nurse reviewer

HMSA

<div>
 <strong>
  Employment Type
  <br/>
  <br/>
 </strong>
 Full-time
 <br/>
 <br/>
 <strong>
  Exempt or Non-Exempt
  <br/>
  <br/>
 </strong>
 Exempt
 <br/>
 <br/>
 <strong>
  Job Summary
  <br/>
  <br/>
 </strong>
 <strong>
  Hybrid Work Environment - Must reside in Hawaii
  <br/>
  <br/>
 </strong>
 <strong>
  Pay Range:
 </strong>
 $59,000 to $116,000
 <br/>
 <br/>
 <strong>
  Note
 </strong>
 : Individuals typically begin between the minimum to middle of the pay range
 <br/>
 <br/>
 Under minimal supervision, conducts detailed analysis and review of precertification requests, post-service and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally accepted clinical guidelines to determine appropriateness of care for all HMSA lines of business.
 <br/>
 <br/>
 <strong>
  Minimum Qualifications
 </strong>
 <br/>
 <br/>
 <ul>
  <li>
   Associates degree in Nursing.
  </li>
  <li>
   Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
  </li>
  <li>
   Two years clinical, case management or utilization management related experience.
  </li>
  <li>
   Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
  </li>
  <li>
   Strong organizational skills
  </li>
  <li>
   Good communication skills both verbally and written
  </li>
  <li>
   Analytical skills
  </li>
  <li>
   Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
  </li>
  <li>
   Currently licensed in Hawaii as an RN or LPN
  </li>
  <ul>
   <li>
    (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)
    <br/>
   </li>
  </ul>
 </ul>
 <strong>
  Duties And Responsibilities
 </strong>
 <br/>
 <br/>
 <ul>
  <li>
   Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
  </li>
  <ul>
   <li>
    Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
   </li>
   <li>
    Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
   </li>
   <li>
    Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
   </li>
   <li>
    Review various types of services, including but not limited to:
   </li>
   <li>
    Transplants
   </li>
   <li>
    Air Ambulance
   </li>
   <li>
    Chemotherapy
   </li>
   <li>
    Clinical trials
   </li>
   <li>
    Genetic testing
   </li>
   <li>
    Cancer treatments/radiation therapy
   </li>
   <li>
    Experimental/Investigational Services/Devices
   </li>
   <li>
    New Technology
   </li>
  </ul>
  <li>
   Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
  </li>
  <ul>
   <li>
    Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
   </li>
   <li>
    Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
   </li>
   <li>
    Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
   </li>
   <li>
    Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
   </li>
  </ul>
  <li>
   Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
  </li>
  <li>
   Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
  </li>
  <li>
   Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
  </li>
  <li>
   Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
  </li>
  <li>
   Performs all other miscellaneous responsibilities and duties as assigned or directed.
   <br/>
   <br/>
  </li>
 </ul>
</div>


Nurse Reviewer - Clinical Review Unit

Palm Medical Centers

<div><b>Position Summary:</b><br>
The <b>Concurrent Review Nurse</b> is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements.<br>
<br>
<b>Key Responsibilities:</b><ul><li>
Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care.</li><li>
Evaluate clinical documentation against evidence-based criteria (e.g., InterQual&reg;, MCG) to determine medical necessity and appropriate level of care.</li><li>
Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning.</li><li>
Communicate utilization review decisions and recommendations to providers and payers.</li><li>
Document all reviews, decisions, and communications in accordance with regulatory and organizational standards.</li><li>
Identify cases requiring escalation or peer review and follow established procedures.</li><li>
Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA.</li><li>
Participate in quality improvement initiatives and departmental meetings</li></ul><b>
Qualifications:</b><br>
<br>
<b>Education &amp; Licensure:</b><ul><li>
Registered Nurse (RN) license, active and in good standing, required.</li><li>
Associate or Bachelor&rsquo;s degree in nursing (BSN preferred).</li></ul><b>
Experience:</b><ul><li>
Minimum 2 years of clinical experience (e.g., med-surg, critical care).</li><li>
At least 1 year of utilization review, case management, or managed care experience preferred.</li></ul><b>
Skills &amp; Competencies:</b><ul><li>
Knowledge of InterQual&reg;, MCG, or other clinical review guidelines.</li><li>
Familiarity with Medicare/Medicaid and commercial insurance regulations.</li><li>
Strong analytical and clinical judgment skills.</li><li>
Effective communication and negotiation skills.</li><li>
Proficient with electronic medical records (EMRs) and utilization review platforms.</li><li>
Detail-oriented with excellent organizational skills.</li></ul><b>
Work Environment:</b><ul><li>
Remote</li></ul><p><br>
Palm Primary Care is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.<br>
<br>
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Primary Care makes hiring decisions based solely on qualifications, merit, and business needs at the time.</p><p>
</p><p>9cbfR8Lziz</p></div>

