medical reviewer

Broadway Ventures

<div><div><div><div><p>At <b>Broadway Ventures</b>, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth. Built on integrity, collaboration, and excellence, we're more than a service provider&mdash;we're your trusted partner in innovation.</p>
</div>
</div></div><p></p><p><b>Max Salary: W-2 ($65,000/$31.25)</b></p>
<p><b>
Job Type</b>: Full-time (40 hours/week)<br>
<b>Schedule</b>: <b>Monday&ndash;Friday, 8:00 AM &ndash; 5:00 PM EST (core hours)</b><br>
<b>Location</b>: Remote (U.S. &ndash; Work from home)<br>
<b>Remote Work Requirements</b>: High-speed internet (non-satellite) and a private, lockable home office<br>
<b>Equipment</b>: You will be provided with all necessary equipment to perform your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.</p>
<p><b>
About the Role:</b></p>
<p>
We are seeking a dedicated <b>Registered Nurse (RN)</b> to join our <b>Medical Review team</b>. This role involves conducting <b>pre- and post-payment medical reviews</b> to ensure compliance with established clinical criteria and guidelines. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting decisions in accordance with regulatory and organizational requirements.</p>
<p><b>
Key Responsibilities:</b></p>
<ul>
<li>Review <b>medically complex claims</b>, pre-authorization requests, appeals, and fraud/abuse referrals.</li>
<li>Assess payment determinations using clinical information and established guidelines.</li>
<li>Evaluate <b>medical necessity, appropriateness, and reasonableness</b> for coverage and reimbursement.</li>
<li>Provide clear, well-documented rationales for service approvals or denials.</li>
<li>Educate internal and external teams on <b>medical review processes, coverage determinations, and coding requirements</b>.</li>
<li>Support quality control activities to meet corporate and team objectives.</li>
<li>Assist with <b>special projects and additional responsibilities</b> as assigned.</li>
</ul>
<p><b>Minimum Qualifications:</b></p>
<p><b>
Licensure:</b></p>
<ul>
<li>Active, unrestricted RN license in the U.S. and in the state of hire<br>
<b>OR</b></li>
<li>Active <b>compact multistate RN license</b> (as defined by the Nurse Licensure Compact).</li>
</ul>
<p><b>Education:</b></p>
<ul>
<li>Associate Degree in Nursing<br>
<b>OR</b></li>
<li>Graduate of an accredited School of Nursing.</li>
</ul>
<p><b>Experience:</b></p>
<ul>
<li><b>Two years</b> of clinical experience <b>plus</b> at least <b>two years</b> in one of the following:</li>
<li><ul><li><b>Inpatient/Outpatient settings (i.e. medical-surgical, rehabilitation, SNF, etc..)</b></li>
<li><b>Utilization/Medical Review</b></li>
<li><b>Quality Assurance</b></li>
</ul></li>
</ul><p><b>Skills &amp; Competencies:</b></p>
<ul>
<li>Strong clinical background in <b>managed care and/or inpatient/outpatient</b></li>
</ul>
<p><b> settings</b>.</p>
<ul>
<li>Ability to interpret and apply <b>medical review criteria and clinical guidelines</b>.</li>
<li>Proficiency in <b>Microsoft Office</b> and word processing software.</li>
<li>Strong <b>analytical, organizational, and decision-making skills</b>.</li>
<li>Ability to work independently while managing priorities effectively.</li>
<li>Excellent <b>customer service, communication, and critical thinking skills</b>.</li>
<li>Ability to handle confidential information with discretion.</li>
</ul>
<p><b>Preferred Qualifications:</b></p>
<ul>
<li><b>Three years</b> of clinical nursing experience in <b>Inpatient/Outpatient settings, Utilization Review, Medical Review, or Quality Assurance</b> (strongly preferred).</li>
<li>Proficiency in using multiple screens and software programs simultaneously.</li>
<li>Training and experience in ICD coding.</li></ul><br>
<p></p>
<p></p><div>
<p><b>What to Expect Next:</b></p>
<p>
After submitting your application, our recruiting team will review your qualifications. This may include a brief telephone interview or email communication to verify resume details and discuss compensation expectations. Interviews will be conducted with the most qualified candidates. Broadway Ventures conducts background checks and drug testing prior to the start of employment. Some positions may also require fingerprinting.</p>
<p>
Broadway Ventures is an equal opportunity employer and a VEVRAA federal contractor. We do not discriminate against applicants or employees on the basis of race, color, religion, sex, national origin, age, disability, protected veteran status, or any other status protected by applicable law.</p>
<p>
Reasonable accommodations are available for applicants with disabilities. Broadway Ventures utilizes the OFCCP-approved Voluntary Self-Identification of Disability Form (CC-305).</p></div></div><p></p>

