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Conducts comprehensive clinical reviews of adverse determinations related to medical necessity. Initiates outreach to providers to obtain clarification or additional documentation in alignment with established clinical criteria and organizational policies, to support Medical Director decision making. Provides support for claim appeals in relation to medical necessity. Ensures the timely and accurate resolution of appeal cases and supports organizational adherence to all state, federal, and accreditation standards. Facilitates member second level appeal process.
EDUCATION/EXPERIENCE
Graduate from an accredited school of professional nursing is required. BSN preferred. Minimum 2 years acute care experience or managed care experience is required. Basic knowledge of Medicaid, Medicare preferred. Knowledge of InterQual screening criteria, ICD-10, CPT coding preferred.
LICENSURE
Current Registered Nurse (RN) license to practice professional nursing issued by the Board of Nurse Examiners for the State of Texas is required. Active Certification in Case Management (CCM) is preferred.
$26.61 - $39.92 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.
Quality Review Sterile Processing Tech ? Sterile Processing -Mid shift
Position Highlights:
- Position: Quality Review Sterile Processing Tech
- Location: Elmhurst, IL
- Full Time/Part Time: Full time
- Hours: Monday-Friday, 12:00noon-8:30pm, must be flexible to travel to other Endeavor Health locations.
What you will do:
- Ensures daily operational compliance with the standards governing sterile processing activities from such agencies as The Joint Commission, OSHA, AORN, AAMI; as well as state and local ordinances
- Assists in coordination, facilitation and monitoring of new and existing sterile processing staff education, training and orientation via one-on-ones, huddles, staff meetings, in-services and formal orientation in collaboration with department leadership
- Assists with the maintenance, inventory, and implementation of newly acquired and existing instrument trays/sets, instruments, and supplies
- Collaboratively works with the appropriate staff to maintain accurate instrument count sheets and make revisions as necessary
- Provides analysis of reported data and recommendations for improvement
- Assists with identification of staff educational needs and development of programs
What you will need:
- Education: Highschool or GED required, Bachelors Degree Preferred
- Certification: Certified Sterile Processing and Distribution Technician (CSPDT) - Certification Board for Sterile Processing and Distribution (CBSPD) or Certified Registered Central Service Technician (CRCST) ? Healthcare Sterile Processing Association (HSPA), formerly IAHSCMM)
- Experience: 2 years? experience in health care sterile processing (or procedural area) and environment AND experience in project management and staff education
Benefits (For full time or part time positions):
- Career Pathways to Promote Professional Growth and Development
- Various Medical, Dental, Pet and Vision options
- Tuition Reimbursement
- Free Parking
- Wellness Program Savings Plan
- Health Savings Account Options
- Retirement Options with Company Match
- Paid Time Off and Holiday Pay
- Community Involvement Opportunities
Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals ? Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) ? all recognized as Magnet hospitals for nursing excellence. For more information, visit you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.
Please explore our website ( ) to better understand how Endeavor Health delivers on its mission to ?help everyone in our communities be their best?.
Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.
Diversity, equity and inclusion is at the core of who we are; being there for our patients and each other with compassion, respect and empathy. We believe that our strength resides in our differences and in connecting our best to provide community-connected healthcare for all.
EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.
At MVP Health Care, we're on a mission to create a healthier future for everyone. That means embracing innovation, championing equity, and continuously improving how we serve our communities. Our team is powered by people who are curious, humble, and committed to making a difference-every interaction, every day. We've been putting people first for over 40 years, offering high-quality health plans across New York and Vermont and partnering with forward-thinking organizations to deliver more personalized, equitable, and accessible care. As a not-for-profit, we invest in what matters most: our customers, our communities, and our team.
What's in it for you:
- Growth opportunities to uplevel your career
- A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team
- Competitive compensation and comprehensive benefits focused on well-being
- An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District, one of the Best Companies to Work For in New York, and an Inclusive Workplace.
You'll contribute to our humble pursuit of excellence by bringing curiosity to spark innovation, humility to collaborate as a team, and a deep commitment to being the difference for our customers. Your role will reflect our shared goal of enhancing health care delivery and building healthier, more vibrant communities.
About the Opportunity
As a Professional, Prospective Review in Health Management - UM Prospective Review, you will play a crucial role in ensuring the quality and efficiency of our prospective review process. You will work closely with the healthcare team to review and assess the appropriateness of medical services, treatments and high dollar medical equipment. This is an exciting opportunity to contribute to the improvement of patient care and outcomes.