Concurrent Review Nurse

Centene

<div><p>You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.<br>
</p><b>Position Purpose:</b> Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.<ul><li>
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care</li>
<li>Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member</li>
<li>Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered</li>
<li>Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines</li>
<li>Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings</li>
<li>Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members</li>
<li>Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines</li>
<li>Reviews member&rsquo;s transfer or discharge plans to ensure a timely discharge between levels of care and facilities</li>
<li>Collaborates with care management on referral of members as appropriate</li><li>
Performs other duties as assigned.</li>
<li>Complies with all policies and standards.</li></ul><p><b>
We are seeking a Clinical Review Nurse - Concurrent Review to join our team!</b></p><p><b>
The ideal candidate will bring expertise in:</b></p><p>
IL Nursing License
<br>
Concurrent Review
<br>
Inpatient Authorizations<br>
Discharge Planning<br>
Acute and/or Critical Care
<br>
Computer Savvy
<br>
Excellent Customer Service and Communication Skills</p><p><b>
Education/Experience:</b> Requires Graduate from an Accredited School of Nursing or Bachelor&rsquo;s degree in Nursing and 2 &ndash; 4 years of related experience. 2+ years of acute care experience required.<br>
<br>
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.<br>
Knowledge of Medicare and Medicaid regulations preferred.<br>
Knowledge of utilization management processes preferred.<br>
<br>
<b>License/Certification:</b></p><ul><li>
LPN - Licensed Practical Nurse - State Licensure required</li></ul>
Pay Range: $27.02 - $48.55 per hour<p>
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.</p><p>
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.</p><p><br>
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</p></div>

