clinical reviewer

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:
<p><b>
Acentra seeks a Clinical Reviewer to join our growing team.</b></p><p></p><p><b><br>
Job Summary:</b></p><p></p><p><br>
The purpose of this position is to review medical records against appropriate criteria in conjunction with contract requirements to determine medical appropriateness.</p><div></div><div><b><i><br>
**Shift hours will be 8:00am to 4:30pm EST including weekend and holiday rotations**</i></b></div><div></div><div><b><br>
Job 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 the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas.</li><li>
Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns.</li><li>
Functions as providers&rsquo; liaison and contact/resource person for provider customer service issues and problem resolution.</li><li>
Performs all applicable review types as workload indicates.</li><li>
Fosters positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process.</li><li>
Attends training and scheduled meetings and for maintenance and use of current/updated information for review.</li><li>
Cross trains and perform duties of other contracts to provide a 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><p></p><p><i><br>
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>
</p>Qualifications:
<p><b>
Required Qualifications/Experience:</b></p><ul><li>
Active unrestricted RN or, or other applicable State and/or Compact State clinical license per contract requirements.</li><li>
Requires a Bachelor&rsquo;s Degree from an accredited college or university in a related field.</li><li>
Must be able to work a schedule of 8:00am to 4:30pm EST including a weekend and holiday rotation.</li></ul><p><b>
Preferred Qualifications/Experience:</b></p><ul><li>
Knowledge of the organization of medical records, medical terminology, and disease process required.</li><li>
Strong clinical assessment and critical thinking skills required. Medical record abstracting skills required.</li><li>
Requires excellent written and verbal communication skills.</li><li>
Medical record abstracting skills required.</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 $28.00 - USD $32.00 /Hr.</div>

Clinical Reviewer - RN (SCA - Remote)

BHM Healthcare Solutions

<p>STATEMENT OF ROLE &amp; RESPONSIBILITY</p><p><b>POSITION TITLE: Psychiatric Physician Clinical Reviewer (Comfortable with ABA/Psychological Testing Reviews)</b></p><p><b>SCOPE OF ROLE &amp; RESPONSIBILITIES</b></p><ul><li>Clinical review of internal and/or external review cases for medical necessity, treatment appropriateness, or administrative compliance.</li><li>Thorough review of all submitted information, documentation of determination, clinical rationale, and citation of sources used to support decision within the specified timeframe.</li><li>Complete Peer-to-Peer phone calls with providers when scheduled.</li></ul><p><b>QUALIFICATION REQUIREMENTS</b></p><ul><li>Have current, non-restricted licensure or certification as required for clinical practice in a state of the United States.</li><li>Have at least five (5) years full-time equivalent experience providing direct clinical care to patients;</li><li>Have a scope of licensure or certification and professional experience that typically manages the medical condition, procedure, treatment, or issue and are clinical peers for each case under review.</li><li>If an M.D. or D.O. has board certification by the American Board of Psychiatry and Neurology.</li><li>If performing External Review, must meet all of the above and have experience providing direct clinical care to patients within the past three (3) years.</li><li>ABA sub-specialty and multiple state licensures are REQUIRED <b>(OR,DC, AR, DE, NJ, GA, SC, NH Preferred)</b></li></ul><p>Job Types: Part-time, Contract</p><p>Pay: $83,445.77 - $100,493.84 per year</p><p>Benefits:</p><ul><li>Flexible schedule</li></ul><p>Application Question(s):</p><ul><li>Are you licensed in multiple states? If so, please ensure they are listed on your resume. </li></ul><p>Work Location: Remote</p>

