clinical reviewer

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)

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

TEEMA

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

Claims Reviewer

MCMC

<div><div><div><b>Ready for a Rewarding Career that Fits Your Lifestyle?</b>
</div></div><p></p><div><div>Imagine a job where you can keep your <b>clinical skills sharp</b>, tackle exciting challenges, AND work from the comfort of your own home. Sounds like the perfect mix, right?</div></div><p>
</p><p></p><div><div><b>MES</b> is looking for a <b>self-driven, high-performing Registered Nurse (RN) or Licensed Vocational Nurse (LVN)</b> to join our dynamic team as a <b>Clinical Quality Assurance Coordinator</b>. In this role, you&rsquo;ll ensure our <b>Peer Review case reports</b> are nothing short of exceptional&mdash;delivering top-notch quality and integrity, all while staying fully aligned with <b>client agreements</b>, <b>regulatory standards</b>, and <b>state and federal mandates</b>.</div></div><p>
</p><div><div>The position is <b>100% remote</b> with a schedule of<b> </b><b>Monday through Friday:</b></div></div><ul><li><div><b>
three days: 12-8:30PM EST
</b></div></li><li><div><b>two days: 8-4:30PM EST</b></div></li></ul><p>
</p><ul><li><div>Performs quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.</div></li><li><div>
Ensures clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.</div></li><li><div>
Ensures that all client instructions and specifications have been followed and that all questions have been addressed.</div></li><li><div>
Ensures each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications.</div></li><li><div>
Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.</div></li><li><div>
Ensure that the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report.</div></li><li><div>
Verifies that the peer reviewer has attested to only the fact(s) and that no evidence of reviewer conflict of interest exists.</div></li><li><div>
Ensures the provider credentials and signature are adhered to the final report.</div></li><li><div>
Identifies any inconsistencies within the report and contacts the Peer Reviewer to obtain clarification, modification or correction as needed.</div></li><li><div>
Assists in resolution of customer complaints and quality assurance issues as needed.</div></li><li><div>
Ensures all federal ERISA and/or state mandates are adhered to at all times.</div></li><li><div>
Provides insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.</div></li><li><div>
Promote effective and efficient utilization of company resources.</div></li><li><div>
Participate in various educational and or training activities as required.</div></li><li><div>
Perform other duties as assigned.</div></li></ul><p>
</p><div></div><div><div>If you&rsquo;re ready to make a real impact in healthcare, all while enjoying the flexibility of working remotely, we want to hear from you!
</div></div><p></p><ul><li><div>Active RN/LVN nursing license required.</div></li><li><div>
Must be a graduate of an accredited nursing program or related medical experience; bachelor's degree preferred.</div></li><li><div>
A minimum of two years clinical or related field experience; or equivalent combination of education and experience.
</div></li><li><div>Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.</div></li><li><div>
Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; Ability to compute rates and percentages.</div></li><li><div>
Must be a qualified typist with a minimum of 40 W.P.M</div></li><li><div>
Must be able to operate a general computer, fax, copier, scanner, and telephone.</div></li><li><div>
Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.</div></li><li><div>
Must possess excellent skills in English usage, grammar, punctuation and style.</div></li><li><div>
Ability to follow instructions and respond to upper managements&rsquo; directions accurately.</div></li><li><div>
Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.</div></li><li><div>
Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.</div></li><li><div>
Must be able to work independently, prioritize work activities and use time efficiently.</div></li><li><div>
Must be able to maintain confidentiality.</div></li></ul><p>
</p><p></p><div><div><b>MES Solutions</b> is a premier provider of independent medical examination and peer review services to the insurance, corporate, legal, and government sectors. Members of our credentialed medical panel conduct physical examinations or medical record reviews, delivering reports that assist clients in the resolution of automotive, disability, liability, and workers' compensation claims. MES has been providing services nationally since 1978 in accordance with the industry's highest standards of operating excellence and regulatory compliance.</div></div><p>
</p><p></p><div><div>Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.</div></div><div><div><b>
Equal Opportunity Employer - Minorities/Females/Disabled/Veterans</b></div></div><div><div><b><i>
MES offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.</i></b></div></div></div>

