utilization 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

Prime Therapeutics

<div>
 At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us.
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  Job Posting Title
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 Initial Review Pharmacy Technician
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  Job Description
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 Plays a key role in medical and pharmacy management initiatives critical to the company achieving revenue goals and operational objectives. Responsible for executing utilization management programs on behalf of health plan/payor customers, while utilizing additional clinical knowledge pertaining to a set list of managed medications across all health plans, with additional training for each medication and therapeutic class. Primary activities center on reviewing both prospective and retrospective requests for therapeutic appropriateness using sound clinical criteria. Responsible for making and receiving calls to and from physicians, patients, and pharmacies to gather additional clinical information to determine medication reimbursement. Recommendations will be based on an in-depth understanding of specific specialty medications and industry guidelines, on both pre- and post-service requests. Coordinates with operations, clinical, medical, reporting and other internal departments as needed.
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  Responsibilities
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   Reviews pertinent patient information and checks appropriateness using clinical criteria. Makes approval recommendations on all services that meet clinical review criteria. Refers all cases not meeting clinical criteria to pharmacist clinical reviewer.
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   Practices and maintains the principles of utilization management by adhering to the company policies and procedures. Upholds clinical integrity of pharmaceutical solutions by participating in on-going training programs to ensure quality performance in compliance with applicable standards and regulations. Expert within the organization.
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   Conducts Program Integrity Audits including outreach and review of medical records to audit authenticity of provider response during Prior Authorization and reporting results to client.
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   Assists with the documentation and implementation of both written and verbal communications to physicians/prescribers and assists in the maintenance of the edits and data elements that support the edits.
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   Available for consultation in pharmacy related questions to resolve claims submission related to medication edits.
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   Contacts physicians/prescribers to obtain pertinent clinical history/information. Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plan`s required timeframes.
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   Regularly reviews and monitors information on pended claims identified as outliers by internal and/or external analysis of pharmacy claims data.
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   Supports Intake call volume and order entry if necessary.
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   Determines eligibility for medication reimbursement based upon established clinical criteria and clinical knowledge and enters approvals or denials in the system.
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   Electronically documents both written and verbal communications with physicians, their staff, cardholders, and pharmacies.
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   Escalates medical exception requests to nurse, pharmacist or physician on the utilization review clinical team when further review is necessary.
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   Other duties as assigned.
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  Minimum Qualifications
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   HS diploma or GED is required
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   4 years of Pharmacy Experience
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   CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy
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 Must be eligible to work in the United States without the need for work visa or residency sponsorship
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  Additional Qualifications
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   Must have an active pharmacy technician licensure or registration in accordance with state requirements.
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   If state does not require an exam for licensure/registration, must possess both active pharmacy technician licensure or
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   registration in accordance with state requirements AND an active national certification (e.g., PTCB or ExCPT).
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   In states that do not require licensure or registration, must have an active national certification (e.g., PTCB or ExCPT).
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   Minimum of 2 years of pharmacy experience without a Bachelors degree OR 2 years of pharmacy experience with a
  </li>
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   Bachelors degree in Science, Health, Medical or related field.
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   Specialty or retail pharmacy experience, previous reimbursement experience, and/or working in a health plan/health care setting.
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   Experience as Pharmacy Technician, Utilization Management or Customer Service in a high-volume, multi-functional call center environment.
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   Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems, typing.
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   Strong team orientation with respect for all members.
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   Excellent verbal and written communications skills.
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   People skills are essential that allow for the successful consultation with physicians, prescribers and pharmacists and for successful collaboration with company employees and external vendors who do not directly report to this position.
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   Analytic skills which can translate into practical and pragmatic recommendations.
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   In-depth knowledge of specialty injectable prescription drugs, disease states, health plan formulary management techniques and medical terminology.
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  Preferred Qualifications
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   Oncology pharmacy or other clinical pharmacy experience.
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   4 years of pharmacy experience
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 Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures
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 Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job.
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 Potential pay for this position ranges from $23.08 - $37.02 based on experience and skills.
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 To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail (https://www.primetherapeutics.com/benefits).
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  Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.
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  We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.
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  Prime Therapeutics LLC is a Tobacco-Free Workplace employer.
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 Positions will be posted for a minimum of five consecutive workdays.
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Initial Review Pharmacy Technician

