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:
<div><b>
Acentra Health is looking for a Clinical Reviewer (SCA) 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 during beneficiary interaction and determine appropriateness for advocacy intervention in conjunction with contract requirements, critical thinking and utilize decision-making skills to assist with communicating determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA and other regulatory standards.</div><div></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 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><b><i>
*This position will be 25 hours/week*</i></b></p><p></p><div><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>
</div>Qualifications:
<div><b>
Required Qualifications</b></div><ul><li>
Active unrestricted LPN, RN or, Social Worker or other applicable State and/or Compact State clinical license</li><li>
Minimum three years of clinical experience in an acute or med-surgical environment</li><li>
Strong clinical assessment and critical thinking skills required</li><li>
Medical record abstracting skills required</li><li>
Excellent written and verbal communication skills</li><li>
Must be proficient in Microsoft Office and Internet/web navigation</li></ul><div><b>
Preferred Qualifications</b></div><ul><li>
Bachelor&rsquo;s Degree from an accredited college or university in a related field</li><li>
Some knowledge of Case Management, UR and/or Prior Authorization or related experience</li><li>
Experience in a behavioral health setting</li><li>
Bilingual</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>
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.icims.com</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><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>
Pay Range: USD $28.00 - USD $33.00 /Hr.</div>

Clinical Reviewer (Remote - SCA - 25 Hrs/Wk)

Expertise Forge Connections Pvt. Ltd.

<p><b>Job title: Physician Reviewer</b><br/><b>Schedule: M-F(8-5)</b><br/><b>Contract: 2+ Years</b><br/><b>Pay rate: $105/Hour on W2</b></p><p><b>Description:</b></p><ul><li>This position requires an initial time commitment of at least 4 weeks to undergo and complete training.</li><li>After training, physician medical reviewer will provide weekend coverage, 8-hour shifts per Saturday and/or Sunday per month. Goal productivity of at least 32 cases per weekend day. This is a remote position.</li><li>Physician medical reviewer evaluates clinical service requests based on company guidelines to make medical necessity determinations.</li></ul><p><b>Required Qualification(s): </b></p><ul><li>Must be board Certified, M.D. or D.O with an unrestricted physician license in a state or territory of the United States.</li><li>Must demonstrate basic computer skills.</li></ul><p>Job Type: Contract</p><p>Pay: $100.00 - $105.00 per hour</p><p>Expected hours: 40 per week</p><p>Benefits:</p><ul><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Referral program</li><li>Travel reimbursement</li><li>Vision insurance</li></ul><p>Work Location: Remote</p>

Physician Reviewer

iMPROve Health

<div><p>iMPROve Health is an seeking an <b>Orthopedic Surgery Non-Spine </b>physician to join our team in conducting independent medical reviews. As a peer reviewer, you&rsquo;ll play a vital role in enhancing the quality of health care by applying your clinical expertise to evaluate cases for medical necessity and quality of care.</p>
<p>This is a flexible, remote opportunity for clinicians who are passionate about maintaining the integrity of their specialty and supporting evidence-based practice.</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></p><p><b>EOE/VET/Disability</b></p></div>

Peer Reviewer - Orthopedic Surgery Non-Spine Physician - remote

The HIRD

<div>
 <p>
  <strong>
   Job Title:
  </strong>
  Medical Reviewer / Medical Quality Reviewer
 </p>
 <p>
  <strong>
   Location:
  </strong>
  Pune | NCR | Kolkata
 </p>
 <p>
  <strong>
   Working Model:
  </strong>
  Hybrid
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Qualifications:
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <ul>
  <li>
   MBBS (Medical Degree), preferably with a postgraduate qualification.
  </li>
  <li>
   Minimum
   <strong>
    2+ years of experience
   </strong>
   in clinical practice or pharmacovigilance (PV).
  </li>
  <li>
   Must hold valid
   <strong>
    Medical Doctor certification/licensure
   </strong>
   in the country of service.
  </li>
  <li>
   Experience in the pharmaceutical industry preferred.
  </li>
  <li>
   Working knowledge of
   <strong>
    international regulations and guidance documents
   </strong>
   related to worldwide reporting requirements (US/EU).
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Key Responsibilities:
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <ul>
  <li>
   Perform comprehensive
   <strong>
    medical review
   </strong>
   of cases, ensuring consistency and accuracy of information.
  </li>
  <li>
   Provide
   <strong>
    causality assessment
   </strong>
   and
   <strong>
    clinical evaluation comments
   </strong>
   as required.
  </li>
  <li>
   Support the preparation of
   <strong>
    clinical trial safety assessments
   </strong>
   ,
   <strong>
    regulatory submissions
   </strong>
   , and
   <strong>
    aggregate safety reports
   </strong>
   .
  </li>
  <li>
   Ensure compliance with
   <strong>
    pharmacovigilance regulations
   </strong>
   and company policies.
  </li>
  <li>
   Identify and resolve issues independently; escalate complex matters appropriately.
  </li>
  <li>
   Demonstrate strong
   <strong>
    analytical and decision-making skills
   </strong>
   in both routine and complex scenarios.
  </li>
  <li>
   Collaborate effectively within a
   <strong>
    matrix organization
   </strong>
   , working both independently and under supervision.
  </li>
  <li>
   Maintain high productivity, organization, and time management to meet regulatory compliance goals.
  </li>
  <li>
   Exhibit
   <strong>
    excellent oral and written communication
   </strong>
   in English.
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Skills &amp; Competencies
  </strong>
 </p>
 <ul>
  <li>
   Strong understanding of
   <strong>
    pharmacovigilance processes
   </strong>
   and
   <strong>
    safety data management
   </strong>
   .
  </li>
  <li>
   Proficiency in
   <strong>
    database management systems
   </strong>
   and computer applications.
  </li>
  <li>
   Excellent organizational and problem-solving skills.
  </li>
  <li>
   Ability to work under tight timelines while maintaining quality standards.
  </li>
 </ul>
 <p>
 </p>
</div>