Remote RN – Medical Claims 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 - LPN/LVN or RN (remote U.S.) to join our growing team.</b></div><div><b><br>
Job Summary:</b></div><div></div><div><br>
The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements.</div><div></div><div><b><br>
***This position is remote within the United States, but applicants must be clinically licensed for the State of Indiana or have a compact license.***</b></div><div></div><div><b><br>
***Work Schedule: Five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays***</b></div><div><b><br>
Responsibilities:</b></div><ul><li>
Assures accuracy and timeliness of all applicable review type cases within contract requirements.</li><li>
Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department.</li><li>
In collaboration with Supervisor, responsible for quality monitoring activities.</li><li>
Maintains current knowledge base related to review processes and clinical practices.</li><li>
Functions as providers' liaison for customer service issues and problem resolution.</li><li>
Performs all applicable review types as workload indicates.</li><li>
Fosters positive and professional relationships with internal and external customers.</li><li>
Attends training and scheduled meetings for current/updated information.</li><li>
Cross trains to provide flexible workforce to meet client/customer needs.</li><li>
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.</li></ul><div><i>
The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.</i></div>
Qualifications:
<div><b>
Required Qualifications:</b></div><ul><li>
Active, unrestricted LPN/LVN or RN license in the state of Indiana or a Compact state clinical license.</li><li>
Associate's degree (bachelor's preferred) or Practical/Professional nursing diploma from an accredited nursing school, college, or university.</li><li>
2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience.</li><li>
2+ years of medical necessity review experience.</li><li>
1+ years of InterQual criteria and/or Milliman Care Guidelines (MCG) experience.</li><li>
Knowledge of medical records, medical terminology, and disease processes.</li><li>
Strong clinical assessment and critical thinking skills.</li><li>
Excellent written and verbal communication skills.</li><li>
Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively.</li><li>
Flexibility and strong organizational skills.</li><li>
Ability to work five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays.</li></ul><div><b>
Preferred Qualifications:</b></div><ul><li>
3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment.</li><li>
Knowledge of current National Committee for Quality Assurance (NCQA) standards.</li><li>
Knowledge of Utilization Review Accreditation Commission (URAC) standards.</li><li>
Ability to work in a team environment.</li><li>
Proficient in Microsoft Office.</li><li>
Efficient time management, including the ability to prioritize tasks, and meet deadlines.</li><li>
Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance when assessing relevant issues.</li></ul><div><b>
Why us?</b></div><div></div><div><br>
We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.</div><div></div><div><b><br>
We do this through our people.</b></div><div></div><div><br>
You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.</div><div></div><div><b><br>
Benefits</b></div><div></div><div><br>
Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.</div><div></div><div><b><br>
Compensation</b></div><div></div><div><br>
The pay range for this position is listed below.</div><div></div><div><br>
&ldquo;Based on our compensation philosophy, an applicant&rsquo;s position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.&rdquo;</div><div></div><div><b><br>
Thank You!</b></div><div></div><div><br>
We know your time is valuable and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may be of interest. Best of luck in your search!</div><div></div><div><br>
~ The Acentra Health Talent Acquisition Team</div><div></div><div><br>
Visit us at https://careers.acentra.com/jobs</div><div></div><div><b><br>
EEO AA M/F/Vet/Disability</b></div><div></div><div><br>
Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.</div>
Pay Range: USD $28.37 - USD $39.19 /Hr.</div>

