Carshield Reviews Bbb Jobs in Usa
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RN Clinical Review Nurse {167271}
Salary not disclosed
Clinical Review Nurse Schedule for Clinical Review Nurse Monday – Friday | 8:00 AM – 5:00 PM Interview Process for Clinical Review Nurse One virtual interview Job Overview for Clinical Review Nurse We are seeking an experienced Clinical Review Nurse to support the investigation and resolution of complex member and provider grievances, appeals, and disputes .
This role is responsible for conducting detailed clinical reviews, evaluating medical necessity, and ensuring compliance with applicable regulatory requirements and organizational policies.
The Clinical Review Nurse will collaborate with internal teams and medical leadership to ensure timely and accurate resolution of cases while maintaining high standards of care and service.
Key Responsibilities for Clinical Review Nurse Conduct investigations and clinical reviews of member and provider grievances and appeals related to medical necessity .
Review prospective, inpatient, and retrospective medical records associated with denied services.
Summarize and present medical findings for Medical Directors, consultants, and external reviewers .
Apply clinical guidelines, policies, and benefit plan documentation when evaluating cases.
Prepare recommendations to uphold or overturn determinations and submit to the Medical Director for final approval.
Ensure appeals, grievances, and disputes are resolved within required regulatory timelines .
Evaluate requests for expedited review and determine urgency criteria.
Document case details and maintain accurate records within relevant tracking systems.
Draft written correspondence for members, providers, and regulatory entities .
Communicate with members, providers, and internal staff to support resolution of clinical concerns.
Identify potential quality-of-care concerns and escalate appropriately.
Serve as a clinical resource and subject matter expert to assist team members with appeals and grievance resolution.
Participate in additional projects and duties as assigned.
Essential Functions for Clinical Review Nurse Conduct thorough investigations of appeals, grievances, and provider disputes .
Evaluate the appropriateness of care within contractual, regulatory, and accreditation standards.
Identify system or process issues that may impact member care or service expectations and recommend improvements.
Perform documentation, reporting, and analytical tasks related to case reviews.
Maintain compliance with organizational policies, regulatory requirements, and professional standards .
Minimum Qualifications for Clinical Review Nurse Education / Licensing Active and unrestricted California Registered Nurse (RN) license Bachelor’s degree preferred Experience for Clinical Review Nurse Minimum 3 years of acute care clinical experience Minimum 2 years of appeals and grievances casework Preferred Experience for Clinical Review Nurse Utilization Management or Quality Management Experience applying standardized clinical guidelines Familiarity with Milliman Care Guidelines (MCG) , Managed Care, and NCQA standards Additional Details for Clinical Review Nurse No direct supervisory responsibilities Collaborative role working with clinical, operational, and leadership teams If you are an experienced nurse with strong clinical review and case evaluation skills and are looking to contribute to a team focused on quality care and regulatory excellence, we encourage you to apply.
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This role is responsible for conducting detailed clinical reviews, evaluating medical necessity, and ensuring compliance with applicable regulatory requirements and organizational policies.
The Clinical Review Nurse will collaborate with internal teams and medical leadership to ensure timely and accurate resolution of cases while maintaining high standards of care and service.
Key Responsibilities for Clinical Review Nurse Conduct investigations and clinical reviews of member and provider grievances and appeals related to medical necessity .
Review prospective, inpatient, and retrospective medical records associated with denied services.
Summarize and present medical findings for Medical Directors, consultants, and external reviewers .
Apply clinical guidelines, policies, and benefit plan documentation when evaluating cases.
Prepare recommendations to uphold or overturn determinations and submit to the Medical Director for final approval.
Ensure appeals, grievances, and disputes are resolved within required regulatory timelines .
Evaluate requests for expedited review and determine urgency criteria.
Document case details and maintain accurate records within relevant tracking systems.
Draft written correspondence for members, providers, and regulatory entities .
Communicate with members, providers, and internal staff to support resolution of clinical concerns.
Identify potential quality-of-care concerns and escalate appropriately.
Serve as a clinical resource and subject matter expert to assist team members with appeals and grievance resolution.
Participate in additional projects and duties as assigned.
