utilization reviewer

Asante

<p></p><div><div><div><p><b>Req #:</b> 24661<br>
<b>Entity:</b> Asante Rogue Regional Medical Center<br>
<b>Location:</b> Medford OR<br>
<b>Department:</b> Case Management<br>
<b>Shift:</b> Variable Schedule Days<br>
<b>Union Position:</b> No<br>
<b>FTE:</b> 0.000001<br>
<b>Schedule:</b> On Call<br>
<b>Salary:</b> $23.28 - $32.02 depending on qualifications</p></div><p></p><div><div><br>
</div></div></div><div><p><b>Description</b>
</p><p><b>Additional Position Details: FTE: 0.000001 | On Call | Variable Schedule Days</b></p><p><b>
Starting Wage</b>: $23.28-$32.02 per hour, depending on experience</p><p></p><p><b>
Position Summary</b></p><p>
The <b>Case Management Specialist </b>functions as a member of the Case Management team. They utilize communication, organizational, and problem-solving skills to carry out the post-hospital care plans and interventions, utilization review, and denials management activities as defined by the RN Discharge Coordinator and RN Utilization Reviewer. They assume a pivotal role with the patient care team to achieve optimal clinical and resource outcomes.</p><p></p><p><b>
Position Qualifications</b></p><p><b>
Experience</b></p><p></p><ul><li>
3 years of experience in administrative functions in care coordination and/or utilization management in healthcare settings is required.</li><li>
Experience with Microsoft Word and Excel is required</li><li>
Experience with EPIC is preferred</li><li>
Current understanding of CMS regulations related to hospital discharge requirements is preferred.</li></ul><p><b>
Education</b></p><p></p><ul><li>
High School Diploma, GED, or equivalent experience demonstrating the ability to effectively communicate as required for the position is required</li><li>
An Associate's degree in business, healthcare administration, or a related field is preferred</li></ul><p><b>
Total Rewards</b></p><p></p><p>
We offer a comprehensive Total Rewards package designed to support your well-being and professional growth, including:</p><p></p><ul><li><b>
Competitive Pay: </b>Hourly and salaried positions earn market-based compensation.</li><li><b>
Health &amp; Wellness: </b>Medical, dental, and vision coverage for part-time and above employees and their eligible dependents beginning within 30 days of hire.</li><li><b>
Retirement Savings: </b>Employer-sponsored retirement plan with company contribution and match.</li><li><b>
Paid Time Off: </b>Generous ETO for part-time and above employees.</li><li><b>
Professional Development: </b>Continue to enhance your education through our tuition reimbursement and tuition repayment program</li><li><b>
Additional Benefits: </b>Life insurance, disability coverage, and employee assistance programs.</li></ul><p></p><p>
At Asante, we are guided by our values:</p><p><b>
Excellence - Respect - Honesty - Service - Teamwork</b></p><p></p><p><i>
Asante is proud to be an Equal Opportunity Employer. We are committed to creating a diverse and inclusive workplace and to employing and advancing qualified individuals of all backgrounds, including women, minorities, individuals with disabilities, and protected veterans.</i></p></div></div><p></p>