Clinical Review Nurse - Concurrent Review

Tanaq Health

<div>
 <strong>
  Description
  <br/>
  <br/>
 </strong>
 <strong>
  Overview
  <br/>
  <br/>
 </strong>
 Tanaq Support Services (TSS) delivers professional, scientific, and technical services and information technology (IT) solutions to federal agencies in health, agriculture, technology, and other government services. TSS is a subsidiary of the St. George Tanaq Corporation, an Alaskan Native Corporation (ANC) committed to serving Federal customers while also giving back to the Tanaq native community and shareholders.
 <br/>
 <br/>
 <strong>
  About The Role
  <br/>
  <br/>
 </strong>
 We are seeking a
 <strong>
  Clinical Appeals Reviewer
 </strong>
 to support a contract with our federal client. The Clinical Appeals Professional performs complex (senior-level) work. Provides dissatisfied parties with the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. Qualified candidates must be licensed health care professionals capable of rendering independent clinical judgment, including but not limited to Registered Nurses (RN), Physical Therapists (PT), Occupational Therapists (OT), and Respiratory Therapists (RT).
 <br/>
 <br/>
 This is a remote position that can be based anywhere in the United States. Must be able to work on a rotating schedule on weekends and holidays.
 <br/>
 <br/>
 <strong>
  Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Reviews medical records/case files, writes reconsideration decision letters that are clear, concise, and impartial, and support the determination made, and documents the review.
  </li>
  <li>
   Makes sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy.
  </li>
  <li>
   Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
  </li>
  <li>
   Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
  </li>
  <li>
   Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
  </li>
  <li>
   Stays abreast of changes in regulations, medical and healthcare practices, policies, and procedures.
  </li>
  <li>
   Participates in case-specific verbal discussions.
  </li>
  <li>
   Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
  </li>
  <li>
   Plans responses to statistical analysis challenges with assistance from statisticians.
  </li>
  <li>
   Attends meetings and participates in workgroups at management's direction.
  </li>
  <li>
   Conducts quality reviews, as needed.
  </li>
  <li>
   Serves as a subject matter expert.
  </li>
  <li>
   Mentors and/or trains staff.
  </li>
  <li>
   May conduct quality reviews and audits.
  </li>
  <li>
   Participates in special projects and performs other duties as assigned.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Requirements
  <br/>
  <br/>
 </strong>
 <strong>
  Required Skills and Experience
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles.
  </li>
  <li>
   Healthcare Professional with experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience.
  </li>
  <li>
   Demonstrated experience writing or making medical necessity decisions.
  </li>
  <li>
   Proficiency in research techniques, medical terminology, and analyzing and interpreting policies, along with knowledge of state and federal laws and regulations.
  </li>
  <li>
   Must have experience and working knowledge of the Medicare program, including coverage and payment rules.
  </li>
  <li>
   Experience with Medicare regulations, claims processing, and the medical review process, as well as applicable laws, rules, and regulations.
  </li>
  <li>
   Prioritize and organize work tasks to handle multitasking and meet deadlines.
  </li>
  <li>
   Ability to prepare correspondence and documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency.
  </li>
  <li>
   Practice logic and reasoning to identify problems, verify facts, and reach valid conclusions.
  </li>
  <li>
   Experience in making decisions that support business objectives and goals.
  </li>
  <li>
   Ability to identify and resolve problems or refer issues appropriately.
  </li>
  <li>
   Communicate effectively verbally and in writing.
  </li>
  <li>
   Adapt to the needs of internal and external customers.
  </li>
  <li>
   Show integrity and ethical behavior, respect confidentiality, business ethics, and organizational standards.
  </li>
  <li>
   Ensure compliance with company policies, procedures, and guidelines, including cybersecurity, regulatory, contractual, and accreditation entities.
  </li>
  <li>
   Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred.
  </li>
  <li>
   Must have resided in the United States for a minimum of three (3) years out of the last five (5) years. This is a contractual requirement.
  </li>
  <li>
   Must possess a valid driver's license with a clear and satisfactory driving record.
  </li>
  <li>
   Ability to obtain and maintain public trust clearance and customer approval.
  </li>
  <li>
   Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Education and Training
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Associate's degree or 60 or more credit hours towards a Bachelor&rsquo;s degree from an accredited college or university in healthcare or related discipline.
  </li>
  <li>
   Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for an Associate&rsquo;s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Physical Requirements And Work Environment
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting, and/or reaching.
  </li>
  <li>
   Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.
  </li>
  <li>
   May require the ability to operate a motor vehicle and travel by motor vehicle and commercial airline. May require overnight travel. Travel may be less than 5% annually.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Who We Are
  <br/>
  <br/>
 </strong>
 Tanaq Management Services (TMS) is a public health contractor, certified 8(a) business, owned by St. George Tanaq Corporation, an Alaska Native Corporation. (ANC). We listen to our stakeholders and leverage our science, technology, communication, and program expertise to understand and provide feedback as we develop solutions.
 <br/>
 <br/>
 <strong>
  Our Commitment to Non-Discrimination
  <br/>
  <br/>
 </strong>
 Tanaq is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to disability, status as a protected veteran or any other status protected by applicable federal, state, or local law. Tanaq complies with the Drug-free Workplace Act of 1988 and E-Verify.
 <br/>
 <br/>
 If you are an individual with a disability and need assistance completing any part of the application process, please email accommodation@tanaq.com to request a reasonable accommodation. This email is for accommodation requests only and cannot be used to inquire about the status of applications.
 <br/>
 <br/>
 <strong>
  Notice on Candidate AI Usage
  <br/>
  <br/>
 </strong>
 Tanaq is committed to ensuring a fair and competitive interview process for all candidates based on their experience, skills and education. To ensure the integrity of the interview process, the use of artificial intelligence (AI) tools to generate or assist with responses during phone, in person and virtual interviews is not allowed. However, candidates who require a reasonable accommodation that may involve AI are required to contact us prior to their interview at accommodation@tanaq.com.
 <br/>
 <br/>
 <strong>
  To Apply For This Positions, Visit
  <br/>
  <br/>
 </strong>
 https://recruiting.paylocity.com/Recruiting/Jobs/Details/4071254
</div>