What You'll Do
- Conduct comprehensive reviews of medical records and treatment plans to determine if the requested services are appropriate based on established guidelines and medical criteria across multiple lines of business.
- Utilize your clinical expertise to evaluate medical necessity and collaborate with MVP Medical Directors to determine the effectiveness of proposed treatments/equipment.
- Document clinical summations, recommendations and send appropriate correspondences accurately and within regulatory timeframes.
- Communicate with healthcare providers and members to collect pertinent information, discuss review outcomes and provide appropriate referrals within MVP.
- Remain up to date with industry standards and guidelines, complete required competency training and proficiency examinations to ensure compliance and best practice.
- Participate in team meetings and training sessions to enhance your knowledge and skills.
- Contribute to process improvement initiatives to streamline the prospective review process.
- Other duties as assigned by leadership.
Skills and Experience
- Education, Licensures, & Certifications
- Current RN (NY or VT)
- Years of Experience (Required & Preferred)
- Minimum of 3-5 years clinical experience required
- Case management certification preferred
- Required Job Skills
- Able to manage multiple tasks in a fast-paced environment.
- Strong clinical knowledge, critical thinking skills and understanding of medical terminology, procedures, concepts.
- Ability to work independently to analyze complex medical information.
- Effective communication skills, both written and verbal.
- Ability to work independently and collaboratively in a team environment.
- Proficiency in using computer systems and software for documentation, data entry and day-to-day work functions.
- Preferred Job Skills
- Prior Utilization review experience
- Knowledge of Government Insurance Programs (Medicare, Medicaid)
Working Conditions
Secure, Quiet area for Desk/Computer to maintain HIPPA compliance
Travel Requirements
Potential for travel to regional offices
Worksite Designation
- Virtual based out of Schenectady NY
Pay Transparency
MVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role.
We do not request current or historical salary information from candidates.
$69,383.00-$92,279.00
MVP's Inclusion Statement
At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration.
MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam-era or special disabled Veteran or other legally protected classifications.
To support a safe, drug-free workplace, pre-employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team at .
The Utilization Review Physician collaborates with the healthcare team in the management and resolution of activities that assure the integrity of clinical records for the patient population and Hackensack University Medical Center.
These include but are not limited to utilization review, hospital reimbursement, clinical compliance, case management, and transitions of care, as outlined in the responsibilities below.
Education, Knowledge, Skills and Abilities Required: 1.
LanceSoft is seeking a travel nurse RN Utilization Review for a travel nursing job in Arcata, California.
Job Description & Requirements
- Specialty: Utilization Review
- Discipline: RN
- Start Date: 04/13/2026
- Duration: 13 weeks
- 40 hours per week
- Shift: 8 hours, days
- Employment Type: Travel
- 3+ Year of experience required.
- BLS Required.
- ACLS Required.
- CA State RN license required. - SS
#HCRR
About LanceSoft
Established in 2000, LanceSoft is a Certified MBE and Woman-Owned organization. Lancesoft Inc. is one of the highest rated companies in the industry. We have been recognized as one of the Largest Staffing firms and ranked in the top 50 fastest Growing Healthcare Staffing firms in 2022. Lancesoft offers short- and long-term contracts, permanent placements, and travel opportunities to credentialed and experienced professionals throughout the United States. We pride ourselves on having industry leading benefits. We understand the importance of partnering with an expert who values your needs, which is why we’re 100% committed to finding you an assignment that best matches your career and lifestyle goals. Our team of experienced career specialists takes the time to understand your needs and match you with the right job Lancesoft has been chosen by Staffing Industry Analysts as one of the Best Staffing Firms to Work for.LanceSoft specializes in providing Registered Nurses, Nurse Practitioners, LPNs/LVNs, Social Workers, Medical Assistants, and Certified Nursing Assistants to work in Acute Care Centers, Skilled Nursing Facilities, Long-Term Care centers, Rehab Facilities, Behavioral Health Centers, Drug & Alcohol Facilities, Home Health & Community Health, Urgent Care Clinics, and many other provider-based facilities.
Benefits
- Weekly pay
- Medical benefits
JOB DESCRIPTION
We are seeking detail‑oriented Document Reviewers to ensure documents meet defined standards for accuracy, formatting, and compliance. In this role, you will systematically review and compare documents against established guidelines using structured checklists, identify inconsistencies, and proofread for quality and clarity. This position is ideal for individuals with strong attention to detail and experience in editing, proofreading, or document quality review.
