Applied Cloud Computing Reviews Jobs in Usa
9,273 positions found — Page 13
The Upfront Review Clerk is responsible for the quality review of all pertinent customer information for accuracy and completeness in order to meet payer requirements for timely and maximum reimbursement.
Responsibilities include:
- Evaluating all received documents to ensure that appropriate information has been obtained to allow for successful Accounts Receivable
- Maintaining Held Sales by assisting customer service representatives weekly in correcting problems so billing may begin or continue
- Responsible for reviewing various reports for quality assurance
- Recording all activity relating to the account in tickler files
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.
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.
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.
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.
Position Title: Medical Reviewer
Work Location: Remote
Assignment Duration: 12 Months
Job Description:
We are seeking a contract Medical Reviewer to support our international Botox Therapeutic Neurotoxin team. The ideal candidate will be responsible for the medical review of clinical and scientific data related to the use of Botox for various therapeutic indications.
Key responsibilities include ensuring the accuracy and compliance of content with regulatory and company standards, providing expert medical input on clinical documents and safety information, and collaborating with cross-functional teams globally.
Qualifications:
The candidate should have a medical degree (MD or equivalent), clinical experience in neurology, physical medicine, or related fields, and a solid understanding of regulatory requirements for therapeutic neurotoxins. Experience with Botox or neurotoxin therapies is strongly preferred. Excellent communication and detail-orientation are essential.
Must have experience as a Reviewer OUS, understanding regulatory complexities of international markets.
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)
This position coordinates utilization review service for defined patient populations across the acute care continuum. This includes discharge planning, utilization management, care coordination collaboration, and support for resource utilization. This position works collaboratively with an interdisciplinary team to improve patient care through the effective utilization of the facility's resources.
1. Current licensure as a Registered Nurse (RN) in the state of California is required.
2. Current American Heart Association (AHA) Healthcare Provider CPR card is preferred.
3. Degree from an accredited baccalaureate nursing program (BSN) is preferred.
4. Certified Case Manager (CCM) national certification is preferred.
5. Interquel training must be obtained within six (6) months of hire into position.
6. Previous experience in at least two (2) areas of clinical specialty in an acute care setting is required.
7. Excellent communication skills, critical thinking, creative problem-solving skills, and competent organizational and planning skills are required.
8. The incumbent must be self-directed and able to tolerate frequent interruptions with a demanding workload.
9. Knowledge regarding hospital protocol and procedures, clinical standards and outcomes, funding options, familiarity with community resources and outside professional agencies, familiarity with federal and state regulations governing hospital and home care, as well as understanding of the financial structure of health plan and delivery system is preferred.
Pay Range:
$49.47 - 71.74
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. 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 any other status protected by federal, state, or local law.
Certification Details
- BLS
- California RN License
Job Details
- Utilization Review Nurse II represents the fully experienced level in utilization review and discharge planning activities.
- Obtains and evaluates medical records for in-patient admissions to determine if required documentation is present.
- Obtains appropriate records as required by payor agencies and initiates Physician Advisories as necessary for unwarranted admissions.
- Conducts on-going reviews and discusses care changes with attending physicians and others.
- Formulates and documents discharge plans.
- Provides on-going consultation and coordination with multiple services within the hospital to ensure efficient use of hospital resources.
- Identifies pay source problems and provides intervention for appropriate referrals.
- Coordinates with admitting office to avoid inappropriate admissions.
- Coordinates with clinic areas in scheduling specialized tests with other health care providers, assessing pay source and authorizing payment under Medically Indigent Adult program as necessary.
- Reviews and approves surgery schedule to ensure elective procedures are authorized.
- Coordinates with correctional facilities to determine appropriate use of elective procedures, durable medical goods and other services.
- Answers questions from providers regarding reimbursement, prior authorization and other documentation requirements.
- Learns the documentation requirements of payor sources to maximize reimbursement to the hospital.
- Keeps informed of patient disease processes and treatment modalities.
- Level II teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital.
- Level II may assist in training Utilization Review Nurse I's.
- Knowledge of payor source documentation requirements and governmental regulations affecting reimbursement; knowledge of acute care nursing principles, methods and commonly used procedures; knowledge of common patient disease processes and the usual methods for treating them; knowledge of medical terminology, hospital routine and commonly used equipment; knowledge of acute hospital organization and the interrelationships of various clinical and diagnostic services.
- Ability to effectively evaluate the medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans.
- Ability to assess and judge the clinical performance of physicians and other health professionals.
- Ability to communicate documentation needs in an effective and tactful manner that promotes cooperation.
- Ability to teach co-workers what is needed and required in the medical record for reimbursement and audit purposes.
- Ability to gather and analyze data and prepare reports and recommendations based thereon.
- Ability to get along with physicians, other health providers, outside payor sources and the general public.
- Performs other job related duties as assigned.
Job Requirements
- Possession of a valid license as a Registered Nurse in the State of California.
- Level I: two (2) years of experience or its equivalent as a registered nurse in an acute care hospital, at least one (1) of which was on a medical/surgical ward or unit.
- Level II: one (1) year of utilization review/discharge planning experience in an acute care hospital or as a Case Manager in an alternate medical setting such as a clinic or physician’s office performing utilization review or discharge planning.
- Alternatively, possession of a valid license as a Registered Nurse in the State of California and five (5) years of experience as a Case Manager in an alternate medical setting such as a clinic or physician’s office performing utilization or discharge planning.
- Incumbents may be required to possess and maintain specific certificates competency based on unit specific requirements as a condition of employment.
Additional Details
- Case management experience in California (excluding Kaiser), preferably more than 1 assignment.
- Able to do both Utilization review and Care Coordination/Discharge planning.
- Experience in acute care/ICU/ED units.
- Extra: Trauma facilities experience.
- Experience with teaching facilities.
