832 Clinical Review jobs in the United States
Clinical Review Coordinator
Posted 9 days ago
Job Viewed
Job Description
As a team member of our naviHealth product, we help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days at home.
We're connecting care to create a seamless health journey for patients across care settings. Join us to start **Caring. Connecting. Growing together.**
The Care Coordinator- IRF/LTAC plays an integral role in optimizing patients' recovery journeys. The Care Coordinator- IRF/LTAC completes weekly functional assessments and engages the post-acute care (PAC) inter-disciplinary care team to coordinate discharge planning to support the members PAC journey. The position engages patients and families to share information and facilitate informed decisions. By serving as the link between patients and the appropriate health care personnel, the Clinical Review Coordinator- IRF/LTAC is responsible for ensuring efficient, smooth, and prompt transitions of care.
**Why naviHealth?**
At naviHealth, our mission is to work with extraordinarily talented people who are committed to making a positive and powerful impact on society by transforming health care. naviHealth is the result of almost two decades of dedicated visionary leaders and innovative organizations challenging the status quo for care transition solutions. We do health care differently and we are changing health care one patient at a time. Moreover, have a genuine passion and energy to grow within an aggressive and fun environment, using the latest technologies in alignment with the company's technical vision and strategy.
**Primary Responsibilities:**
+ By serving as the link between patients and the appropriate health care personnel, the Care Coordinator is responsible for ensuring efficient, smooth, and prompt transitions of care
+ Perform Inpatient Rehabilitation Facilities (IRFs) and Long-Term Acute care hospitals (LTACs) assessments on patients using clinical skills and utilizing CMS criteria upon admission to IRF and LTAC periodically through the patient stays
+ Review target outcomes, and discharge plans with providers and families
+ Complete all IRF/LTAC concurrent reviews, updating authorizations on a timely basis
+ Collaborate effectively with the patients' health care teams to establish an optimal discharge The health care team includes physicians, referral coordinators, discharge planners, social workers, physical therapists, etc.
+ Assure patients' progress toward discharge goals and assist in resolving barriers
+ Participate weekly in IRF Rounds providing accurate and up to date information to the H&C Transitions Sr. Manager or Medical Director
+ Assure appropriate referrals are made to the Health Plan, High-Risk Case Manager, and/or community-based services
+ Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed
+ Attend patient/family care conferences
+ Assess and monitor patients' continued appropriateness for IRF/LTAC setting (as indicated) according to CMS criteria
+ When H&C Transitions is delegated for utilization management, review referral requests that cannot be approved for continued stay and are forward to licensed physicians for review and issuance of the LCD when appropriate
+ Coordinate peer to peer reviews with H&C Transitions Medical Directors
+ Support new delegated contract start-up to ensure experienced staff work with new contracts
+ Manage assigned caseload in an efficiently and effectively utilizing time management skills
+ Enter timely and accurate documentation into coordinate
+ Daily review of census and identification of barriers to managing independent workload and ability to assist others
+ Review monthly dashboards, readmission reports, quarterly, and other reports with the assigned Clinical Team Manager, as needed, to assist with the identification of opportunities for improvement
+ Adhere to organizational and departmental policies and procedures
+ Maintain confidentiality of all PHI information in compliance with HIPPA, federal and state regulations, and laws
+ Complete cross-training and maintain knowledge of multiple contracts/clients to support coverage needs across the business
+ Keep current on federal and state regulatory policies related to utilization management and care coordination (CMS guidelines, Health Plan policies, and benefits)
+ Adhere to all local, state, and federal regulatory policies and procedures
+ Promote a positive attitude and work environment
+ Attend H&C Transitions meetings as requested
+ Hold patients' protected health information confidential as required by applicable laws, regulations, or agency/institution procedures
+ Perform other duties and responsibilities as required, assigned, or requested
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
**Required Qualifications:**
+ Active, unrestricted registered clinical license required in Pennsylvania or NLC - Registered Nurse
+ 5+ years of clinical experience with a solid background in acute or critical care
+ Ability to support specific location(s) for on-site facility needs within 30-mile maximum radius of home location based on manager discretion
+ Reside within or near Pittsburgh, PA - may consider remote candidate with qualified background
+ Driver's License and access to a reliable transportation
**Preferred Qualifications:**
+ Experience working with the geriatric population
+ Familiarity with care management, utilization/resource management processes and disease management programs
+ Patient education background, rehabilitation, LTAC, ICU
+ Proficient with Microsoft Office applications including Outlook, Excel and PowerPoint
+ Proven to be detail-oriented
+ Proven to be a team player
+ Proven exceptional verbal and written interpersonal and communication skills
+ Proven solid problem solving, conflict resolution, and negotiating skills
+ Proven independent problem identification/resolution and decision-making skills
+ Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously
**Work Conditions and Physical Requirements**
+ Ability to establish a home office workspace
+ Ability to manipulate laptop computer (or similar hardware) between office and site settings
+ Ability to view screen and enter data into a laptop computer (or similar hardware) within a standard period of time
+ Ability to communicate with clients and team members including use of cellular phone or comparable communication device
+ Ability to remain stationary for extended time periods (1 - 2 hours)
+ Ability to mobilize to and within sites within an assigned local or regional market/area, including car transport, up to 25% of the time
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $34.23 to $61.15 per hour based on full-time employment. We comply with all minimum wage laws as applicable.