Clinical Quality Assurance Coordinator

Developmental Disabilities Ministries

<div><p>Job Summary:</p><p>
The Developmental Disability Nurse &ndash; Oversight provides clinical oversight and monitoring to ensure that individuals with intellectual and developmental disabilities receive quality, person-centered health services in compliance with Centers for Medicare &amp; Medicaid Services (CMS) guidelines and Department of Behavioral Health and Developmental Disabilities (DBHDD) standards. This role ensures that nursing and healthcare services delivered by providers align with regulatory expectations for safety, documentation, care coordination, and clinical best practices.</p><p>
Key Responsibilities:</p><ul><li><p>
Conduct oversight visits to group homes, and other service sites to assess compliance with DBHDD and CMS standards for nursing care and health services.</p></li><li><p>
Monitor and review health-related documentation, including Health Risk Screening Tools (HRST), Individual Service Plans (ISPs), medication administration records (MARs), incident reports, and nursing care plans.</p></li><li><p>
Write a care plan that addresses ROB (Risk, Obstacles, and Barriers)</p></li><li><p>
Provide clinical assessments and make recommendations to improve care delivery and mitigate risks to individuals served.</p></li><li><p>
Ensure implementation of person-centered planning and health services coordination.</p></li><li><p>
Participate in mortality reviews, incident investigations, and quality assurance activities as required.</p></li><li><p>
Collaborate to develop and monitor corrective action plans (CAPs) when deficiencies are identified.</p></li><li><p>
Educate staff on nursing best practices, state and federal requirements, and changes in policy related to health oversight.</p></li><li><p>
Act as a liaison between healthcare professionals, and family members.</p></li><li><p>
Maintain accurate and timely oversight documentation in accordance with agency protocols.</p></li><li><p>
Stay current with CMS, DBHDD, and state regulations affecting developmental disability nursing care.</p></li></ul><p>
Qualifications:</p><p>
Education and Licensure:</p><ul><li><p>
Registered Nurse (RN) licensed in the state of Georgia.</p></li><li><p>
Bachelor's Degree in Nursing (BSN) preferred; Associate&rsquo;s degree accepted with relevant experience.</p></li><li><p>
HRST Clinical Reviewer Certification (or willingness to obtain).</p></li></ul><p>
Experience:</p><ul><li><p>
Minimum of 3 years of nursing experience, including 2 years working with individuals with intellectual and/or developmental disabilities.</p></li><li><p>
Experience with Medicaid waiver services and familiarity with CMS oversight requirements.</p></li><li><p>
Prior experience in clinical quality assurance, case management, or regulatory compliance preferred.</p></li></ul><p>
Skills and Competencies:</p><ul><li><p>
Strong clinical judgment and knowledge of chronic disease management in IDD populations.</p></li><li><p>
Familiarity with CMS Quality Indicators and DBHDD Quality Management Systems.</p></li><li><p>
Excellent written and verbal communication skills.</p></li><li><p>
Ability to work independently and manage multiple oversight activities simultaneously.</p></li><li><p>
Proficiency in using electronic health records (EHR) and Microsoft Office Suite.</p></li></ul><p>
Working Conditions:</p><ul><li><p>
Frequent travel within assigned regions for onsite visits.</p></li><li><p>
Flexible work schedule may be required to accommodate operations.</p></li><li><p>
Remote documentation and administrative work may be allowed in accordance with agency policy.</p></li><li><p>
Monthly Assessments.</p></li></ul></div><p></p>

