medical review nurse

Machinify

<div>
 
 About Machinify
 
 
 
 In October 2025, Machinify acquired Performant and we are now part of the Machinify organization. Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, Machinify&rsquo;s AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We&rsquo;re reshaping healthcare payment through seamless intelligence.
 
 
 
 About The Opportunity
 
 
 
 Expected Hiring Range: $72-78k, may be adjusted to reflect applicant experience
 
 
 The
 
 Medical Review Nurse II - Readmissions
 
 primarily performs medical claims audit reviews. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government and Commercial Payers. You will work remotely in a fast paced and dynamic environment and be part of a multi-location team.
 
 
 
 Key Responsibilities
 
 
 
 <ul>
 <li>
 Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules.
 </li>
 <li>
 Document all findings referencing the appropriate policies and rules.
 </li>
 <li>
 Generate letters articulating audit findings.
 </li>
 <li>
 Supporting your findings during the appeals process if requested.
 </li>
 <li>
 Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.
 </li>
 <li>
 Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits.
 </li>
 <li>
 Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients.
 </li>
 <li>
 Work with the team to minimize the number of appeals; Suggest ideas that may improve audit workflows; Assist with QA functions and training team members.
 </li>
 <li>
 Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines.
 </li>
 <li>
 Interface with and support the Medical Director and cross train in all clinical departments/areas.
 </li>
 <li>
 Other duties as required to meet business needs.
 
 
 </li>
 </ul>
 
 Knowledge, Skills And Abilities Needed
 
 
 
 <ul>
 <li>
 Knowledge of insurance programs, particularly the coverage and payment rules.
 </li>
 <li>
 Ability to maintain high quality work while meeting strict deadlines.
 </li>
 <li>
 Excellent written and verbal communication skills.
 </li>
 <li>
 Ability to manage multiple tasks including desk audits and claims review.
 </li>
 <li>
 Must be able to independently use standard office computer technology.
 </li>
 <li>
 Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
 </li>
 <li>
 Effectively work independently and as a team, in a remote setting.
 
 
 </li>
 </ul>
 
 Required And Preferred Qualifications
 
 
 
 <ul>
 <li>
 Active unrestricted RN license in good standing, is required.
 </li>
 <li>
 Must not be currently sanctioned or excluded from the Medicare program by the OIG.
 </li>
 <li>
 Minimum of five (5) years diversified nursing experience providing direct care in an inpatient setting.
 </li>
 <li>
 One (1) or more years' experience performing medical records review.
 </li>
 <li>
 One (1) or more years' experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.
 </li>
 <li>
 Other qualifications may be required and would be discussed during an interview.
 
 
 </li>
 </ul>
 
 What We Offer
 
 
 
 Machinify offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually. For more information about our benefits package, please refer to our benefits page on our website or discuss with your Talent Acquisition contact during an interview.
 
 
 
 Physical Requirements &amp; Additional Notices
 
 
 
 
 If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required
 
 . Proof of such may be required prior to an offer being made. It is the Employee&rsquo;s responsibility to maintain this Internet access at their home office location.
 
 
 The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.
 
 
 <ul>
 <li>
 Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.
 </li>
 <li>
 Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).
 </li>
 <li>
 Regularly sit/stand 8 or more hours per day.
 </li>
 <li>
 Occasionally lift/carry/push/pull up to 10lbs.
 
 
 </li>
 </ul>
 
 Requirements
 
 
 
 Machinify is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position:
 
 
 <ul>
 <li>
 Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.
 </li>
 <li>
 Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.
 </li>
 <li>
 Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.
 </li>
 <li>
 Other requirements may apply.
 
 
 </li>
 </ul>
 All employees and contractors for Machinify may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times. Violations to Machinify's policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.
 
 
 Machinify is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Machinify will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you believe a reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Machinify&rsquo;s Human Resources team to discuss further.
 
 
 Our diversity makes Machinify unique and strengthens us as an organization to help us better serve our clients. Machinify is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.
 
 
 THIRD PARTY RECRUITMENT AGENCY SUBMISSIONS ARE NOT ACCEPTED UNLESS EXPLICITY AGREED TO IN WRITING
</div>

Medical Review Nurse - Readmissions

Novacore

<div>
 
 Why join the Novacore team?
 
 
 
 
 Because your next stellar chapter starts here &mdash; and we&rsquo;re building something bold and meaningful.
 
 
 
 At Novacore, we&rsquo;re not your average insurance company. We&rsquo;re a team of driven professionals passionate about redefining the specialty insurance experience for our agents, carrier partners &mdash; and for each other.
 