Clinical Reviewer - LPN/LVN or RN

Staffing Solutions Organization LLC (SSO)

Staffing Solutions Organization LLC (SSO), an affiliate of Public Consulting Group LLC (PCG), is focused on delighting clients with world-class managed staffing and talent consulting services. SSO is committed to a diverse workforce, which is a reflection of our clients and the people they serve.
<br><br>
Nurse Reviewer – Illinois
<br><b>Location:</b> Remote with on site visits across Illinois
<br><br>
Position Overview
<br>The Nurse Reviewer conducts provider compliance reviews to ensure adherence to state regulations, quality standards, and program requirements. This role includes conducting onsite visits, evaluating documentation, and determining provider compliance. The Nurse Reviewer works independently, exercises sound judgment, and provides recommendations that guide provider improvement and support statewide oversight efforts.
<br><br>
Duties & Responsibilities
<br><ul>
<li>Build and maintain effective relationships with providers and users to support high quality customer service.</li>
<li>Evaluate providers for compliance with applicable state and program regulations.</li>
<li>Coordinate and schedule on site provider visits; clearly communicate visit requirements.</li>
<li>Conduct compliance interviews with providers and gather all necessary information.</li>
<li>Review provider documentation, policies, and business practices for regulatory alignment.</li>
<li>Collect, organize, and submit documentation supporting compliance findings.</li>
<li>Utilize technology and web based systems to convert paper documentation to electronic format.</li>
<li>Conduct in person assessments of provider sites to evaluate compliance with oversight requirements.</li>
<li>Summarize on site visit findings accurately and professionally.</li>
<li>Exercise independent judgment to evaluate compliance and make final determinations based on documented evidence.</li>
<li>Identify deficiencies and recommend appropriate next steps to support provider improvement.</li>
<li>Analyze trends in non compliance and identify gaps in provider business processes.</li>
<li>Provide timely recommendations and updates to the Supervisor.</li>
<li>Maintain HIPAA standards and confidentiality at all times.</li>
<li>Perform other duties as assigned.</li>
</ul>
Required Skills
<br><ul>
<li>Strong interpersonal skills with the ability to relate well to staff and providers.</li>
<li>Active listening and effective communication skills.</li>
<li>Proficiency in MS Word, Excel, Outlook, and web based applications.</li>
<li>Process oriented and results driven work approach.</li>
<li>Ability to foster teamwork and collaborate across levels of management and staff.</li>
<li>Ability to work independently and within a team environment.</li>
<li>Excellent written and verbal communication skills and customer service techniques.</li>
<li>High accuracy, strong attention to detail, and commitment to quality.</li>
<li>Proven ability to meet deadlines and follow strict standards.</li>
<li>Ability to travel regularly to provider sites across Illinois.</li>
</ul>
Qualifications
<br>Education
<br><ul>
<li>Bachelor’s degree in any field (Nursing preferred)</li>
</ul>
Experience
<br><ul>
<li>Minimum 2 years of clinical experience working with critical care providers, public health providers, or providers serving children, older adults, individuals with traumatic brain injury, or individuals with developmental disabilities.</li>
<li>Minimum 1 year of experience conducting quality assurance reviews.</li>
</ul>
Certification
<br><ul>
<li>Active Illinois Registered Professional Nurse (RN) license required.</li>
</ul>
Working Conditions
<br><ul>
<li>Remote work with 2–3 on site provider visits per week throughout the state of Illinois.</li>
</ul>
Benefits (Through SSO)
<br>SSO offers a competitive benefits package that supports your health, financial well being, and long term growth, including:
<br><ul>
<li>Medical, dental, and vision insurance</li>
<li>401(k) with discretionary employer match</li>
<li>Paid time off and holidays</li>
<li>Flexible spending accounts</li>
<li>Additional employee perks</li>
</ul>
Keyword Search Terms
<br>Nurse Reviewer, RN Reviewer, Provider Management Specialist, Compliance Nurse, Healthcare Quality Review, Provider Compliance, Medicaid Compliance, Clinical Reviewer, Illinois RN, Site Visit Nurse, Healthcare Auditor, Public Health Nursing, QA Nurse, Provider Monitoring.
<br><br>
Compensation for roles at Staffing Solutions Organization LLC (SSO) varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience. As required by applicable law, SSO provides a reasonable range of compensation for this role. In addition, SSO provides a range of benefits for this role.
<br><br>
Applicants must be authorized to work in the U.S. This position is not eligible for work authorization sponsorship (including H-1B sponsorship) by SSO and under the federal laws relating to the F-1 STEM EAD program, this position is not eligible to support a STEM EAD extension application.
<br><br>
All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, marital status, age, national origin, protected veteran status, or disability. Staffing Solutions Organization LLC is an E-Verify participant.