_At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission._
_UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations._
_UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment._
Clinical Review Registered Nurse
Posted today
Job Viewed
Job Description
COMPENSATION: The base salary range for this position is $73,000 - $82,000. Additional compensation opportunities and incentives will be detailed during the interview process. Please note that the range listed above is our good faith estimate of the hiring range for this role. If you are hired at Blue Cross and Blue Shield of Vermont, your final base salary compensation will be determined based on factors such as skills, competencies, education, experience, and internal equity across the current team. We also offer a robust benefits package with significant value (see below).
LOCATION: Blue Cross has transitioned to a hybrid workplace where employees within driving distance of our Berlin, VT office work Wednesdays in the office with flexibility to work remotely the rest of the week. We are only hiring Vermonters for this role.
The Clinical Review Registered Nurse will be responsible for facilitating members' healthcare needs, authorizing medically necessary services including behavioral health at the right level of care to promote optimal health.
Clinical Review Registered Nurse Responsibilities:
- Self-directed and works independently and collaboratively with the team to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies.
- Conduct clinical reviews for preservice, concurrent, and retrospective authorizations that promote efficient and medically appropriate use of members benefits to provide cost effective and high-quality care.
- Emphasis on utilization management, discharge planning, clinical outcomes and the ability to assess, analyze, draw conclusions, and construct effective solutions, identify questionable cases and refer to superior or medical director for review.
- Proficient with multiple IT systems.
- Strong written and spoken communication skills
- Able to follow regulatory requirements with audit feedback incorporated into future work.
Clinical Review Registered Nurse Qualifications:
- RN with Vermont License required, BSN desired.
- 3-5 years of relevant experience in a variety of appropriate clinical health care settings (inpatient, outpatient, or differing levels of care),
- 1- 3 years of insurance related experience desired.
- Must be willing to participate in on-going CEU training.
- Must be willing to participate in after hours on call rotation
Clinical Review Registered Nurse Benefits:
- Health insurance (including vision)
- Dental coverage (free to employees)
- Wellness Program
- 401(k) with employer match + automatic employer contribution
- Life Insurance
- Disability Insurance
- Combined time off (CTO) - 20 days per year + 10 paid holidays
- Tuition Reimbursement
- Student Loan Repayment
- Dependent Caregiver Benefits
Diversity, Equity, and Inclusion: Blue Cross VT is committed to creating an inclusive environment where employees respect, appreciate, and value individual differences, both among ourselves and in our communities. We welcome applicants from all backgrounds and experiences to join us in our commitment to the health of Vermonters, outstanding member experiences, and responsible cost management for all the people whose lives we touch. Learn more about our DE&I commitment at job description attached to ADP posting
Clinical Review Clinician - Appeals
Posted 2 days ago
Job Viewed
Job Description
Clinical Review Clinician - Appeals: Job Title: Clinical Review Clinician - Appeals Address: Various, Ohio 999 Schedule: Full shift, various days and times Job Description: Bullet point description of duties… Critical Information: Bullet points about travel, residency, etc†Education/Licenses Needed: Required certifications and degrees†Benefits: Benefits are available to full-time employees after 90 days of employment. A 401(k) with company match is available to full-time employees after 1 year of service. This is an AI-formatted job description; therefore, this does not remove human decision-making. Verify with a Recruiter or Staffing Manager!