 
 We specialize in tailored solutions for niche industries, powered by advanced analytics, modern technology and a culture of innovation. Backed by strong leadership and strategic growth initiatives, Novacore is poised to scale and lead in the specialty insurance market.
 
 
 But at our core, we believe it&rsquo;s not just what we do &mdash; it&rsquo;s
 
 how
 
 we do it and
 
 who
 
 we do it with.
 
 
 Recognized as a top workplace, Novacore is a place where ambition is supported, growth is continuous and culture matters. From day one, you&rsquo;ll find mentorship, hands-on learning and clear paths for advancement. You&rsquo;ll grow your skills, expand your expertise and become even more exceptional &mdash; because when you succeed, we all do.
 
 
 
 We Offer
 
 
 
 <ul>
 <li>
 A collaborative, results-driven environment
 </li>
 <li>
 Competitive compensation and comprehensive benefits
 </li>
 <li>
 Year-round social and community events
 </li>
 <li>
 Ongoing mentorship and professional development
 </li>
 <li>
 Endless opportunities for upward mobility
 
 
 </li>
 </ul>
 So if you're ready to be part of something extraordinary &mdash; with a team that&rsquo;s transforming commercial insurance &mdash; we want to meet you.
 
 
 Reinsurance Nurse Case Manager
 
 
 
 Overview
 
 
 
 Carbon Stop Loss Solutions is a leading managing general underwriter (MGU) in the field of employer stop loss and managed care insurance.
 
 
 Carbon&rsquo;s team of experts are known as the industry leader in delivering best-in-class risk solutions to effectively lower healthcare costs. Carbon&rsquo;s offerings support clients and brokers in a rapidly changing healthcare market with best-in-class service, underwriting, claims support and effective cost containment strategies.
 
 
 Carbon Stop Loss Solutions makes up Novacore&rsquo;s Healthcare Segment.
 
 
 The Medical Review Nurse is a registered nurse who can assist Novacore&rsquo;s Claim and Underwriting Departments in managing risk and mitigating claims exposure.
 
 
 <ul>
 <li>
 We are open to candidates local to the Philadelphia-area Home Office or fully remote.
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Assist underwriters in the timely evaluation of clinical and claim data during the disclosure process to identify potential risk.
 </li>
 <li>
 Work with Third-Party Administrators and producers as a medical resource for discussion and assistance with potential catastrophic claim management.
 </li>
 <li>
 Assist Case Managers, either employed by Carbon&rsquo;s TPAs, or with outside firms, with high dollar catastrophic claimants.
 </li>
 <li>
 Evaluate claims reporting for potential exposure and reserve recommendations.
 </li>
 <li>
 Clinical review and claims analysis to assess claim trends and possible group resources.
 </li>
 <li>
 Maintain patient confidentiality in compliance with standards set forth by Carbon as well as HIPAA.
 </li>
 <li>
 Work with the department manager in seeking and employing new business partners to promote health care resources and mitigate claims exposure.
 </li>
 <li>
 Serve as a back-up for other department medical staff as needed.
 </li>
 <li>
 Maintain licensure and certifications as indicated to promote personal professional advancement.
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Registered Nurse active license required - BSN preferred.
 </li>
 <li>
 CCM certification, preferred.
 </li>
 <li>
 At least one year of acute care clinical experience.
 </li>
 <li>
 UM or CM experience on either the payer or provider side.
 </li>
 <li>
 Prior TPA, MGU or Stop loss carrier experience is highly preferable.
 </li>
 <li>
 Prior experience analyzing health care claims and coding.
 </li>
 <li>
 Prior experience working with catastrophic health care claims.
 </li>
 <li>
 Experience with data entry and analysis of medical reporting.
 </li>
 <li>
 Provide risk assessment and communicate the analysis succinctly in reporting.
 </li>
 <li>
 Ability to conduct independent medical research as an adjunct to medical underwriting tasks.
 </li>
 <li>
 Ability to meet tight time frames.
 </li>
 <li>
 Strong organizational and time management skills.
 </li>
 <li>
 Ability to work independently in a remote setting.
 </li>
 <li>
 Ability to work with multiple offices and underwriters and prioritize time frames.
 </li>
 <li>
 Proficient with MS Office software. Ability to communicate effectively and professionally both internally and with external clients.
 </li>
 </ul>
</div>

Medical Review Nurse (Insurance)