Clinical Appeals Reviewer (Licensed Healthcare Professional)

MCMC

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

Clinical Quality Assurance Coordinator

VanderHouwen

<div>
 Our client is seeking a detail-oriented and clinically strong Registered Nurse who excels at applying sound judgment to complex healthcare scenarios. This individual will bring a balance of analytical thinking, regulatory awareness, and clear communication to ensure fair and accurate appeal outcomes. The ideal candidate is collaborative, adaptable, and confident navigating both clinical and non-clinical conversations in a remote environment.
 <br/>
 <br/>
 <em>
  This role is a Hybrid model in Idaho. Applicants must be able to maintain flexibility to occasionally support work outside of standard business hours may be required.
  <br/>
  <br/>
 </em>
 <strong>
  Clinical Appeals Nurse (RN) Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Conduct comprehensive clinical reviews of member and provider appeals, ensuring alignment with medical necessity, policies, and standards of care.
  </li>
  <li>
   Apply clinical expertise to interpret medical records, benefit plans, and contractual requirements to support accurate determinations.
  </li>
  <li>
   Collaborate with physician advisors when needed to validate complex or high-risk clinical decisions.
  </li>
  <li>
   Ensure all appeal decisions meet regulatory, accreditation, and organizational compliance requirements.
  </li>
  <li>
   Provide guidance and education to non-clinical team members on clinical aspects of appeals and case reviews.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Clinical Appeals Nurse (RN) Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Must hold a current, unrestricted Registered Nurse (RN) license in Oregon, Washington, Idaho, or Utah; Bachelor&rsquo;s degree in Nursing preferred.
  </li>
  <li>
   Minimum of 2 years of experience in health insurance, utilization management, or clinical appeals review, plus at least 3 years of direct patient care experience.
  </li>
  <li>
   Strong knowledge of medical terminology, procedures, coding systems (CPT, ICD, HCPCS), and clinical guidelines (e.g., MCG).
  </li>
  <li>
   Proven ability to interpret medical records, claims, and benefit structures, and translate findings into clear, concise written determinations.
  </li>
  <li>
   Familiarity with regulatory and accreditation standards, along with proficiency in Microsoft Office tools and remote work environments.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Compensation: $28-$30/hr. (DOE)
 </strong>
 <strong>
  VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
  <br/>
  <br/>
 </strong>
 As an eligible contract employee with VanderHouwen, you'll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.
 <br/>
 <br/>
 <strong>
  Meet VanderHouwen
  <br/>
  <br/>
 </strong>
 What kind of recruiter do you see yourself working with? One who prioritizes your best interest, no matter what? VanderHouwen does, and we're in it for the long game! Our recruiters focus on YOU, building meaningful, long-term relationships while developing a deep understanding of companies' staffing needs and workplace cultures. This approach helps us find an ideal job match that aligns with your unique career aspirations and goals.
 <br/>
 <br/>
 VanderHouwen is an award-winning, Women &amp; Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!
 <br/>
 <br/>
 VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.
 <br/>
 <br/>
</div>


Clinical Appeals Nurse (RN)

