Utilization Reviewer

This role is an open-end contract position with a hybrid work setup. Please apply only if you are amenable to these terms.The Utilization Reviewer evaluates the appropriateness and necessity of medical services provided to patients. Meticulously reviewing medical records ensures that care aligns with medical guidelines, insurance coverage, and patient needs....

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...

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...

Nezda is currently looking for Utilization Review Nurse (USRN) - WFH candidates.Qualifications: Active USRN and PHRN License With at least 1 Year Clinical or Hospital ExperienceJob Description: Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits and contracts. Responsible for conducting...

This role is an open-end contract position with a hybrid work setup. Please apply only if you are amenable to these terms.The Quality Improvement Specialist is responsible for ensuring the quality and compliance of utilization management processes within the organizations. They will also ensure quality and effectiveness as well as compliance with all the...

This role is an open-end contract position with a hybrid work setup. Please apply only if you are amenable to these terms.The Clinical Trainer is responsible for developing and delivering training programs to onboarding nurses and other contractors joining the company, collaborating with subject matter experts to design curriculum, develop training...

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,...

This role is an open-end contract position with a hybrid work setup. Please apply only if you are amenable to these terms.The Clinical Document Specialist assists in clarifying documentation regarding patient diagnoses and/or procedures, co-morbid conditions, complications, and any other related data for reporting. The work involves the use of proprietary...

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,...

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...

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...