Performant Financial Corporation

<div>ABOUT MACHINIFY:
In October 2025, Machinify acquired Performant and we are now part of the Machinify organization. Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, Machinify&rsquo;s AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We&rsquo;re reshaping healthcare payment through seamless intelligence.
ABOUT THE OPPORTUNITY:
Expected Hiring Range: $84,000 - $100,000 (based on experience)
The Medical Review Nurse II - SNF/MDS primarily performs medical claims audit reviews. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government and Commercial Payers. You will work remotely in a fast paced and dynamic environment and be part of a multi-location team.
Key Responsibilities:<ul><li>
Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules.</li><li>
Document all findings referencing the appropriate policies and rules.</li><li>
Generate letters articulating audit findings.</li><li>
Supporting your findings during the appeals process if requested.</li><li>
Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.</li><li>
Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits.</li><li>
Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients.</li><li>
Work with the team to minimize the number of appeals; Suggest ideas that may improve audit workflows; Assist with QA functions and training team members.</li><li>
Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines.</li><li>
Interface with and support the Medical Director and cross train in all clinical departments/areas.</li><li>
Other duties as required to meet business needs.</li></ul>
Knowledge, Skills and Abilities Needed:<ul><li>
Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.</li><li>
Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding.</li><li>
Knowledge of insurance programs program, particularly the coverage and payment rules.</li><li>
Ability to maintain high quality work while meeting strict deadlines.</li><li>
Excellent written and verbal communication skills.</li><li>
Ability to manage multiple tasks including desk audits and claims review.</li><li>
Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.</li><li>
Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload</li><li>
Effectively work independently and as a team, in a remote setting.</li></ul>
Required and Preferred Qualifications:<ul><li>
Active unrestricted RN license in good standing, is required.</li><li>
Must not be currently sanctioned or excluded from the Medicare program by the OIG.</li><li>
Minimum of five (5) years diversified nursing experience providing direct care in an inpatient or outpatient setting.</li><li>
One (1) or more years' experience performing medical records review.</li><li>
One (1) or more years' experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.</li><li>
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.</li></ul>
WHAT WE OFFER:
Machinify offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually. For more information about our benefits package, please refer to our benefits page on our website or discuss with your Talent Acquisition contact during an interview.
Physical Requirements &amp; Additional Notices:
If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required. Proof of such may be required prior to an offer being made. It is the Employee&rsquo;s responsibility to maintain this Internet access at their home office location.
The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.<ul><li>
Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.</li><li>
Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).</li><li>
Regularly sit/stand 8 or more hours per day.</li><li>
Occasionally lift/carry/push/pull up to 10lbs.</li></ul>
Machinify is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position:<ul><li>
Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.</li><li>
Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.</li><li>
Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.</li><li>
Other requirements may apply.</li></ul>
All employees and contractors for Machinify may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times. Violations to Machinify's policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.
Machinify is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Machinify will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you believe a reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Machinify&rsquo;s Human Resources team to discuss further.
Our diversity makes Machinify unique and strengthens us as an organization to help us better serve our clients. Machinify is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.
THIRD PARTY RECRUITMENT AGENCY SUBMISSIONS ARE NOT ACCEPTED UNLESS EXPLICITY AGREED TO IN WRITING</div>

Medical Review Nurse - SNF/MDS Auditor (Government-CMS RAC))

CVS Health

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.
Position Information
Schedule: Monday&ndash;Friday 8:00am-5:00pm EST
Location: 100% Remote (U.S. only)
About Us
American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members.
Position Summary
Join a team that&rsquo;s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Medical Review, you&rsquo;ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers.
This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect.
Key Responsibilities<ul><li>
Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases.</li><li>
Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client.</li><li>
Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed.</li><li>
Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback.</li><li>
Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs.</li><li>
Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction.</li><li>
Must be able to work independently without personal distractions to meet quality and metric expectations.</li></ul>
Remote Work Expectations<ul><li>
This is a 100% remote role; candidates must have a dedicated workspace free of interruptions.</li><li>
Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.</li></ul>
Required Qualifications<ul><li>
Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed.</li><li>
Minimum 3 years of clinical experience.</li><li>
5 years demonstrated to make thorough independent decisions using clinical judgement.</li><li>
5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems.</li><li>
1+ Year of Utilization Review Management and/or Medical Management experience.</li><li>
Commitment to attend a mandatory 3-week training (Monday&ndash;Friday, 8:30am&ndash;5:00pm EST) with 100% participation.</li></ul>
Preferred Qualifications<ul><li>
Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity.</li><li>
MCG Milliman, CPB or other criteria guideline application experience is preferred.</li></ul>
Education
<ul><li>Associate's degree in nursing (RN) required, BSN preferred.</li></ul>
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$29.10 - $62.32
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 04/24/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Utilization Management Nurse Consultant - Medical Review (Remote)