Part Time Agency Nurse

CorVel Corporation

<div><p>The Diagnostic Related Groups (DRG) Clinical Supervisor is responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves completing medical review forms, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination.</p>
<p>
This is a remote position.</p>
<p><b>
ESSENTIAL FUNCTIONS &amp; RESPONSIBILITIES:</b></p>
<ul>
<li>Supervises all daily activities of the DRG Clinical Auditors</li>
<li>Demonstrated knowledge of, ICD-10-CM and PCS codes, and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid with the ability to work independently with minimal supervision and demonstrate initiative</li>
<li>Completes DRG audits as needed</li>
<li>Responsible for the overall integrity of the quality of diagnosis and procedure codes verified by the clinical review nurses, for inpatient records and documentation received with the accompanied claim</li>
<li>Responsible for holding the DRG Clinical Auditors to the quota and error/accuracy rate</li>
<li>Assists with team coverage and provide support when needed</li>
<li>May be required to travel overnight and attend meetings or training</li>
<li>Additional duties as assigned</li></ul><br>
<p></p>
<p><b>
KNOWLEDGE &amp; SKILLS:</b></p>
<ul>
<li>Clinical knowledge of medical necessity rules</li>
<li>Working knowledge of HIPAA Privacy and Security Rules</li>
<li>Ability to build strong working relationships both internally and externally</li>
<li>Strong attention to detail</li>
<li>Must possess problem solving, critical thinking skills</li>
<li>Minimal typing experience</li>
<li>Excellent written and verbal communication skills</li>
<li>Ability to think and work independently, while working in an overall team environment</li>
<li>Ability to work in a fast paced/production environment</li>
<li>Proficient in Microsoft Office applications</li></ul><br>
<p></p>
<p><b>
EDUCATION &amp; EXPERIENCE:</b></p>
<ul>
<li>N./L.V.N. preferred</li>
<li>CCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCS</li>
<li>Proficient in Medicare, CMS guidelines and ICD-10 coding guidelines</li>
<li>Minimum of 3-5 years of inpatient/DRG auditing experience in a hospital setting and/or payer setting</li>
<li>A minimum of 2 years of supervisory experience dealing with clinical auditors is required</li>
<li>Experience with claims denials and appeals required</li></ul><br>
<p></p>
<p><b>
PAY RANGE:</b></p>
<p>
CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.</p>
<p>
For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.</p>
<p>
Pay Range: $77,960 &ndash; $120,368</p>
<p>
A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management</p>
<p>
In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.</p><br>
<p></p>
<p><b>
ABOUT CERIS:</b></p>
<p>
CERIS, a division of CorVel Corporation, a certified Great Place to Work&reg; Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).</p>
<p>
A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.</p>
<p><b>
CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.</b></p>
<p>
#LI-Remote</p></div>

Clinical Review Supervisor

Centene

<div><p>You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.<br>
</p><b>Position Purpose:</b> Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.<ul><li>
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care</li>
<li>Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member</li>
<li>Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered</li>
<li>Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines</li>
<li>Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings</li>
<li>Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members</li>
<li>Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines</li>
<li>Reviews member&rsquo;s transfer or discharge plans to ensure a timely discharge between levels of care and facilities</li>
<li>Collaborates with care management on referral of members as appropriate</li><li>
Performs other duties as assigned.</li>
<li>Complies with all policies and standards.</li></ul><p><b>
We are seeking a Clinical Review Nurse - Concurrent Review to join our team!</b></p><p><b>
The ideal candidate will bring expertise in:</b></p><p>
IL Nursing License
<br>
Concurrent Review
<br>
Inpatient Authorizations<br>
Discharge Planning<br>
Acute and/or Critical Care
<br>
Computer Savvy
<br>
Excellent Customer Service and Communication Skills</p><p><b>
Education/Experience:</b> Requires Graduate from an Accredited School of Nursing or Bachelor&rsquo;s degree in Nursing and 2 &ndash; 4 years of related experience. 2+ years of acute care experience required.<br>
<br>
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.<br>
Knowledge of Medicare and Medicaid regulations preferred.<br>
Knowledge of utilization management processes preferred.<br>
<br>
<b>License/Certification:</b></p><ul><li>
LPN - Licensed Practical Nurse - State Licensure required</li></ul>
Pay Range: $27.02 - $48.55 per hour<p>
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.</p><p>
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. 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 other characteristic protected by applicable law.</p><p><br>
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</p></div>

Clinical Review Nurse - Concurrent Review

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