Case Management Specialist

Atrium Health

<div>
 <strong>
  Department
  <br/>
  <br/>
 </strong>
 11215 Navicent Non Enterprise Corporate - Utilization Management
 <br/>
 <br/>
 <strong>
  Status
  <br/>
  <br/>
 </strong>
 Full time
 <br/>
 <br/>
 <strong>
  Benefits Eligible
  <br/>
  <br/>
 </strong>
 Yes
 <br/>
 <br/>
 <strong>
  Hours Per Week
  <br/>
  <br/>
 </strong>
 40
 <br/>
 <br/>
 <strong>
  Schedule Details/Additional Information
  <br/>
  <br/>
 </strong>
 Monday-Friday 8a-5p including afterhours and on-call weekends
 <br/>
 <br/>
 <strong>
  Pay Range
  <br/>
  <br/>
 </strong>
 $26.55 - $39.85
 <br/>
 <br/>
 <strong>
  Major Responsibilities
  <br/>
  <br/>
 </strong>
 Coordinates the patient&rsquo;s care throughout their stay.
 <br/>
 <br/>
 <ul>
  <li>
   Collaborates with the health care team in evaluating the appropriate use of resources, such as medications, procedures, protocols, and tests. Ensures progress towards departmental improvement goals relative to length of stay (LOS) and cost per case.
  </li>
  <li>
   Identifies need for referral to appropriate discipline. Participates in Care Conferences as requested.
   <br/>
   <br/>
  </li>
 </ul>
 Engages in utilization management activities appropriate to the patient&rsquo;s level of care.
 <br/>
 <br/>
 <ul>
  <li>
   Maintains an informed status of reimbursement plans, requirements, and guidelines for hospitalization and alternate level of care services.
  </li>
  <li>
   Communicates status to the health care team.
  </li>
  <li>
   Contacts the attending physician and other health care providers whenever additional information is needed for assessment, care planning, or reimbursement purposes.
  </li>
  <li>
   Obtains insurer&rsquo;s approval for services by providing the insurer with pertinent medical information. Ensures progress towards departmental goals for denial management.
  </li>
  <li>
   Collaborates with the health care team (nurse, pharmacist, physician, therapist, Physician) in monitoring appropriateness of test/procedures, medications, consultations, and treatment plans.
  </li>
  <li>
   In conjunction with Social Service, handles Hospital Issued Notice of Non-Coverage (HINN). Coordinates insurance approvals and obtains pre-certs for all payer sources.
  </li>
  <li>
   Documents insurance information/authorization numbers in relative software applications. Documents calls and related information on designated forms.
  </li>
  <li>
   Establishes and maintains positive relationships with patients, physicians, allied professionals, and all peers. Supports facility internal and external customer service standards.
  </li>
  <li>
   Participates in training and development activities to enhance own knowledge and skills Reviews all cases to assure admission criteria is met.
  </li>
  <li>
   Communicates to the physician if further documentation is needed by regulatory regulations.
  </li>
  <li>
   Assist with chart audits from outside insurance companies. Writes appeals as needed to insurance companies. Arranges peer to peer reviews with physicians and insurance companies.
  </li>
  <li>
   Reports any known compliance issues to Director and Assistant Director of Coordinated Care and Director of BH Financial Operations/Revenue Cycle Operations.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Licensure, Registration, And/or Certification Required
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   None
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Education Required
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Bachelor's degree in Business, Education, Counseling, Human Services or related field from an accredited institute
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Experience Required
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Minimum of two years&rsquo; experience in the care of assigned patient population Working knowledge of community resources
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Knowledge, Skills &amp; Abilities Required
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Expert knowledge of ICD, CPT, and HCPCS coding guidelines.
  </li>
  <li>
   Expert knowledge of medical terminology, anatomy, and physiology.
  </li>
  <li>
   Expert ability to identify coding quality issues/concerns and provide recommendations for improvement.
  </li>
  <li>
   Expert ability to analyze trends and data and display them in a statistical reporting format.
  </li>
  <li>
   Expert organization and communication (verbal and written) skills.
  </li>
  <li>
   Expert ability to effectively train others through oral and/or written methods.
  </li>
  <li>
   Expert organization, prioritization, and reading comprehension skills.
  </li>
  <li>
   Expert analytical skills, with high attention to detail.
  </li>
  <li>
   Expert knowledge of Microsoft Office, video and web conferencing, email, and experience with electronic coding and EHR systems or applications.
  </li>
  <li>
   Expert knowledge of care delivery documentation systems and related medical record documents.
  </li>
  <li>
   Expert interpersonal communication skills (oral and written) necessary to collaborate with Physicians, other clinicians, and Professional Coding Department team members and leadership.
  </li>
  <li>
   Ability to work independently and exercise independent judgment and decision-making.
  </li>
  <li>
   Ability to meet deadlines while working in a fast-paced environment.
  </li>
  <li>
   Ability to take initiative and work collaboratively with others.
  </li>
  <li>
   Ability to meet deadlines while working in a fast-paced environment.
  </li>
  <li>
   Strong sense of ethics.
  </li>
  <li>
   Experience with remote workforce operations required.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Physical Requirements And Working Conditions
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Frequent sitting and/or standing, often for long periods of time. Frequent walking bending, stooping, pushing, twisting and turning. Occasionally lifts 10 pounds or more of office related equipment or supplies. Eye-hand coordination and manual dexterity in reaching, grasping and handling with repetitive use of hands and fingers in operating computer, calculator, telephone, copier, fax and similar office equipment. Ability to distinguish letters, numbers and symbols with normal range of vision and hearing and ability to communicate verbally and in writing. Work-related stress due to volume and time constraints. May require travel by vehicle to alternative locations.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Job Requirements
  <br/>
  <br/>
 </strong>
 <strong>
  Preferred Certification/License/Registration
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Case Management and Utilization Review certification encouraged
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Education
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Master's Degree in related field
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Experience
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Working knowledge of community resources
   <br/>
   <br/>
  </li>
 </ul>
 <em>
  This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
  <br/>
  <br/>
 </em>
 <strong>
  Our Commitment To You
  <br/>
  <br/>
 </strong>
 Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more &ndash; so you can live fully at and away from work, including:
 <br/>
 <br/>
 <strong>
  Compensation
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
  </li>
  <li>
   Premium pay such as shift, on call, and more based on a teammate's job
  </li>
  <li>
   Incentive pay for select positions
  </li>
  <li>
   Opportunity for annual increases based on performance
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Benefits And More
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Paid Time Off programs
  </li>
  <li>
   Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
  </li>
  <li>
   Flexible Spending Accounts for eligible health care and dependent care expenses
  </li>
  <li>
   Family benefits such as adoption assistance and paid parental leave
  </li>
  <li>
   Defined contribution retirement plans with employer match and other financial wellness programs
  </li>
  <li>
   Educational Assistance Program
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  About Advocate Health
  <br/>
  <br/>
 </strong>
 Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation&rsquo;s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.
 <br/>
 <br/>
 The Non-clinical Case Manager is responsible for collaborating with other utilization reviewers/case managers, providers, assessors, outpatient/inpatient clinical staff, therapists, revenue cycle staff, and insurance plans to provide a comprehensive presentation of a patient&rsquo;s plan of care, progress towards goals, and ongoing care needs. The non-clinical case manager advocates for authorization for services in compliance with Centers for Medicare and Medicaid Services (CMS) guidelines and applies applicable utilization review criteria as per the expectation pertaining to specific payers, such as Medicare, Medicaid, and private insurance. The non-clinical Case Manager is also responsible for keeping organized and current documentation on patients and ensures the availability of sufficient clinical and financial information to enable the health care team to function efficiently within the continuum of care and resources.
</div>