Key Responsibilities:
- Meet productivity and quality benchmarks in a deadline‑driven environment of 100 assets/items per week.
- Review documents against predefined guidelines and standards using structured checklists..
- Compare documents for accuracy, consistency, and compliance with requirements.
- Identify and document errors, omissions, formatting issues, and inconsistencies.
- Proofread content for grammar, spelling, punctuation, and overall clarity.
- Verify document formatting, layout, and presentation align with established standards.
- Confirm documents have incorporated recommended changes
- Record findings clearly and escalate issues as needed.
- Maintain accuracy and consistency while handling repetitive review tasks.
REQUIRED:
- 2+ years of experience reviewing documents for accuracy on a daily basis.
- Strong attention to detail and ability to spot inconsistencies or errors.
- Excellent reading comprehension and written communication skills.
- Comfort working with structured checklists and completing repetitive tasks.
PREFERRED:
- Degree or coursework in English, Communications, Journalism, Writing, or a related field.
- Experience working with style guides or compliance‑based documentation.
- Familiarity with educational formatting standards and document comparison processes.
LOCATION:
- This role requires you to live in Houston, TX or a surrounding area, so you can be on-site at least once every three months for meetings etc.
- When not on-site, you can work from home.
HOURS:
- 7am – 3:30pm or 7:30am – 4pm CST.
- Monday – Friday.
DURATION:
- This is a contract job through April of 2027.
At Tata Technologies we make product development dreams a reality by designing, engineering, and validating the products of tomorrow for the world’s leading manufacturers. Due to our continued growth, we are now recruiting for a Quality Review Coordinator (Quality Engineer) to strengthen our team in Columbus, GA.
Quality Review Coordinator (Quality Engineer)
Job Location: Columbus, GA
Duration: Full time
Citizenship Requirement: U.S. Citizen
Key Responsibilities:
Good understanding of Engine Manuals and other pertinent instruction and/or Approved Technical Data
Perform necessary mathematical computations to determine extent of nonconformance and complete appropriate paperwork.
Review and document previous history including part characteristic yield information when required by procedure or determining disposition recommendation.
Disposition basic Rework, Scrap, RTV tasks; Invoke repairs authorized by MRB via approved SRP and recommended Accept/Repair under the guidance of lead.
(Verifies/documents nonconforming characteristic classification of features being dispositioned.
Attach/record partner MRB dispositions.
Basic Qualifications:
High School Diploma or equivalent
U.S. citizenship is required, as only U.S. citizens are authorized to access information under this program/contract.
Preferred Qualifications:
1 year of inspection/quality experience required.
Previously approved by the MRB
Additional Information:
Must be a U.S. Citizen. This position may require access to systems/tools that are restricted to individuals who possess US citizenship.
Equal Opportunity Statement:
Tata Technologies Inc. is an Equal Opportunity/ Affirmative Action employer. We provide equal employment opportunities to all qualified employees and applicants for employment without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, veteran status, disability, or any other legally protected status. We prohibit discrimination in decisions concerning recruitment, hiring, compensation, benefits, training, termination, promotions, or any other condition of employment or career development.
Tata Technologies: Engineering a better world.
Tata Technologies would like to thank all applicants for their interest, each application will be reviewed against the set criteria for the role. We would like to advise that only candidates under consideration will be contacted. If you do not hear from us within 10 working days following the closing date it will mean that unfortunately your application has not been successful. We will however retain your details for any suitable future opportunities.
Position Summary
Lead position that requires multi-certification and disciplines necessary to handle project approvals from start to finish through the plan review and inspection processes in accordance with the Division's mission and performance objectives.
Direct and lead Building Inspector/Plans Examiners and seasonal/casual staff. Assist the Division Manager and Building Official with program planning and personnel direction. Oversee the coordination of the building safety plan review and inspection process. Conduct construction code reviews and inspections for residential, commercial, industrial and multi-family development proposals. Depending on the Division's needs, employees in this position may be assigned to focus primarily on plan review or inspection duties. This program is highly visible and often the first contact made with the City from those outside the community. These tasks are illustrative only and may include other related duties.