Clinical Review Clinician - Appeals
Posted 2 days ago
Job Viewed
Job Description
Position Title: Clinical Review Clinician - Appeals
Work Location: Remote in Ohio - Columbus area preferred
Assignment Duration: 6 months (Potential to extend or convert)
Work Schedule: 8am-5pm
Position Summary: Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
Background & Context:
Buckeye HP
Cohesive; works closely together (including with Sups) to ensure any assistance needed
Backfill for temp, Megan Moss, who retired her role on 8/14
Key Responsibilities:Perform appeal review for medical necessity
Complete appeal cases (making determination, documenting outcome, sending out letter, and closing out appeal in system)
Behavior and accountability and ability to pivot when new priorities come up
Emails and Team chats to ensure communication is reached and assistance is available, if needed
Qualification & Experience:Required: LPN Minimum
Preferred: RN - Not required
Licensure: Required LPN minimum
Must haves:
Experience with Utilization Review/Management - 2 yrs
Reviews relevant information within denied authorization/prior authorization case to ensure a complete case summary is provided to the Medical Director for review of the appeal case.
Review medical code data and records to determine whether a denial is warranted.
Utilizing multiple appeals/claims systems to conduct medical reviews.
Comfortable with Microsoft office programs and utilizing systems to input medical criteria.
Nice to haves: Direct patient care experience; Longevity at positions; Writing appeal or authorization outcome letters; Experience with Trucare and/or Amisys systems.
Disqualifiers: Not possessing the must haves
Performance indicators: 10 to 15 appeals a day after training. Not letting any items in work queues go over compliance Turn Around Time.
Clinical Review Clinician - Appeals
Posted 3 days ago
Job Viewed
Job Description
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Must have a New York State clinical license.
Hours: 8:30am-5pm EST Monday - Friday.
Position Purpose: Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
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Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
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Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
-
Communicates with members, providers, facilities, and other departments regarding appeals requests
-
Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
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Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
-
Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
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Performs other duties as assigned
-
Complies with all policies and standards
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
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LPN - Licensed Practical Nurse - State Licensure required or
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LVN - Licensed Vocational Nurse required or
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RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
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LCSW- License Clinical Social Worker required or
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LMHC-Licensed Mental Health Counselor required or
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LPC-Licensed Professional Counselor required or
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Licensed Marital and Family Therapist (LMFT) required or
-
Licensed Psychologist required
Pay Range: $26.50 - $47.59 per hour
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Clinical Review Registered Nurse
Posted 7 days ago
Job Viewed
Job Description
COMPENSATION: The base salary range for this position is $73,000 - $82,000. Additional compensation opportunities and incentives will be detailed during the interview process. Please note that the range listed above is our good faith estimate of the hiring range for this role. If you are hired at Blue Cross and Blue Shield of Vermont, your final base salary compensation will be determined based on factors such as skills, competencies, education, experience, and internal equity across the current team. We also offer a robust benefits package with significant value (see below).
LOCATION: Blue Cross has transitioned to a hybrid workplace where employees within driving distance of our Berlin, VT office work Wednesdays in the office with flexibility to work remotely the rest of the week. We are only hiring Vermonters for this role.
The Clinical Review Registered Nurse will be responsible for facilitating members' healthcare needs, authorizing medically necessary services including behavioral health at the right level of care to promote optimal health.
Clinical Review Registered Nurse Responsibilities:
* Self-directed and works independently and collaboratively with the team to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies.
* Conduct clinical reviews for preservice, concurrent, and retrospective authorizations that promote efficient and medically appropriate use of members benefits to provide cost effective and high-quality care.
* Emphasis on utilization management, discharge planning, clinical outcomes and the ability to assess, analyze, draw conclusions, and construct effective solutions, identify questionable cases and refer to superior or medical director for review.
* Proficient with multiple IT systems.
* Strong written and spoken communication skills
* Able to follow regulatory requirements with audit feedback incorporated into future work.
Clinical Review Registered Nurse Qualifications:
* RN with Vermont License required, BSN desired.
* 3-5 years of relevant experience in a variety of appropriate clinical health care settings (inpatient, outpatient, or differing levels of care),
* 1- 3 years of insurance related experience desired.
* Must be willing to participate in on-going CEU training.