Case Manager Behavioral Health

PTCL.Official

<div>
 <p>
  <strong>
   ARE YOU READY TO RISE WITH PTCL GROUP
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <p>
  We are not just industry leaders; we are redefining excellence with groundbreaking solutions. PTCL Group stands out in the technology industry with its commitment to high-end innovation and leading the way in delivering integrated ICT and Cellular Network services in Pakistan, all rooted in our journey of Culture Transformation &amp; Change Management.
 </p>
 <p>
  <br/>
 </p>
 <p>
  <em>
   PTCL Group actively cultivates an inclusive &amp; diverse culture that values and uplifts every individual, regardless of their gender, social background, religion, belief, or disability
  </em>
  .
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   PTCL Group Vision &amp; Values:
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <p>
  With a clear vision to become the largest technology player and champion driving the digital transformation of Pakistan, PTCL Group is guided by a set of our unified core values:
 </p>
 <p>
  <br/>
 </p>
 <ul>
  <li>
   Be Resilient
  </li>
  <li>
   Think Big
  </li>
  <li>
   Win Every Battle
  </li>
  <li>
   Value Success
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   IN THIS ROLE YOU WILL:
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <p>
  The purpose of this position is to ensure the quality, security, and maintainability of software applications by performing systematic source code reviews. The role involves analyzing code for compliance with coding standards, identifying potential vulnerabilities, improving performance and readability, and ensuring adherence to best practices in software development. The Source Code Reviewer collaborates with development, QA, and security teams to deliver reliable, efficient, and secure software products
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   HOW CAN YOU EXPRESS YOUR TALENT:
  </strong>
 </p>
 <ul>
  <li>
   Carefully examines software source code to ensure accuracy, efficiency, and alignment with established coding standards. This involves reviewing logic, structure, naming conventions, and adherence to best practices. The reviewer identifies deviations or potential issues early in the development process to maintain high-quality, reliable code before deployment.
  </li>
  <li>
   To detect defects, inefficiencies, and security vulnerabilities within the codebase. The reviewer documents each finding clearly, describing the issue, its potential impact, and recommended corrective actions. This systematic documentation ensures traceability, accountability, and compliance with organizational and security standards.
  </li>
  <li>
   Works closely with developers to discuss findings, explain coding issues, and suggest effective solutions. This collaboration helps build shared understanding and promotes consistent application of best practices across the development team. Constructive feedback is provided to improve both individual coding skills and overall software quality.
  </li>
  <li>
   Beyond syntax and structure, the reviewer ensures that the code meets defined functional and performance requirements. This includes verifying logic correctness, evaluating code efficiency, and ensuring that changes do not introduce regressions or performance bottlenecks. This step helps guarantee that the final product performs as intended and meets user expectations.
  </li>
  <li>
   Maintains detailed records of review outcomes, including issues identified, corrective actions taken, and final approval status. These reports serve as essential documentation for internal audits, compliance checks, and process improvement initiatives. Accurate recordkeeping supports transparency and continuous quality assurance.
  </li>
  <li>
   To ensure a seamless development lifecycle, the reviewer collaborates regularly with Quality Assurance, Security, and Project Management teams. This coordination helps align review activities with testing cycles, security assessments, and release schedules. By maintaining open communication, the reviewer contributes to timely, secure, and high-quality software delivery.
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   WHAT YOU NEED TO BE SUCCESSFUL:
  </strong>
 </p>
 <p>
  <strong>
   Qualification
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <p>
  Bachelors in relevant field.
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   <em>
    PTCL Group's family-centric policies, offering 6-month maternity and 30-day paternity leave, along with a hybrid work model, redefine the workplace for a balanced and fulfilling career.
   </em>
  </strong>
 </p>
 <p>
 </p>
</div>