Nurse Reviewer

Maryland Department of Transportation

<p></p><div><div><div><div><b>(Open Recruitment)</b></div><div><b>
State Highway Administration</b></div><div><b>
Access Management Project Reviewer (Transportation Engineer IV)</b></div><div><b>
 Grade 18 (0516) SP# 26-84-04</b></div><div><b><br>
 YOU MUST APPLY ONLINE TO BE CONSIDERED FOR THIS POSITION</b></div><div><b>
http://www.governmentjobs.com/careers/mdotmd</b></div><div></div><div><br>
The State Highway Administration's (SHA) <b>District 4 (Baltimore County)</b> is currently recruiting for an <b>Access Management Project Reviewer (Transportation Engineer IV) </b>position. This position is <b>open to anyone who meets the minimum qualifications </b>listed below. The resulting list of eligible candidates will be used to fill this vacancy and may be used to fill future vacancies in this classification.</div><div><br>
<b>Nature of Work</b><b>: </b>The primary purpose of this position is to represent State Highway Administration (SHA) in District 4 as a Project Reviewer in the Access Management Section through interface and coordination with federal, state, county, and municipal agencies as well as citizens, developers, and consulting engineers. This position works directly for the Regional Engineer and assists the Regional Engineer in the review of development project documents, preparation of comments related to the district, and, under the supervision of the Regional Engineer, negotiates the application of requirements for access and highway related improvements, providing technical direction and consultant engineer coordination of SHA requirements. The primary purpose of this position is to enforce the regulations stipulated in the Annotated Code of Maryland. The Project Reviewer has the authority to recommend to the Regional Engineer that immediate corrective action is necessary. Under the direction of the Regional Engineer, the Project Reviewer will coordinate as necessary with appropriate parties to withhold the issuance of a SHA approval of a development submission and/or the access permit in the review of subdivision plans, site development plans, grading plans, and building permits through the County Review and SHA development review processes for all assigned projects.</div><div></div><i><br>
MDOT offers a generous and competitive benefits package. You can learn about our amazing benefits here</i><b><i>: </i></b><b><i>MDOT Benefits Guide</i></b><br>
<br>
<i>&ldquo;The State Highway Administration (SHA) has been named a Training magazine Training Awards winner for the seventh consecutive year.&quot;</i></div><p></p>
<div><h2 class="jobSectionHeader"><b>Qualifications</b></h2></div>
<p></p><div><p><b>MINIMUM QUALIFICATIONS:</b></p><p><b>
Education</b>: Possession of a bachelor's degree in engineering from an accredited college or university.<br>
<br>
<b>Experience</b>: Four (4) years of experience in professional engineering.</p><div><b>
Selective Qualification: </b>Two (2) years of the required experience must have involved traffic engineering, highway design, land development, access management, or<b> </b>construction project engineer experience.<br>
<br>
<ul><li><b>This statement contains a selective qualification, which is more focused in scope than the minimum qualifications for this classification. Selective qualifications are utilized when the position requires specific or additional bona fide occupational qualifications (i.e., knowledge, skill or ability).</b></li></ul></div><p><b>
Preferred Qualifications:</b></p><p><i>
The ideal candidate should possess the following:</i></p><div><ul><li>
Ability to negotiate with parties outside of state government; facilitate agreements between parties that have differences between them.</li><li>
Good computer skills and knowledge of Microsoft Office programs (e.g., Word, Excel, Access and PowerPoint) are desirable.</li><li>
Working knowledge of AASHTO (American Association of State Highway and Transportation Officials) guidelines.</li><li>
Working knowledge of Standards and Specifications for Highway Design and Construction.</li><li>
Working knowledge of Traffic Engineering principles.</li><li>
Excellent written and oral communication skills.</li><li>
Knowledge in preparing technical reports.</li><li>
Possession of an Engineer-in-Training License from the Maryland Department of Labor, Licensing, and Regulation</li></ul></div><div><br>
<b>Notes:</b><br>
<br>
1. Additional work experience in professional engineering, or in technical engineering at the journey level or above, may be substituted on a year for year basis for the required education.<br>
<br>
2. Possession of a master's degree in engineering may be substituted for one year of the required experience.</div><br>
<div></div>
3. Persons currently registered as Professional Engineers in the State of Maryland, or in a state with comparable requirements, are considered to have met the education requirements.</div><p></p>
<div><h2 class="jobSectionHeader"><b>Licenses &amp; Certifications</b></h2></div>
<p></p><div><div>Candidate must possess a motor vehicle operator's license valid in the state of Maryland.</div></div></div></div><p></p>