Medical Doctor

Dane Street

<div><p>As Physician Reviewer/Advisor for Independent Medical Exams (IME), you will utilize 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><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 in a timely manner</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>
<li>Board certification required, active practice required</li>
</ul></li></ul><p></p><p>PLEASE BE AWARE: In the interest of the security of all parties, Dane Street will never conduct interviews via text or request checks from candidates for any reason including the purchase of equipment.</p><p></p><p><b>
Benefits</b></p><p><b>
Benefits</b></p><p></p><ul>
<li>Robust opportunity for supplemental income</li>
<li>Schedule flexibility and predictable work hours - You choose services and case types, dictate volume, and conduct exams and reviews based on your schedule availability</li>
<li>No doctor/patient relationship is established and no treatment is provided. These are advisory-only opinions.</li>
<li>Enhanced industry expertise strengthening your medical practice with medical necessity and utilization review/management expertise</li>
<li>Expanded credentials as an expert in Independent Medical Exams and physician advisor services</li>
<li>Fully prepped cases, streamlined case flow, transcription services at no cost, and user-friendly work portal</li></ul></div>

Board Certified-(M.D, D.O) Oklahoma City Immunology Advisor, Certified for IME

Adeptmed Healthcare Solutions

<p><b>Location:</b> Gurugram, Haryana<br/><b>Company:</b> AdeptMed Healthcare Solutions LLP<br/><b>Shift:</b> Night Shift (US Healthcare Process)<br/><b>Experience:</b> 4 &ndash; 9 years<br/><b>Working Days:</b> Monday to Friday</p><p><b>About the Role:</b></p><p>AdeptMed Healthcare Solutions LLP is hiring experienced <b>Nurse Auditors / Clinical Documentation Specialists</b> to join our growing US Healthcare team.<br/>You&rsquo;ll be responsible for reviewing clinical documentation, auditing medical records, and ensuring compliance with US healthcare standards.</p><p><b>Key Responsibilities:</b></p><ul><li>Review and audit clinical documentation in <b>EHR systems</b> for accuracy and completeness.</li><li>Identify and correct discrepancies in nursing notes, care plans, and assessments.</li><li>Ensure compliance with <b>MDS / PDPM</b> and other regulatory requirements.</li><li>Work closely with MDS coordinators, physicians, and facility staff to resolve documentation issues.</li><li>Prepare audit reports and recommend corrective actions.</li><li>Stay updated with <b>CMS</b> and <b>SNF compliance</b> guidelines.</li></ul><p><b>Qualifications:</b></p><ul><li><b>B.Sc. / M.Sc. Nursing</b> (AIIMS or equivalent preferred).</li><li><b>Registered Nurse (RN)</b> &ndash; India or International License (preferred).</li><li>4&ndash;9 years of experience in hospital, clinical, or documentation roles.</li><li>Prior experience in <b>clinical review / medical audit / DRG validation</b> preferred.</li><li>Excellent communication, analytical, and computer skills (MS Office, EHR).</li></ul><p><b>Perks &amp; Benefits:</b></p><ul><li>Competitive salary based on experience.</li><li>5-day working week (Saturday&ndash;Sunday off).</li><li>Growth opportunities in the <b>US Healthcare audit domain</b>.</li><li>Supportive and collaborative work environment.</li></ul><p>You can share your resume at Info@adeptmed.in or share your resume at 9220511288 ( onlywhatsapp )</p><p>Job Type: Full-time</p><p>Pay: &#8377;500,000.00 - &#8377;1,000,000.00 per year</p><p>Benefits:</p><ul><li>Flexible schedule</li><li>Health insurance</li><li>Leave encashment</li></ul><p>Work Location: In person</p>

Nurse Auditor / Clinical Documentation Specialist (Night Shift)

Abhinav Institute of Technology and Management

<p>Must be a certified nursing professional (GNM/B.Sc Nursing/MBBS/BAMS/BHMS) with a valid Indian medical/nursing degree - Mandatory</p><p>1&ndash;2 years of experience in a supervisory or quality role in a US healthcare BPO/KPO process (e.g., claims, RCM, utilization review) - Preferred</p><p>Strong understanding of US healthcare workflows such as claims adjudication, prior authorization, clinical documentation, or medical coding - Preferred</p><p>Excellent medical judgment and clinical knowledge to support case reviews, escalations, and documentation validations - Mandatory</p><p>Good communication skills to liaise between operations, QA teams, and US-based clients or providers</p><p>Experience in process audits, compliance checks, and training new hires on clinical guidelines</p><p>Familiar with HIPAA regulations, EMR/EHR systems, and US insurance terminologies and ICD/CPT codes - - Preferred</p><p>Job Type: Full-time</p><p>Pay: &#8377;30,000.00 - &#8377;40,000.00 per month</p><p>Work Location: In person</p>

Clinical Supervisor

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