This recruitment is accepting applications for
Building Inspector/Plans Examiner III
Building Inspector/Plans Examiner IV (Plan Review Lead)
Full-Time 40 hours per week
AFSCME-represented positions
12-month probationary period
Must meet all qualifications and requirements as listed in the position description below.
Building Inspector/Plans Examiner III $38.25 - 48.66 Hourly
Building Inspector/Plans Examiner IV (Plan Review Lead) $41.27 - $52.51 Hourly
These positions are anticipated to be assigned primarily to commercial and residential plan review.Essential Duties
Building Inspector/Plans Examiner III
Leads and coordinates members of the development review and inspection teams to ensure a timely, predictable, comprehensive and accurate plan review and inspection process for any development proposal.
Reviews and inspects residential, commercial, industrial, and multi-family development proposals to ensure compliance with State and City codes/ordinances, engineering/architectural, and fire/life safety principles.
Depending on the Division's needs, performs construction plan review and site inspections:
- Conducts Pre-Development, Plan Intake, and Pre-Construction meetings.
- Takes the lead in coordinating plan reviews and inspections internally, with customers, and with other departments and agencies.
- Maintains communication with contractors to anticipate and resolve onsite issues.
- Performs building safety inspections and plan reviews.
- Calculates and assesses fees.
- Monitors permit and project status and follow-up with expired applications and permits.
- Maintains accurate records and files of construction plan reviews, inspections, and related correspondence. Archives documents as required.
- Manages phased development and deferred submittal process for assigned projects.
- Ensures special inspection and structural observation is accomplished where required.
- Recommends or issues Stop Work Orders, violation notifications, and other building code compliance actions when necessary.
- Issues final approval of construction permits.
Provides technical interpretations of code issues and requirements.
Leads and coordinates teams to investigate and resolve matters of community concern, public health, building safety and dangerous building situations. Examples include fire scene investigations, flooding, mold growth, post-earthquake inspections, electrical hazards, hazardous materials, boiler explosions, sanitation issues, mechanical failures, and any condition identified in the Dangerous Building Code.
Represents the City at national, state and local boards, meetings, hearings, seminars, classes, and public
outreach events involving construction codes or building safety.
Provides training, support and assistance to cross-trained staff, and participates in cross-training programs.
Conducts compliance verifications for appropriate contractor licensing and registration.
Acts ethically and honestly; applies ethical standards of behavior to daily work activities and interactions. Builds confidence in the City through own actions.
Conforms with all safety rules and performs work is a safe manner.
Operates a motor vehicle safely and legally.
Delivers excellent customer service to diverse audiences.
Maintains effective work relationships.
Adheres to all City and Department policies.
Arrives to work, meetings, and other work-related functions on time and maintains regular job attendance.
Building Inspector/Plans Examiner IV (Plan Review Lead)
Assists with and prepares short and long range work plans, and schedules daily activities for Building Inspector/Plans Examiners.
Directs, trains and assists Building Inspector/Plans Examiners. Participates in recruitment process. Provides input concerning performance evaluations.
Performs Construction Plan Reviews and Inspections on complex residential, commercial, industrial, and multi-family development proposals to ensure compliance with State and City codes/ordinances, engineering/architectural, and fire/life safety principles.
Coordinates scheduling and organization of Pre-Development and Pre-Construction and other related meetings. Coordinates review/inspection approvals with internal/external agencies.
Coordinates Over-the-Counter, Rapid Review, and other processes. Ensures adequate staffing and oversight of a timely, predictable, comprehensive, and accurate plan review and inspection process for any development proposal.
Monitors and inspects work and projects completed by Building Inspector/Plans Examiners and contractors. Makes field decisions on procedures and methods.
Conducts quality control and internal audits for building safety code administration and enforcement.
Assists in budget preparation. Monitors expenses. Maintains staff supplies and resources.
Provides technical expertise and guidance in interpretations of code issues and requirements for development proposals.
Leads, guides, and ensures successful staff resolution of matters of community concern, public health, building safety and dangerous building situations. Examples include fire scene investigations, flooding, mold growth, post-earthquake inspections, electrical hazards, hazardous materials, boiler explosions, sanitation issues, mechanical failures, and any condition identified in the Dangerous Building Code. When necessary, issue notices of violation, notices to vacate, dangerous building declarations and stop work orders.
Represents the City at national, state and local boards, meetings, hearings, seminars, classes, and public outreach events involving development, construction codes or building safety.
Conforms with all safety rules and performs work is a safe manner.