* Must be willing to participate in after hours on call rotation
Clinical Review Registered Nurse Benefits:
* Health insurance (including vision)
* Dental coverage (free to employees)
* Wellness Program
* 401(k) with employer match + automatic employer contribution
* Life Insurance
* Disability Insurance
* Combined time off (CTO) - 20 days per year + 10 paid holidays
* Tuition Reimbursement
* Student Loan Repayment
* Dependent Caregiver Benefits
Diversity, Equity, and Inclusion: Blue Cross VT is committed to creating an inclusive environment where employees respect, appreciate, and value individual differences, both among ourselves and in our communities. We welcome applicants from all backgrounds and experiences to join us in our commitment to the health of Vermonters, outstanding member experiences, and responsible cost management for all the people whose lives we touch. Learn more about our DE&I commitment at Complete job description attached to ADP posting
Clinical Review Registered Nurse
Posted 7 days ago
Job Viewed
Job Description
This position executes utilization management processes to ensure the delivery of medically necessary and appropriate, cost-effective and high-quality care through the performance of clinical reviews. Reviews requests against standardized medical necessity and appropriateness criteria for an initial and a continued service authorization. Identifies questionable cases and refers to superior or a medical director for review.
Top 3 Required Skills/Experience -
- Subject Matter Expertise
- Strong knowledge base in health care delivery systems, health insurance, medical care practices and trends, regulatory and accreditation agencies/standards, and provider network management.
- Strong knowledge of all Plan products and services benefits that effect clinical decision making.
- Strong knowledge of clinical nursing practice.
- Communication Skills - Strong written and oral communication skills
- Interpersonal Skills - Strong interpersonal skills
- Organizational Abilities - Strong organizational skills
- 5 - 7 years of clinical practice required
- 1- 3 years of insurance related experience desired.
- Willing to participate in required on-going CEU training.
- Licensed RN ; BSN desired; Licensed in compact state desired
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Clinical Review Clinician - Appeals
Posted 4 days ago
Job Viewed
Job Description
**Must have a New York State clinical license.**
**Hours: 8:30am-5pm EST Monday - Friday.**
**Position Purpose:** Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
+ Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
+ Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
+ Communicates with members, providers, facilities, and other departments regarding appeals requests
+ Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
+ Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
+ Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
+ Performs other duties as assigned
+ Complies with all policies and standards
**Education/Experience:** Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
**License/Certification:**
+ LPN - Licensed Practical Nurse - State Licensure required or
+ LVN - Licensed Vocational Nurse required or
+ RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
+ LCSW- License Clinical Social Worker required or
+ LMHC-Licensed Mental Health Counselor required or
+ LPC-Licensed Professional Counselor required or
+ Licensed Marital and Family Therapist (LMFT) required or
+ Licensed Psychologist required
Pay Range: $26.50 - $47.59 per hour
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Sleep Clinical Review Technician
Posted 17 days ago
Job Viewed
Job Description
At **Hackensack Meridian** **_Health_** we help our patients live better, healthier lives - and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one another and how we show up for our community.
Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.
The **Sleep Clinical Review Technician** is responsible for clinical history, signs/symptoms, diagnosis code and test order review. Works directly with team members and ordering clinicians and their staff to educate and support appropriate documentation for coding, authorizations and appropriate testing.
This position will offer a hybrid schedule. Will be on site in Neptune/ Edison on occasion. Must also have the ability to travel to various sites within the network if needed.
**Education, Knowledge, Skills and Abilities Required** :
+ High School diploma, general equivalency diploma (GED), and/or GED equivalent programs or equivalent relevant experience.
+ Minimum of 2 years of Healthcare experience.
+ Prior experience with Authorizations, Scheduling and Coding of associated testing.
**Education, Knowledge, Skills and Abilities Preferred** :
+ More than 5 years healthcare experience
**Licenses and Certifications Required** :
+ Registered Polysomnography Technologist Certification.
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!
159247
Starting at $34.65 Hourly
**HMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market-competitive total rewards package.**
**The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non-discriminatory factors, including but not limited to: Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness. Experience: Years of relevant work experience. Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training. Skills: Demonstrated proficiency in relevant skills and competencies. Geographic Location: Cost of living and market rates for the specific location. Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization. Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered. Some jobs may also be eligible for performance-based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts.**
**In addition to our compensation for full-time and part-time (20+ hours/week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.**
HACKENSACK MERIDIAN HEALTH (HMH) IS AN EQUAL OPPORTUNITY EMPLOYER
All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, breastfeeding, genetic information, refusal to submit to a genetic test or make available to an employer the results of a genetic test, atypical hereditary cellular or blood trait, national origin, nationality, ancestry, disability, marital status, liability for military service, or status as a protected veteran.