Lexington Health

<div><p>Interview &amp; Assessment Holding
<br>
Full Time<br>
AM Shift<br>
40</p><br>
<p></p>
<p>
Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet <i>with Distinction</i> status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News &amp; World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer.</p><br>
<p></p>
<p>
Lexington Health also includes an accredited Cancer Center of Excellence, the state&rsquo;s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer&rsquo;s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.</p><div><div><div><h2 class="jobSectionHeader"><b>
Job Summary</b></h2>
</div><div><p>
Coordinates orientation, training and competency validation of unit staff. Provides ongoing leadership, support and guidance to all nursing staff. Presents a positive image and attitude to staff, patients and visitors. Utilizes the nursing process to promote and restore patient&rsquo;s health status; collaborates with physicians and multidisciplinary team members; provides physical and psychological support to patients, family members and significant others; and supervises assigned team members. Uses a systematic critical-thinking approach to guide data gathering, assessment, nursing judgement, intervention and evaluation of human responses to actual and potential health problems through activities such as health teaching and the provision of care, supportive and restorative care and/or support of a peaceful death. All responsibilities are carried out in accordance with the mission, vision, strategic imperatives and standards of the organization, American Nurses Association Standards and in accordance with the provisions/statues set forth by the South Carolina Nurse Practice Act.</p>
</div></div><div><div><h2 class="jobSectionHeader"><b>
Minimum Qualifications</b></h2>
</div><div><p><b>
Minimum Education</b>: Bachelors of Science in Nursing<br>
<b>Minimum Years of Experience</b>: 2 Years of experience in areas of specialty within the past 5 years.<br>
<b>Substitutable Education &amp; Experience (Optional)</b>: Consideration will be given to candidates with an ADN or Diploma nursing degree who are presently enrolled in a RN to BS in Nursing or RN to MS in nursing program with the expectation that the degree be completed within 12 months of hire/promotion into the Clinical Mentor role.<br>
<b>Required Certifications/Licensure</b>: Current RN license to practice in the State of South Carolina;</p>
<p>National nursing certification in specialty at time of hire / promotion or must be obtained within 6 months of hire/promotion into role.</p>
<p>**Refer to Mandatory Certification Requirements P&amp;P for required education/certification for various nursing specialties<br>
<b>Required Training</b>: None.<br>
</p></div></div><div><div><h2 class="jobSectionHeader"><b>Essential Functions</b></h2>
</div><div><p>
PATIENT CARE AND SUPPORT</p>
<ul><li>Establishes positive rapport with patient and family.</li>
<li>Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families.</li>
<li>Promotes patient's independence by establishing patient care goals; provides education to patient, and family in a manner they can understand their condition, medications, and self-care skills, etc. and provides them ample opportunity to ask questions.</li>
<li>Serves as patient/family advocate.</li>
<li>Maintains continuity among nursing teams by documenting accurately and timely; communicating actions, irregularities, and on-going needs.</li>
<li>Uses a systematic critical-thinking approach to guide data gathering, assessment, nursing judgement, intervention and evaluation of human responses to actual and potential health problems.</li>
<li>Identifies, synthesizes and interprets sources of data using reasonable clinical judgement to respond to dynamic situations in a timely and effective manner.</li>
<li>Maintains patient confidence and protects operations by keeping information confidential.</li>
<li>Uses ethical decision making processes and advocates for acceptable patient outcomes.</li>
<li>L&amp;D Only: A nurse must have documented competency and completion of department orientation to complete a medical screening exam (EMTALA). Nurses will have 3 consecutive medical screenings reviewed and signed off by their preceptor prior to independently completing screenings.</li>
</ul>
<p>CLINICAL WORK QUALITY</p>
<ul><li>Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following hospital and nursing division's philosophies and standards of care set by state board of nursing, state nurse practice act, and other governing agency regulations.</li>
<li>Resolves patient problems and needs by utilizing multidisciplinary team strategies.</li>
<li>Participates in process/performance improvement activities and initiatives utilizing evidence based practice to maintain and/or improve quality of care and safe patient care systems and processes.</li>