Operates and drives a motor vehicle safely and legally.
Delivers excellent customer service to diverse audiences.
Maintains effective work relationships.
Adheres to all City and Department policies.
Arrives to work, meetings, and other work-related functions on time and maintains regular job attendance.
Qualifications and Skills
Building Inspector/Plans Examiner III
Education and Experience
High school diploma, or equivalent required. Associates degree in Building Inspection Technology, Drafting, Engineering, Fire Prevention, or other related field preferred.
Four years of formal education, training, and/or experience in construction management, architecture, structural engineering, building design, construction inspection, and/or plan review providing the knowledge, skills and abilities necessary to perform the essential functions of the position.
Knowledge, Skills and Abilities
Thorough knowledge of construction practices, engineering concepts, and architectural principles.
Excellent customer service, communication, and public relations skills and the ability to mediate adversarial situations. Ability to proactively anticipate and mitigate problem areas before they become issues.
Prioritize and meet multiple demands by the construction industry, the general public and other City staff.
Organize, coordinate, chair, and effectively facilitate high profile meetings.
Interpret, disseminate, and communicate complex technical information, state and local construction regulations, City review process, and City policies effectively with technicians and non-technicians.
Possess a self-directed commitment to maintain current knowledge of construction standards, methods, technologies, and codes.
Get along well and maintain effective work relationships with coworkers and the public.
Special Requirements
Certifications: Incumbent must be certified in accordance with OAR 918-098. Oregon Inspector Certification is required within 60 days of appointment.
Certifications giving the incumbent the legal ability to perform work described in sets A, B, C, or D:
A: Inspection/Plan Review:
Commercial Inspection (A-Level Building, Mechanical)
Residential Inspection (Building , Mechanical)
Residential Plan Review
Commercial Plan Review (A-Level, Mechanical) must be obtained within the probationary period.
OR
B: Residential Multi-Discipline:
Residential Plan Review
Residential Inspection for 4: Building, Mechanical, Plumbing and Electrical
OR
C: Commercial Plan Review:
Commercial Plan Review (A-level, Mechanical)
Fire and Life Safety
Residential Plan Review and Residential Inspection required within the probationary period
D: Specialty Discipline- Commercial and Residential Inspection and Plan Review to include:
- Plumbing - Commercial and Residential Plumbing Inspector; obtain a Medical Gas Certification within the probationary period; or
- Electrical - Commercial and Residential Electrical Inspector; obtain a Fire Investigation Certificate within the probationary period.
Experience in use of permit tracking systems. Excellent ability to use computer hardware, printers, and computer programs to conduct inspections, complete plan reviews, communicate and present information, track progress, schedule projects, and to perform the essential functions of the position. Demonstrable commitment to quality and timely customer service.
Possession or ability to obtain a valid Oregon Drivers License.
Demonstrable commitment to sustainability.
Demonstrable commitment to promoting and enhancing equity, diversity and inclusion.
The individual shall not pose a direct threat to the health or safety of the individual or others in the workplace.
Building Inspector/Plans Examiner IV (Plan Review Lead)
Education and Experience
High school diploma, or equivalent required. Bachelor's degree in Architecture, Engineering, Construction Management, Public Administration or a closely related field preferred. Two years of experience in construction management, architecture, structural engineering, building design, construction inspection, and/or plan review.
Six years of formal education, training and/or experience in construction management, architecture, structural engineering, building design, construction inspection, and/or plan review providing the knowledge, skills and abilities necessary to perform the essential functions of the position.
Knowledge, Skills and Abilities
Thorough knowledge of construction practices, engineering concepts, and architectural principles.
Excellent customer service, communication, and public relations skills and the ability to mediate adversarial situations, and proactively anticipate and mitigate problem areas before they become issues.
Prioritize and meet multiple demands by the construction industry, the general public and other City staff.
Organize, coordinate, chair, and effectively facilitate high profile meetings.
Travel among City worksites, off-site meetings and presentations.
Interpret, disseminate, and communicate complex technical information, state and local construction regulations, City review process, and City policies effectively with technicians and non-technicians.
Experience in use of permit tracking systems. Excellent ability to use computer hardware, printers, and computer programs to conduct inspections, complete plan reviews, communicate and present information, track progress, schedule projects, and to perform the essential functions of the position.
Get along well and maintain effective work relationships with coworkers and the public.
Demonstrable commitment to quality and timely customer service.