Novant Health

<div>What We Offer:
<p><b>
</b><b> Why This Role Matters</b></p><p>
The Utilization Review RN plays a critical role in ensuring the integrity and compliance of patient health records, while supporting patient care by driving accuracy and adherence to ensure accurate and compliant billing.</p><p></p><p><b><br>
What You&rsquo;ll Do:</b></p><ul><li><b>
Schedule</b> - Monday - Friday, daytime hours, <b>weekend, and holiday rotations are required.</b></li><li>
Conduct thorough chart reviews, within the assigned facilities, to ensure Medicare rules are adhered to for compliance and reimbursement.</li><li>
Provide administrative and technical support to the Utilization Review team to ensure timely payer communication, authorization tracking, and accurate documentation.</li><li>
Process large volumes of confidential patient and payer information to support billing workflows (includes managing payor communications and processing authorizations).</li><li>
Collaborate with physicians and other members of the healthcare team to promote and adhere to regulatory compliance.</li><li>
Participate in quality improvement initiatives within the department.</li><li>
Maintain compliance and regulatory standards and organizational policies. All Utilization Review activities are performed in accordance with the current policies and procedures, mission, vision, and values of Novant Health.</li><li>
Establish and maintain effective work relationships with both internal and external customers.</li></ul><p><b>
What You&rsquo;ll Need:</b></p><p><b>
Required:</b></p><ul><li>
Current RN licensure in the appropriate state.</li><li>
Graduate of an accredited school of nursing.</li></ul><p><b>
Preferred:</b></p><ul><li>
Bachelor&rsquo;s degree in Nursing.</li><li>
2+ years of healthcare experience including utilization review or related experience.</li></ul><p><b>
What&rsquo;s In It for You:</b></p><ul><li>
Comprehensive benefits include health, dental, vision, and life insurance.</li><li>
Retirement fund with matching contributions.</li><li>
Tuition assistance for qualifying team members.</li></ul></div>

Utilization Review RN

BRADFORD HEALTH SERVICES

<div><p><b>About Company:</b></p><p></p><p>
We&rsquo;re officially a <b>Great Place To Work&reg;</b>! We&rsquo;ve always believed that supporting our team is just as important as supporting our patients. Now, we&rsquo;re proud to share that we&rsquo;ve earned Great Place To Work&reg; Certification - based entirely on feedback from our own employees.</p><p>
Read more here: https://ow.ly/YQ1C50WuRH1</p><p>
This certification reflects the culture we&rsquo;ve worked hard to build - one rooted in trust, inclusion, and purpose-driven leadership.</p><p>
At Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.</p><p>
Our benefits include:</p><ul><li><p><b>
Medical Coverage</b> &ndash; Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.</p></li><li><p><b>
Expanded Coverage</b> &ndash; Options for domestic partners and a wider network of in-network providers.</p></li><li><p><b>
Mental Health Support</b> &ndash; Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.</p></li><li><p><b>
Voluntary Coverages</b> &ndash; Pet insurance, home and auto insurance, family legal services, and more.</p></li><li><p><b>
Student Loan Repayment</b> &ndash; Available for nurses and therapists.</p></li><li><p><b>
Retirement Benefits</b> &ndash; 401(k) plan through Voya to help employees plan for the future.</p></li><li><p><b>
Generous PTO</b> &ndash; A robust paid time off policy to support work-life balance.</p></li><li><p><b>
Voluntary Benefits for Part-Time Employees</b> &ndash; Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.</p></li></ul><p>
At Bradford Health Services, we don&rsquo;t just invest in our patients&mdash;we invest in our people.</p><p></p><p><b><br>
About the Role:</b></p><p>
The Utilization Review Specialist plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This position involves thorough evaluation of patient records, treatment plans, and clinical data to determine the appropriateness of care and resource utilization. The specialist collaborates closely with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes. By applying clinical knowledge and regulatory guidelines, the role helps control healthcare costs while maintaining high-quality patient care. Ultimately, the Utilization Review Specialist contributes to the integrity and sustainability of healthcare delivery systems across the United States.</p><p><b>
Minimum Qualifications:</b></p><ul><li>
Bachelor&rsquo;s degree in a healthcare or related field.</li><li>
At least 2 years of experience in utilization review, case management, or clinical healthcare roles.</li><li>
Strong knowledge of medical terminology, clinical procedures, and healthcare regulations.</li><li>
Familiarity with insurance authorization processes and healthcare reimbursement models.</li><li>
Excellent analytical, communication, and organizational skills.</li></ul><p><b>
Preferred Qualifications:</b></p><ul><li>
Experience with electronic health records (EHR) systems and utilization management software.</li><li>
Certification in Utilization Review (e.g., Certified Professional in Utilization Review or Certified Case Manager).</li><li>
Prior experience working with managed care organizations or insurance companies.</li><li>
Advanced knowledge of Medicare, Medicaid, and other payer-specific guidelines.</li></ul><p><b>
Responsibilities:</b></p><ul><li>
Review and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services.</li><li>
Coordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details.</li><li>
Make informed decisions regarding authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory requirements.</li><li>
Maintain accurate and detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards.</li><li>
Stay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.</li></ul><p><b>
Skills:</b></p><p>
The Utilization Review Specialist applies clinical expertise and analytical skills daily to evaluate patient care plans against established medical criteria and payer policies. Effective communication skills are essential for collaborating with multidisciplinary teams, including physicians, nurses, and insurance representatives, to gather necessary information and explain review decisions. Organizational skills enable the specialist to manage multiple cases simultaneously while maintaining detailed documentation and meeting deadlines. Proficiency with healthcare IT systems supports efficient data retrieval and documentation of utilization review activities. Continuous learning and adaptability are important to stay updated on regulatory changes and evolving clinical standards, ensuring compliance and optimal patient care.</p></div>

