company guidelines.</li><li>Order and review laboratory studies and diagnostic procedures, including ECGs.</li><li>Deliver Preventive Medicine Counseling, Program counseling, and Product and Supplement Education.</li><li>Adhere to prescription guidelines as per the collaborative agreement with the supervising physician.</li><li>Maintain required documentation for patient care and medication management in the EMR according to company standards.</li><li>Review patient progress and manage patient care accordingly.</li><li>Facilitate referrals to other healthcare professionals and medical facilities as necessary.</li><li>Conduct follow-up calls to patients to discuss progress and address concerns</li></ul><p><i><b>General Responsibilities</b></i><b>:</b></p><ul><li>Weekly review of Weight Tracker Report, Slipping Report, and assigned KPIs to provide clinical oversight and mentor clinical staff.</li><li>Serve as the company liaison for medical and clinical affairs at the locations.</li><li>Participate in ongoing training initiatives and serve as the in-house trainer for medical staff.</li><li>Seek opportunities to improve franchise clinical operations' efficiency, effectiveness, and capacity.</li><li>Develop strategic recommendations to support patient experience improvement initiatives.</li><li>Program Development &ndash; Participate in the launch of test pilots for new programs, services, and products.</li><li>Demonstrate strong project management skills and effectively develop and monitor project work plans.</li></ul><p><i><b>Who We Are:</b></i> Medi-Weightloss&reg; prides itself on its evidence-based approach to treatment through clinical research. We address the unique needs of patients affected by excess weight and obesity, recognizing obesity as a disease that requires a range of medical interventions. Our individualized treatment is supported by clinical research and translational science.</p><p><i><b>License/Certification:</b></i></p><ul><li>DEA Certification</li><li>CT Certified Nurse Practitioner (Required)</li><li>CT Physician Assistant License (Required)</li></ul><p>Job Types: Part-time, Per diem</p><p>Benefits:</p><ul><li>401(k)</li><li>401(k) matching</li><li>Employee discount</li></ul><p>Work Location: In person</p>

Nurse Practitioner or Physician Assistant

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