Special Requirements
Certifications: Incumbent must be certified in accordance with OAR 918-098. Oregon Inspector Certification is required within 60 days of appointment.
State of Oregon Building Official Certification; or State of Oregon Inspector Certification and International Code Council Certified Building Official Certification, must be obtained within the probationary period.
Certifications giving the incumbent the legal ability to perform work described in sets A, B, or C:
A: Inspection/Plan Review:
Commercial Inspection (A-Level Building, Mechanical)
Commercial Plan Review (A-Level, Mechanical, Fire and Life Safety)
Residential Inspection (Building , Mechanical)
Residential Plan Review
OR
B: Residential Multi-Discipline:
Residential Plan Review
Residential Inspection for 4: Building, Mechanical, Plumbing and Electrical
OR
C: Specialty Discipline - Commercial and Residential Inspection and Plan Review to include:
- Plumbing - Commercial and Residential Plumbing Inspector plus obtain a Medical Gas Certification within the probationary period; or
- Electrical - Commercial and Residential Electrical Inspector plus obtain a Fire Investigation Certificate within the probationary period.
Demonstrable commitment to diversity and promote diversity principles with employees in day to day operations.
The individual shall not pose a direct threat to the health or safety of the individual or others in the workplace.
Ability to pass a background check and/or criminal history check
Possession or ability to obtain a valid Oregon Drivers License.
How to Apply
Qualified applicants must submit an online application located on the City of Corvallis website(click on "Apply" above).
Position is open until filled.
First review of applications will occur after 8:00 AM on Friday March 6, 2026.
Resumes will not be accepted in lieu of a completed online application.
Late or incomplete applications will not be accepted/considered.
*Please do not include personal or protected information in attached resumes or cover letters, this includes your birth date, age, dates of education, and graduation dates.*
Position Title: Clinical Review Clinician - Appeals
Work Location: Remote - Nationally sourced (Preference for 2 candidates in AZ)
Assignment Duration: 6 months
Work Schedule: 8:00 AM - 5:00 PM EST or CST
Work Arrangement: Remote
Position Summary
Schedule is 8-5 EST or CST hours. Staff will work when there are members of the supervisor/leadership on.
Cases are assigned in round robin fashion for staff to review and work.
Background & Context
The Organization's clinical team handles various types of authorization and claim review requests from various markets nationwide, processing clinical reviews to ensure members have the best outcomes and access to care needed.
Key Responsibilities
Nurses review case files, add, update or edit authorizations.
Work closely with the MD team to make final decisions on cases.
Process clinical reviews to ensure members have access to care needed.
Help reduce provider abrasion by processing retrospective claim reviews.
Work closely with supervisors, senior clinicians, and the coordinator team on end-to-end case processes.
Participate in team collaboration via Teams group chats for routine questions.
Qualification & Experience
Education/Certification (Required): Associate in nursing, Bachelor's in nursing or higher.
Licensure (Required): RN, LPN
Licensure (Preferred): LVN
Must haves:
Medicare knowledge
InterQual or Milliman Experience
Clinical reviews for Utilization Management or Appeals
Nice to haves:
Medicare Appeals Experience
Disqualifiers:
Not having a valid/active RN/LPN license
Performance indicators:
Productivity expectations vary based on platform.
Prime: 7 CPD
iCP: 9 CPD
CenPas: 20 CPD cases per day
95% quality on all cases
Candidate Requirements
Education/Certification
Required: Associate in nursing, Bachelor's in nursing or higher.
Preferred:
Licensure
Required: RN, LPN
Preferred: LVN- Years of experience required
- Disqualifiers
- Best vs. average
- Performance indicators
Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals
Nice to haves: Medicare Appeals Experience
Disqualifiers: Not having a valid/active RN/LPN license
Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases
Best vs. average: Productivity expectations are set based on platform.- Top 3 must-have hard skills
- Level of experience with each
- Stack-ranked by importance
- Candidate Review & Selection
1
Utilization Management or Appeals review background (1 plus year)
2
Medicare NCD/LCD and InterQual/Milliman Software (1 plus year)
3
Retrospective claims clinical reviews (1 plus year)
The Review Assistant II is responsible for inbound and outbound communication in support of case review activities including collection and confirmation of data integrity in support of clinical review services.
Essential functions include interpreting review guidelines to facilitate forward movement of the case review process including requests for clinical information, treatment plans, and more.