Multi-State Licensed Psychiatrist PRN Remote

Michigan Peer Review Organization

<div><p>iMPROve Health is seeking a <b>Cardiothoracic Surgeon</b> to serve as an <b>independent contractor (1099) </b>performing independent external medical reviews remotely on an ad hoc basis. As a peer reviewer, you will apply your clinical expertise to evaluate cases, specific to your specialty, medical necessity and/or standard of care, supporting efforts to enhance the overall quality and integrity of health care and your profession. Please note, this is not an employed position and our contracted fee is based on credential and specialty type.</p><p><b>
BENEFITS:</b></p><ul><li><b>
Make a Difference:</b> Use your clinical knowledge to improve the quality of care patients receive.</li><li><b>
Professional Recognition:</b> Join a network of highly respected experts in your specialty.</li><li><b>
Competitive Compensation:</b> Receive fair pay for your time and expertise.</li><li><b>
Protect Standards of Care:</b> Help uphold the integrity of your profession.</li><li><b>
Work Remotely:</b> Review cases from the convenience of your home or office.</li></ul><p><b>
DUTIES AND RESPONSIBILITIES:</b></p><ul><li>
Conduct objective, evidence-based peer reviews of clinical cases.</li><li>
Make final determinations regarding medical necessity and quality of care.</li><li>
Ensure decisions are fair, unbiased, and aligned with current standards of practice.</li><li>
Submit reviews in a timely and professional manner using the IT systems provided.</li></ul><p><b>
QUALIFICATIONS:</b></p><ul><li><b>
Medical License:</b> Must hold an unrestricted medical license in any U.S. state.</li><li><b>
Board Certification: </b>Required (if applicable), through a board recognized by:<ul><li>
The American Board of Medical Specialties (ABMS),</li><li>
The American Osteopathic Association (AOA), or</li><li>
Another nationally recognized board granting certification.</li></ul></li><li><b>
Clinical Experience:</b><ul><li>
Have at least five (5) years full-time equivalent experience providing direct clinical care to patients.</li><li>
Have experience providing direct clinical care to patients within the past three (3) years.</li><li>
Knowledgeable of the issue under review, or of the current, evidence-based clinical guidelines and novel treatments for the medical or behavioral health condition, disease, treatment, or procedure under review.</li><li>
Have the clinical expertise to manage the medical or behavioral health condition or disease under review.</li><li>
Must be actively engaged in direct or virtual patient care for at least 20 hours per week. Administrative work does not qualify.</li></ul></li></ul><p><b>
TECHNOLOGY REQUIREMENTS:</b></p><ul><li>
Reliable Wi-Fi access.</li><li>
Proficiency with Microsoft Word.</li><li>
Access to a computer compatible with iMPROve Health&rsquo;s IT systems.</li></ul><p><b>
OTHER REQUIREMENTS:</b></p><ul><li>
Must complete the electronic credentialing application and receive organizational approval prior to performing a case review.</li><li>
Must complete a conflict of interest attestation upon credentialing and prior to performing a case review.</li><li>
Active hospital medical staff privileges may be required, as applicable.</li><li>
Notify the organization in a timely manner of an adverse change in licensure or certification status, including board certification status.</li><li>
Cannot have current employment or affiliation with any Veterans Affairs (VA) hospital, health care system, or medical center if applying to perform VA-related peer reviews.</li></ul><p><b>
EOE/VET/Disability</b></p></div>

PEER REVIEWER - CARDIOTHORACIC SURGEON - REMOTE

Dane Street

<div><p>This telework opportunity allows you to customize your schedule and caseload within the week while maintaining client-mandated turnaround times. Our reviewers are compensated on a per-case basis as a 1099 independent contractor</p><p></p><p>
Physician Specialty: Medical Oncology
</p><p></p><p><b>JOB SUMMARY</b></p><p>
Utilizes clinical expertise, and reviews insurance appeals, and prospective and retrospective claims. The physician reviewer will provide an interpretation of the medical necessity of services provided by other healthcare professionals in compliance with client-specific policies, nationally recognized evidence-based guidelines, and standards of care.</p><p></p><p><b>
MAJOR DUTIES AND RESPONSIBILITIES:</b></p><ul>
<li>
Reviews all medical records and addresses each question posed by the client utilizing client-specific criteria or other nationally recognized evidence-based criteria</li>
<li>Ensures that the rationale for the determination is clear, concise, and contains adequate supporting documentation to substantiate the decision</li>
<li>Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews; refrains from using case studies, cohorts, and the like to make decisions due to their limited sample sizes</li>
<li>Provides copies of any criteria utilized in a review with the report on time</li>
<li>Returns cases on or before the due date and time</li>
<li>Makes telephone calls as mandated by the state and/or client specifics</li>
<li>Maintains proper credentialing and state licenses and any special certifications or requirements necessary to perform the job</li>
<li>Attends all required orientation and training</li>
<li>Performs other duties as assigned including identifying and responding to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits</li>
</ul><p></p><p><b>
PLEASE BE AWARE: In the interest of the security of both parties, please be aware that Dane Street will never conduct an interview via text or request checks from candidates for purchasing equipment.</b></p></div>