Executive Software Security & Source Code Review

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

EGBank

<div></div><div><div><div><div><div><div><div><div><b>KEY ACCOUNTABILITIES</b></div></div></div><div><br>
<div>
<div><b>Description</b></div></div></div><div><br>
<div>
<div><ul><li><div>Ensure credit applications are processed within the approved time frame and approved lending parameters while maintaining deviation caps approved by policy.</div>
</li></ul>
<ul><li><div>Verify all credit applications related documents are complete and complying with approved policy and CBE regulations</div>
</li></ul>
<ul><li><div>Must be able to detect fraud applications &amp; ensure that good quality of credit applications is processed</div>
</li></ul>
<ul><li><div>Ensure the standard Operating Procedures for credit underwriting, verification, documentation, delegation is compliant with policy and any exceptions are to be regularly reported to management.</div>
</li></ul>
<ul><li><div>Communicate major deficiencies &amp; policy violations to direct manager to take the needed corrective actions to maintain a good healthy retail credit portfolio.</div>
</li></ul>
<ul><li><div>Provide the needed support with Recommendations with additions &amp; modifications to credit policy, product manual &amp; Operational procedures.</div>
</li></ul>
<ul><li><div>Thrive to maintain good healthy retail credit portfolio through checking various reports such as I-Score reports, CBE Negative list to check credit history and DBR calculations</div>
</li></ul>
<ul><li><div>Conducting contact point verification (CPV) with customer, STL/HR checks with employer, residence verification and mobile verification (If required by credit policy)</div>
</li></ul>
<ul><li><div>Ensure quality of service to Internal &amp; External customers by adhering to the committed turnaround time.</div></li></ul></div></div><br>
</div><br>
<div><div><div><b>Policies, processes and procedures:</b></div>
<div>
Follow all relevant approved department&rsquo;s policies, and procedures and monitor adherence so that work is carried out in a controlled manner.</div></div></div><div><br>
<div>
<div><b>Day-to-Day Management:</b></div>
<div>
Follow the day-to-day operations related to own jobs in the department to ensure continuity of work</div></div></div><div><br>
<div>
<div><b>Compliance:</b></div>
<div>
Comply with all relevant CBE regulations, banking laws, AML regulations and internal EG Bank policies and code of conduct to maintain EG Bank&rsquo;s sound legal position and mitigate any potential risks</div></div></div></div></div><br>
</div>
<p></p><br>
<br>
<div><div><div><div><div><div><b>5. COMMUNICATION &amp; WORKING RELATIONSHIPS</b></div></div></div><div><br>
<div>
<div><b>Internal: Retail Business, Portfolio management, Fraud unit, Legal, compliance,</b></div>
<div><b>
Collection, HR and internal Audit.</b></div>
<div><b>
External:</b> External Clients (call verifications)</div></div></div></div></div><br>
</div>
<p></p><br>
<br>
<div><div><div><div><div><div><b>6. QUALIFICATIONS, EXPERIENCE AND SKILLS</b></div></div></div><div><br>
<div>
<div><b>Qualifications and Experience:</b></div>
<div>
<ul><li><div>Bachelor&rsquo;s degree in Business Administration, Accounting, Economics or a related field.</div>
</li></ul>
<ul><li><div>For the Retail Credit Reviewer role 0-3 years of experience of relevant experience</div>
</li></ul>
<ul><li><div>For the Retail Credit Senior Reviewer role 3-5 years of relevant experience</div>
</li></ul>
<ul><li><div>Experience within the Banking Industry is preferred for the credit reviewer role and is a must for the senior reviewer role.</div>
</li></ul>
</div><div><b>Skills:</b></div>
<div>
<ul><li><div>Excellent command of English and Arabic languages (written and spoken)</div>
</li></ul>
<ul><li><div>Excellent decision making and negotiation skills
</div></li></ul><ul><li><div>Excellent communication skills</div>
</li></ul>
<ul><li><div>Excellent planning and organizing skills</div>
</li></ul>
<ul><li><div>Good Use of Microsoft office tools</div>
</li></ul>
<ul><li><div>Good Business Acumen of external market and up-to date market trends and practices</div></li></ul></div></div></div></div></div></div></div></div><p></p>

Retail Credit Reviewer - Senior Reviewer (3899)

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

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 – State of Illinois
<br><b>Location:</b> Remote with on site visits across Illinois
<br>We are currently seeking Nurses who reside in Central Illinois - preferably in McLean and Sangamon Counties.
<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>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>
Education
<br><ul>
<li>Bachelor’s degree preferred</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

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