<li>Maintains safe and clean working environment by complying with procedures, rules, and regulations; calling for assistance from health care support personnel.</li>
<li>Protects patients and employees by adhering to infection-control policies and protocols, medication administration and storage procedures, and controlled substance regulations.</li>
<li>Documents all patient care activities accurately and timely.</li>
<li>Provides safe, appropriate, quality of care and support to patients and family members.</li>
<li>Holds team members accountable for standards of care, policy and procedures, bedside reporting, etc.</li>
<li>Serves as a teacher, coach and mentor to staff.</li>
<li>Contributes to the development and revision of unit standards.</li>
<li>Efficient conflict resolution and problem solving skills</li>
<li>Serves as staff leader related to process/performance improvement activities / initiatives.</li>
<li>Fosters interdisciplinary communication and collaboration.</li>
<li>Supports shared governance activities by serving on a unit or hospital based committee.</li>
<li>Positive rapport with health care team and demonstrates strong collaboration skills.</li>
</ul></div></div><div><div><h2 class="jobSectionHeader"><b>Duties &amp; Responsibilities</b></h2>
</div><div><ul><li>Collaborates with instructors from affiliating agencies to assure continuity of patient care as well as positive learning experiences for students.</li>
<li>Monitors performance of new staff and provides feedback to orientee and appropriate manager.</li>
<li>Assists the Nurse Manager with onboarding of new hires, and facilitates the orientation process.</li>
<li>Identifies unit specific educational and competency needs of staff.</li>
<li>Plans and coordinates teaching methods and content to achieve desired outcomes; provides continuing education on the unit, (i.e. posters, classes, lectures, newsletters, in-services, etc.)</li>
<li>Coordinates and assists with training and implementation of new equipment, policies, procedures, and protocols.</li>
<li>Provides feedback and insight regarding unit operations and employee performance to the Nurse Manager.</li>
<li>Serves as a resource and role model to all members of the patient care team for patient care and professionalism.</li>
<li>Protects patients and employees by adhering to infection-control policies and protocols medication administration and storage procedures, and controlled substance regulations.</li>
<li>Ensure Hazardous Waste or Hazardous Waste Pharmaceuticals are discarded, stored, and managed with other compatible waste streams in containers that are properly labeled and closed prior to being shipped offsite for proper disposal. Initial RCRA training is received within 6 months of the hire date and continuing with annual RCRA training.</li>
</ul>
<p>RESOURCE MANAGEMENT</p>
<ul><li>Ensures operation of equipment by completing preventive maintenance requirements; following manufacturer's instructions; troubleshooting malfunctions; calling for repairs; maintaining equipment inventories; evaluating new equipment and techniques.</li>
<li>Appropriately utilizes all nursing supplies and equipment.</li>
<li>Demonstrates effective teamwork skills and maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team problem-solving methods.</li>
<li>Promptly responds to all communication devices in order to meet patient needs.e. Assists in performing and documenting environmental checks as required by LMC policy and regulatory agencies.</li>
</ul>
<p>PROFESSIONAL RESPONSIBILITIES</p>
<ul><li>Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.</li>
<li>Meets or exceeds all LMC requirements for attendance and service expectations.</li>
<li>Maintains required certifications.</li>
<li>Completes yearly safety training and other mandatory classes.</li>
<li>Complies with all annual employee health requirements.</li>
<li>Earns a minimum of 20 hours of continuing education annually within specialty.</li>
<li>Performs all other duties as assigned.</li>
</ul>
</div></div></div><p>We are committed to offering quality, cost-effective benefits choices for our employees and their families:</p>
<ul>
<li>Day ONE medical, dental and life insurance benefits</li>
<li>Health care and dependent care flexible spending accounts (FSAs)</li>
<li>Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%.</li>
<li>Employer paid life insurance &ndash; equal to 1x salary</li>
<li>Employee may elect supplemental life insurance with low cost premiums up to 3x salary</li>
<li>Adoption assistance</li>
<li>LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment</li>
<li>Tuition reimbursement</li>
<li>Student loan forgiveness</li>
</ul>
<p><b>Equal Opportunity Employer</b><br>
It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee&rsquo;s desires and abilities and the hospital&rsquo;s needs.</p></div>

Clinical Mentor RN - Interview and Assessment

Search 2146+ Nurse reviewer jobs near you this June. New roles added regularly across leading industries. Apply today.