Board Certified Physician Reviewers - Medical Oncology

Elevance Health

<div>
 <strong>
  Location:
 </strong>
 This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
 <br/>
 <br/>
 Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
 <br/>
 <br/>
 A proud member of the Elevance Health family of brands, Carelon Health (formerly CareMore Health) offers clinical programs and primary care options for seniors. We are a team of committed clinicians and business leaders passionate about transforming American healthcare delivery.
 <br/>
 <br/>
 <strong>
  Work Hours:
 </strong>
 Monday - Friday (9:30 AM -6:00 PM Centeral)
 <br/>
 <br/>
 The
 <strong>
  Nurse Reviewer I
 </strong>
 is responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits. Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.
 <br/>
 <br/>
 <strong>
  How You Will Make An Impact
  <br/>
  <br/>
 </strong>
 <strong>
  Primary duties may include, but are not limited to:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
  </li>
  <li>
   Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.
  </li>
  <li>
   Notifies ordering physician or rendering service provider office of the preauthorization determination decision.
  </li>
  <li>
   Follows-up to obtain additional clinical information.
  </li>
  <li>
   Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.
  </li>
  <li>
   Other duties as assigned
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Minimum Qualifications
  <br/>
  <br/>
 </strong>
 Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required.
 <br/>
 <br/>
 <strong>
  Preferred Skills, Capabilities And Experiences
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Familiarity with Utilization Management Guidelines is preferred
  </li>
  <li>
   ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.
  </li>
  <li>
   BA/BS degree preferred.
  </li>
  <li>
   Previous utilization and/or quality management and/or call center experience preferred.
  </li>
  <li>
   Proficiency in Microsoft Office Products is strongly preferred
   <br/>
   <br/>
  </li>
 </ul>
 For candidates working in person or virtually in the below locations, the salary* range for this specific position is $34.69 to $54.41 (hourly)
 <br/>
 <br/>
 <strong>
  Location(s):
 </strong>
 California, Illinois, Minnesota
 <br/>
 <br/>
 In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
 <br/>
 <br/>
 <ul>
  <li>
   The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company&rsquo;s sole discretion, consistent with the law.
   <br/>
   <br/>
  </li>
 </ul>
 Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
 <br/>
 <br/>
 Who We Are
 <br/>
 <br/>
 Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
 <br/>
 <br/>
 How We Work
 <br/>
 <br/>
 At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
 <br/>
 <br/>
 We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
 <br/>
 <br/>
 Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
 <br/>
 <br/>
 The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
 <br/>
 <br/>
 Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
 <br/>
 <br/>
 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
</div>


Nurse Reviewer I

Cactus Communications

<div>
 We are currently looking for
 <strong>
  researchers, retired researchers, and former researchers
 </strong>
 who can perform peer reviews for journals and publishers.
 <br/>
 <br/>
 <strong>
  Note:
 </strong>
 You should be able to disclose your full name and affiliations with the publishers.
 <br/>
 <br/>
 <strong>
  WHAT YOU NEED to Have:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Doctorate (PhD/MD) or equivalent advanced degree in the subject area.
  </li>
  <li>
   At least two publications in the last two years in your field.
  </li>
  <li>
   Thorough understanding of research methodologies and ethical principles within the relevant discipline.
  </li>
  <li>
   Excellent analytical and critical thinking skills.
  </li>
  <li>
   Strong written communication skills with the ability to provide clear, concise, and constructive feedback.
  </li>
  <li>
   Ability to adhere to deadlines and manage time effectively.
  </li>
  <li>
   Commitment to maintaining confidentiality and objectivity.
  </li>
  <li>
   Prior experience as a peer reviewer for academic journals is highly desirable.
  </li>
  <li>
   Familiarity with online manuscript submission and review systems.
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  WHAT YOU WILL DO:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Assess Novelty: Assess whether the manuscript is original and adds new knowledge or insights to the field of study.
  </li>
  <li>
   Evaluate Study Design and Methodology: Assess whether the study design and methods are appropriate, comprehensive, and clearly described to ensure that the research can be accurately reproduced in the future.
  </li>
  <li>
   Literature Review: Check whether the manuscript thoroughly incorporates and cites relevant, up-to-date research in the field.
  </li>
  <li>
   Analyse Results and Conclusions: Evaluates whether the results are presented clearly and appropriately, and whether the conclusions are supported by the data and significant to the field.
  </li>
  <li>
   Providing Constructive Feedback: Provide constructive feedback, suggesting improvements or highlighting any flaws, omissions, or ethical concerns.
  </li>
  <li>
   Recommend Publication: Based on your evaluation, the journal editor will decide whether the manuscript should be accepted, revised, or rejected.
  </li>
 </ul>
</div>


Freelance Peer Reviewer - Obstetrics, Gynecology, and Reproductive Medicine

Trinity Health

<b>Employment Type:</b><br>
Full time
<br><br>
<b>Shift:</b><br>
<b>Description:</b><br>
Utilizes clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness and accuracy of medical record documentation through extensive record review.
<br><br>
Our Commitment
<br><br>
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Clinical Documentation Specialist Remote

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