Utilization Review Specialist

Providence

<div><p><b>Description</b></p>
<p><b>Utilization Review RN at Providence System Offices Discovery Park-Irvine, CA. This position is Part-Time and will work 8-hour, Day shifts.</b></p>
<p>Provide prospective, retrospective, and concurrent utilization reviews for our Southern CA ministries. Conduct clinical reviews and review medical records daily during admission for all payers, as required by the health plans. This role requires a strong clinical background combined with well-developed knowledge and skills in Utilization Management, medical necessity, and patient status determination. The Utilization Management RN must effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment, demonstrating excellent negotiation, communication, problem-solving, and decision-making skills.</p>
<p>Providence caregivers are not simply valued &ndash; they&rsquo;re invaluable. Join our team at Providence California Regional Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.</p>
<p><b>Required Qualifications:</b></p>
<ul><li>Associate's Degree in Nursing.</li>
<li>Upon hire: California Registered Nurse License</li>
<li>2 years experience working in a remote UR environment or working as an acute hospital case manager.</li>
</ul><p><b>Preferred Qualifications:</b></p>
<ul><li>Bachelor's Degree in Nursing.</li>
<li>Master's Degree in Nursing.</li>
<li>Experience working with Interqual guidelines.</li>
<li>Experience in a multi-hospital and/or integrated healthcare system.</li>
</ul><p><b>Why Join Providence?</b></p>
<p>Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.</p>
<p><b>About Providence</b></p>
<p>At Providence, our strength lies in Our Promise of &ldquo;Know me, care for me, ease my way.&rdquo; Working at our family of organizations means that regardless of your role, we&rsquo;ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.</p>
<p>Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.</p>
<p>Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits.</p>
<p>Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.</p>
<p><b>About the Team</b></p>
<p>The Sisters of Providence and Sisters of St. Joseph of Orange have deep roots in California, bringing health care and education to communities from the redwood forests to the beach shores of Orange county - and everywhere in between. In Southern California, Providence provides care throughout Los Angeles County, Orange County, High Desert and beyond.</p>
<p>Our award-winning and comprehensive medical centers are known for outstanding programs in cancer, cardiology, neurosciences, orthopedics, women's services, emergency and trauma care, pediatrics and neonatal intensive care. Our not-for-profit network provides a full spectrum of care with leading-edge diagnostics and treatment, outpatient health centers, physician groups and clinics, numerous outreach programs, and hospice and home care, and even our own Providence High School.</p>
<p>Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.</p>
<p><b>Requsition ID:</b> 420761
</p><p><b>Company:</b> Providence Jobs
</p><p><b>Job Category:</b> Health Information Management
</p><p><b>Job Function:</b> Revenue Cycle
</p><p><b>Job Schedule:</b> Part time
</p><p><b>Job Shift:</b> Day
</p><p><b>Career Track:</b> Nursing
</p><p><b>Department:</b> 7000 UTILIZATION MGMT OCHD
</p><p><b>Address:</b> CA Irvine 15480 Laguna Canyon Rd
</p><p><b>Work Location:</b> Providence System Offices Discovery Park-Irvine
</p><p><b>Workplace Type:</b> On-site
</p><p><b>Pay Range:</b> $57.28 - $88.92
</p><p>The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.</p></div><p></p>