Access Management Project Reviewer (Transportation Engineer IV)

AllMed Healthcare Management, Inc

<div><div><div><b>AllMed </b>is looking for a dedicated <b>Pharmacy Technician</b> to join our growing team! This is your chance to work in a dynamic, supportive environment where your skills and attention to detail help improve lives every day.</div></div><div><div>
The Pharmacy Technician is responsible to ensure reports are of the highest quality and integrity and in full compliance with client contractual agreement, regulatory agency standards and/or federal and state mandates.</div></div><div><div>
This position is <b>100% remote</b> and full time.
</div></div><div><div><b>Responsibilities may include:</b></div></div><ul><li><div><div>
Performs quality assurance review of reports, correspondences, addendums or supplemental reviews.</div></div></li><li><div><div>
Ensures clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.</div></div></li><li><div><div>
Ensures that all client instructions and specifications have been followed and that all questions have been addressed.</div></div></li><li><div><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></div></li><li><div><div>
Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.</div></div></li><li><div><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></div></li><li><div><div>
Verifies that the peer reviewer has attested to only the fact(s) and that no evidence of reviewer conflict of interest exists.</div></div></li><li><div><div>
Ensures the provider credentials and signature are adhered to the final report.</div></div></li><li><div><div>
Identifies any inconsistencies within the report and contacts the Peer Reviewer to obtain clarification, modification or correction as needed.</div></div></li><li><div><div>
Assists in resolution of customer complaints and quality assurance issues as needed.</div></div></li><li><div><div>
Ensures all federal ERISA and/or state mandates are adhered to at all times.</div></div></li><li><div><div>
Provides insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.</div></div></li><li><div><div>
Promotes effective and efficient utilization of company resources.</div></div></li><li><div><div>
Participates in various educational and or training activities as required.</div></div></li><li><div><div>
Performs other duties as assigned.</div></div></li></ul><div><div>
If you're ready to take the next step in your pharmacy career, we&rsquo;d love to hear from you!</div></div><ul><li><div><b>
A minimum of two years of working as a pharmacy tech or clinical/related field experience equivalent combination of education and experience.</b></div></li><li><div>
High school diploma or equivalent required.
</div></li><li><div>Active Pharmacy Tech License/ Certificate
</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 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 accurately follow instructions and respond to directions from upper management.</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><li><div>
Must be able to demonstrate and promote a positive team-oriented environment.</div></li></ul><div><div>
AllMed provides clinical decision making and utilization management solutions to leading payer and provider organizations. We work closely with your team toward a shared vision of healthcare that delivers the highest quality, values patient experience, and ensures both appropriate care and utilization of health-related services.</div></div><p>
</p><div><div><b>AllMed </b>offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.</div></div><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>