Blue Cross Blue Shield

<div><h1 class="jobSectionHeader">Summary
 
</h1>We are currently hiring for an RN Medical Reviewer III to join BlueCross BlueShield of South Carolina. In this role as an RN Medical Reviewer III, you will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines, document decisions using indicated protocol sets or clinical guidelines, and provide support and review of medical claims and utilization practices.
<h1 class="jobSectionHeader"> 
Description 
 
</h1>Location:
This position is full-time (40 hours/week) Monday-Friday, working an 8-hour shift between 6:00am &ndash; 5:00pm and will be fully remote after 1-2 weeks of on-site training in Columbia, SC.
What You&rsquo;ll Do:
<ul><li>Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process&rsquo;s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.
</li><li>Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
</li><li>Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management.
</li></ul>To Qualify for This Position, You'll Need the Following:
<ul><li>Required Education: Associates in a job-related field
</li><li>Degree Equivalency: Graduate of Accredited School of Nursing
</li><li>Required Experience: 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience.
</li><li>Required Skills and Abilities: Working knowledge of managed care and various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same.
</li><li>Working knowledge of word processing software.
</li><li>Ability to work independently, prioritize effectively, and make sound decisions.
</li><li>Good judgment skills.
</li><li>Demonstrated customer service and organizational skills.
</li><li>Demonstrated oral and written communication skills.
</li><li>Ability to persuade, negotiate, or influence others.
</li><li>Analytical or critical thinking skills.
</li><li>Ability to handle confidential or sensitive information with discretion.
</li><li>Required Software and Tools: Microsoft Office.
</li><li>Required Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.
</li></ul>What We Prefer You to Have:
<ul><li>Preferred Work Experience: Well-rounded adult, clinical experience (i.e., medical-surgical, ER, critical care)
</li><li>Preferred Skills and Abilities: Knowledge of spreadsheet and database software.
</li><li>Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review.
</li><li>Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet database software.
</li></ul>Our Comprehensive Benefits Package Includes the Following:
We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.
<ul><li>Subsidized health plans, dental and vision coverage
</li><li>401k retirement savings plan with company match
</li><li>Life Insurance
</li><li>Paid Time Off (PTO)
</li><li>On-site cafeterias and fitness centers in major locations
</li><li>Education Assistance
</li><li>Service Recognition
</li><li>National discounts to movies, theaters, zoos, theme parks and more
</li></ul>What We Can Do for You:
We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.
What To Expect Next:
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information .
Some states have required notifications. Here's more information .</div>

RN Medical Reviewer III (W@H South Carolina)

The Healing Hands Clinic

MUST BE LICENSED IN or reside within 25 miles of Chipley, FL.We are looking for a Physician to review and provide support care for a provider looking to provide microneedling and medical grade skin care services.<ul><li>Be available for telephone consultations with nurse</li><li>Accept Telehealth consults if needed</li><li>Review any charts, if required by the state</li><li>Review and sign administrative documents for practice</li><li>Maintain malpractice insurance</li></ul>Skills<ul><li>Proven experience as a physician</li><li>Supportive of nurse practitioner and nurse business owners</li><li>In-depth knowledge of legal medical guidelines and medicine best practices</li><li>Respect for patient&rsquo;s confidentiality</li><li>Compassionate and approachable</li><li>Responsible and trustworthy</li><li>MD or DO degree and valid license to practice the profession</li></ul>Job Types: Full-time, Part-time, ContractPay: From $750.00 per monthBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Flexible schedule</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Work Location: On the road

Consulting Dermatologist

MUST BE LICENSED IN CALIFORNIAWe are looking for a Physician to review and provide support care for a provider looking to provide weight loss services.<ul><li>Be available for telephone consultations with nurse</li><li>Accept Telehealth consults if needed</li><li>Review any charts, if required by the state</li><li>Review and sign administrative documents for practice</li><li>Maintain malpractice insurance</li></ul>Skills<ul><li>Proven experience as a physician</li><li>Supportive of nurse practitioner and nurse business owners</li><li>In-depth knowledge of legal medical guidelines and medicine best practices</li><li>Respect for patient&rsquo;s confidentiality</li><li>Compassionate and approachable</li><li>Responsible and trustworthy</li><li>MD or DO degree and valid license to practice the profession</li></ul>Job Types: Full-time, Part-time, ContractPay: From $750.00 per monthBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Flexible schedule</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Work Location: On the road

Consulting Physician

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