Utilization Reviewer

Required Qualifications:• Bachelor’s degree in nursing (BSN)• Active unrestricted RN license that can be validated thru PRC website• 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department• Written and verbal fluency in English•...

Required Qualifications: • Bachelor’s degree in nursing (BSN) • Active unrestricted RN license that can be validated thru PRC website • 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department • Written and verbal fluency in...

Required Qualifications Bachelor's degree in nursing (BSN) Active unrestricted RN license that can be validated thru PRC website 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department Written and verbal fluency in English Candidate should...

Required Qualifications Bachelor's degree in nursing (BSN) Active unrestricted RN license that can be validated thru PRC website 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department Written and verbal fluency in English Candidate should...

Roles and Responsibilities: • PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t...

Roles and Responsibilities: • PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t...

Summary: The Clinical Review Nurse position assesses the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the Client Claims Adjuster team to expedite medically necessary treatment for each claim. Maintains a solid understanding of Client’s mission, vision, and values. Upholds the standards of the...

Summary: The Clinical Review Nurse position assesses the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the Client Claims Adjuster team to expedite medically necessary treatment for each claim. Maintains a solid understanding of Client’s mission, vision, and values. Upholds the standards of the...

The Records Reviewer is responsible for reviewing and analyzing documents pertaining to an individual, and composing accurate and complete reviews of records, either by paraphrasing or quoting the original documents, utilizing the Client guidelines.Coordinates with the Production Supervisor and other Reviewers with regard to job assignment.Constructs clear...

Job Description :As a Business Process Analyst, you'll provide support on a variety of initiatives by analyzing existing processes, identifying process gaps, identifying areas for improvement, and developing the appropriate controls for each. You'll support business partner deliverables, including documenting business requirements, providing testing support,...

Responsibilities: Carry out quality assurance oversight activities defined in the Client Managed Care National Best Practices and Quality Assurance Standards Conduct regular and systematic review of Managed Care internal and external claim files with focus towards validation of consistent evaluation of evidence-based medicine, comprehensive assessments,...

Responsibilities: Carry out quality assurance oversight activities defined in the Client Managed Care National Best Practices and Quality Assurance Standards Conduct regular and systematic review of Managed Care internal and external claim files with focus towards validation of consistent evaluation of evidence-based medicine, comprehensive assessments,...

Responsibilities:Carry out quality assurance oversight activities defined in the Client Managed Care National Best Practices and Quality Assurance StandardsConduct regular and systematic review of Managed Care internal and external claim files with focus towards validation of consistent evaluation of evidence-based medicine, comprehensive assessments,...

Responsibilities: Research, plan, develop, implement and evaluate training strategies, initiatives, and materials including comprehensive education programs to meet orientation and ongoing competency needs and professional development needs Assess data and information related to claim medical outcome and other pertinent situations including identification of...

Responsibilities: Research, plan, develop, implement and evaluate training strategies, initiatives, and materials including comprehensive education programs to meet orientation and ongoing competency needs and professional development needs Assess data and information related to claim medical outcome and other pertinent situations including identification of...

Responsibilities:Research, plan, develop, implement and evaluate training strategies, initiatives, and materials including comprehensive education programs to meet orientation and ongoing competency needs and professional development needsAssess data and information related to claim medical outcome and other pertinent situations including identification of...

Job Description Responsibilities: Develops innovative approaches. Serves as a leader/ mentor. Comply with the terms and conditions of the employment contract, company policies and procedures. Sought out as expert. Reviews the work of others. Required Skills: BS Nursing – USRN Active Mainland License. Hospital Experience in Critical Areas (ER, Med...

Shift Schedule: NightshiftWork Setup: HybridSummary:The clinical support specialist (CSS) provides administrative support to clinical staff within Member Health. The CSS adheres to established customer service standards of accuracy, courtesy, and professionalism. This position supports timely determination turnaround times on all prior authorization requests...

Job Description: 1. Encourage customers to utilize new features that will help them drive their business forward. 2. Provide insight and relay customer feedback with internal teams, including Sales, Marketing, Product, Technical Support, Operations, Finance, and Engineering. 3. Evaluate and down sell risk for each customer and proactively...

Job Description:1. Encourage customers to utilize new features that will help them drive their business forward.2. Provide insight and relay customer feedback with internal teams, including Sales, Marketing, Product, Technical Support, Operations, Finance, and Engineering.3. Evaluate and down sell risk for each customer and proactively address...