Pharmacy Technician

MES Solutions

<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)</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>3 days: 12 - 8:30pm EST</div></li><li><div>
2 days: 8 - 4:30pm/ 9 - 5:30pm EST (flexible)</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 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

ProgenyHealth

<div>Description:
<p><b>
Job Role</b></p><p>
The Clinical RN Chart Reviewer will perform clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered. The Clinical RN Chart Reviewer will report to the Payment Assurance Manager and support a culture and work environment that promotes and inspires an active, continuous improvement philosophy regarding products and services in line with our company mission. This role requires certified coding expertise and a strong understanding of DRG validation, medical necessity, and regulatory guidelines.</p>
Requirements:
<p><b>
Responsibilities will include:</b></p><ul><li>
Audits and analyzes neonatal intensive care unit (NICU) claims according to ICD-10 coding principles and clinical guidelines.</li><li>
Analysis of claims data to optimize reimbursement by ensuring that the diagnosis codes, procedure codes, and supporting documentation accurately support the service rendered.</li><li>
Ensures claims analysis complies with ethical coding standards, guidelines, and regulatory requirements.</li><li>
Responsible for performing clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered.</li><li>
Utilize Clinical Review Tools and EMR Systems.</li><li>
Research reimbursement regulations for claim payment compliance to support and validate audit findings.</li><li>
Assist with the development of claims audit process documentation, including workflow diagrams, policies and procedures, and standard operating procedures.</li><li>
Detect discrepancies in provider billing and recommend adjustments to ensure proper reimbursement.</li></ul><p><b>
Qualifications:</b></p><ul><li>Registered Nurse required.</li></ul><ul><li>
2+ years with inpatient claims, preferably NICU and maternity required.</li><li>
Inpatient Coding Certification required - CCS or CIC</li><li><i>
If not currently certified, requirement to obtain CIC or CCS within 6 months of hire.</i></li><li><i>
Applicant responsible for exam and associated fees.</i></li><li>
Experience in nursing, inpatient coding and reimbursement guidelines, and specifically, has a solid understanding of the MS-DRG, AP-DRG and APR-DRG payment systems.</li><li>
2+ years of working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.</li><li>
Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates.</li><li>
Requires expert coding knowledge - DRG, ICD-10, CPT, HCPCS codes.</li><li>
Experience with appeals is strongly preferred.</li><li>
Excellent communication skills, both oral and written.</li><li>
Strong interpersonal skills that will support collaborative teamwork.</li><li>
Proficient in Microsoft Office: Word and Excel; Access &ndash; highly preferred.</li><li>
Ability to work independently and within a team.</li><li>
Critical listening, thinking, decision making and problem solving.</li></ul><p><b>
Benefits</b></p><p>
Some of the benefits we offer our team are:</p><ul><li>
Paid Time Off</li><li>
Paid Parental Leave</li><li>
Medical, dental, vision benefits</li><li>
401K with company match</li><li>
Short- and Long-Term Disability</li><li>
Group Life Insurance</li><li>
Tuition reimbursement</li><li>
Professional development opportunities</li><li>
Business Casual work environment</li></ul><b>
ProgenyHealth positively recruits people from diverse backgrounds, including individuals with disabilities - if you need an accommodation to interview, please contact us by email: careers@progenyhealth.com</b><b>Equal Opportunity Employer, including individuals with disabilities and veterans.</b></div>

Nurse Inpatient Coding Auditor, (Remote) CIC or CCS certified

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