Utilization Review RN - Part-time - REMOTE

Dane Street

<div>
 MUST ALREADY HAVE EXPERIENCE DOING BILL AUDIT REVIEWS FOR DIFFERENT STATES.
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 We are seeking an experienced CPC-certified medical coder with multi-state experience to perform coding audits, utilization reviews, demand package reviews, and provide litigation support including deposition and testimony services as needed. The ideal candidate must have experience reviewing medical records and billing across multiple states and payer environments.
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  Responsibilities
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   Perform comprehensive medical coding audits (ICD-10-CM, CPT, HCPCS)
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   Conduct utilization reviews to assess medical necessity and documentation compliance
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   Review and prepare demand packages for personal injury and insurance cases
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   Analyze medical records for payer disputes, recoupments, and appeals
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   Prepare detailed, defensible written audit reports
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   Provide expert review, affidavit support, deposition preparation, and testimony when required
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   Interpret CMS guidelines, LCD/NCD policies, and state-specific Medicaid and commercial payer rules
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   Review E/M services under 2021+ guidelines
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   Identify compliance risks and documentation deficiencies
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  </li>
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  Required Qualifications
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 <ul>
  <li>
   Active CPC certification through the American Academy of Professional Coders (AAPC)
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  <li>
   CPMA strongly preferred
  </li>
  <li>
   Minimum 5&ndash;7 years of professional coding experience
  </li>
  <li>
   Documented experience performing audits or utilization reviews in multiple states
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   Strong knowledge of CMS regulations and state Medicaid variations
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   Experience with Medicare, Medicare Advantage, and commercial payer audits
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   Prior demand package review or litigation support experience required
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   Deposition and/or expert testimony history preferred
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   Excellent written reporting and analytical skills
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   Ability to work independently and meet strict deadlines
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  </li>
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  Preferred Experience
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  <li>
   RAC, UPIC, or commercial payer audit response
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   Multi-state Medicaid policy interpretation
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   Expert witness experience in civil litigation
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   Data analysis and audit trend reporting
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  </li>
 </ul>
 This position may be structured as part time Candidates must be comfortable reviewing policies and payer rules across multiple jurisdictions and is able to do multiple types of reviews/audits
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  Benefits
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 </strong>
 Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additionally, we offer voluntary life insurance options for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace.
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 <strong>
  About Dane Street
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  <br/>
 </strong>
 A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers&rsquo; Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.
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General Coder - Must have experience doing bill audit reviews

MagnaCare

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 <strong>
  Primary Responsibilities
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  <br/>
 </strong>
 <ul>
  <li>
   Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
  </li>
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   Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
  </li>
  <li>
   Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning.
  </li>
  <li>
   Provides referrals to Case management, Disease Management, Appeals &amp; Grievances, and Quality Departments as needed.
  </li>
  <li>
   Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
  </li>
  <li>
   Triages and prioritizes cases and other assigned duties to meet required turnaround times.
  </li>
  <li>
   Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements.
  </li>
  <li>
   Experience with Complex Medical case reviews including but not limited to: Oncology, Clinical Trials, High Cost Medical Pharmacy and Transplants.
  </li>
  <li>
   Act as a resource for complex case discussions for all staff.
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  </li>
 </ul>
 <strong>
  Essential Qualifications
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  <br/>
 </strong>
 <ul>
  <li>
   Current licensed Registered Nurse (RN) with state licensure. Must retain active licensure throughout employment.
  </li>
  <li>
   Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
  </li>
  <li>
   Must be able to work independently.
  </li>
  <li>
   Adaptive to a high pace and changing environment.
  </li>
  <li>
   Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
  </li>
  <li>
   Working knowledge of URAC and NCQA.
  </li>
  <li>
   3+ years&rsquo; experience in a UM team within managed care setting.
  </li>
  <li>
   5+ years experience in clinical nurse setting preferred.
  </li>
  <li>
   TPA Experience preferred.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  About
  <br/>
  <br/>
 </strong>
 At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you&rsquo;ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you&rsquo;ll be encouraged to bring your authentic self to work with all of your unique abilities.
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 Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today&rsquo;s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today&rsquo;s challenges into tomorrow&rsquo;s solutions.
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 Come be a part of the Brightest Ideas in Healthcare&trade;.
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 <strong>
  Company Mission
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  <br/>
 </strong>
 Transform the health plan experience &ndash; how health care is accessed and delivered &ndash; by bringing outstanding products and services to our partners.
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  Company Vision
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  <br/>
 </strong>
 Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
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 <strong>
  DEI Purpose Statement
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  <br/>
 </strong>
 At BHPS, we encourage all team members to bring your authentic selves to work with all of your unique abilities. We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace. We are building, nurturing and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.
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 <ul>
  <li>
   We are an Equal Opportunity Employer
  </li>
 </ul>
</div>


Utilization Review Nurse, Complex Care

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