Essential Functions for Clinical Review Nurse Conduct thorough investigations of appeals, grievances, and provider disputes .
Evaluate the appropriateness of care within contractual, regulatory, and accreditation standards.
Identify system or process issues that may impact member care or service expectations and recommend improvements.
Perform documentation, reporting, and analytical tasks related to case reviews.
Maintain compliance with organizational policies, regulatory requirements, and professional standards .
Minimum Qualifications for Clinical Review Nurse Education / Licensing Active and unrestricted California Registered Nurse (RN) license Bachelor’s degree preferred Experience for Clinical Review Nurse Minimum 3 years of acute care clinical experience Minimum 2 years of appeals and grievances casework Preferred Experience for Clinical Review Nurse Utilization Management or Quality Management Experience applying standardized clinical guidelines Familiarity with Milliman Care Guidelines (MCG) , Managed Care, and NCQA standards Additional Details for Clinical Review Nurse No direct supervisory responsibilities Collaborative role working with clinical, operational, and leadership teams If you are an experienced nurse with strong clinical review and case evaluation skills and are looking to contribute to a team focused on quality care and regulatory excellence, we encourage you to apply.
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Not Specified
P
Registered Nurse Clinical Review-Hybrid-Los Angeles, California
Salary not disclosed
The Clinical Consultant – RN provides clinical leadership, consultation, and oversight across care management programs.
This role supports interdisciplinary care teams serving individuals with complex medical, behavioral health, and social needs, including people experiencing homelessness, serious mental illness, substance use disorders, chronic disease, and socioeconomic instability.
The Clinical Consultant – RN partners with Care Managers, Behavioral Health clinicians, Primary Care Providers, hospitals, Managed Care Plans, and community-based organizations to ensure high-quality, whole-person, and evidence-based care.
This position plays a critical role in care planning, clinical decision-making, transitions of care, medication management, quality improvement, and staff development while addressing social determinants of health and system barriers to care.
Essential Duties and Responsibilities Clinical Oversight & Consultation Provide clinical support and consultation to Care Managers, and interdisciplinary care teams across care management programs.
Serve as a clinical resource for chronic disease management, medication monitoring, and complex case review.
Guide staff in ensuring member safety and provide immediate consultation and escalation support for high-risk clinical situations.
Ensure clinical services align with evidence-based practices, regulatory standards, and program contracts, including requirements with Managed Care Plans (MCPs).
Care Planning & Coordination Provide clinical oversight and tracking of comprehensive intake assessments.
Participate in the development, review, and approval of patient-centered care plans, including initial plans and required updates.
Monitor progress toward care plan goals and recommend adjustments based on clinical findings and data.
Collaborate with Primary Care Providers, Behavioral Health clinicians, specialists, ACOs, MCOs, hospitals, and community partners to ensure services outlined in care plans are delivered.
Coordinate hospital admissions, discharges, and transitions of care to promote continuity, safety, and prevent avoidable readmissions.
Perform timely medication reconciliation following transitions of care and support medication adherence.
Data, Quality Improvement & Compliance Use data to evaluate outcomes of targeted interventions and assist in modifying care plans and care strategies accordingly.
Participate in quality improvement initiatives, audits, peer reviews, and program evaluations conducted by internal leadership, health plans, or external administrators.
Monitor continuous quality improvement measures through documentation review, clinical consultation, and chart audits.
Oversee charting and documentation standards to ensure compliance with contracts, program requirements, and organizational policies.
Documentation & Systems Complete and review care plans, assessments, and case notes using required systems (e.g., Salesforce, EHRs, or health plan platforms).
Maintain accurate, timely, and compliant documentation using SMART format where applicable.
Ensure confidentiality and compliance with HIPAA and all applicable federal and state regulations.
Staff Development & Team Collaboration Provide staff development training, coaching, and clinical guidance for care management staff.
Participate in weekly, bi-weekly, and monthly interdisciplinary care team meetings to review client progress, evaluate program effectiveness, and develop strategies to enhance care delivery.
Present cases and clinical insights during scheduled case conferences.
Attend required trainings, webinars, meetings, and conferences to maintain clinical excellence and program knowledge.
Support and expand programming that addresses social determinants of health and strengthens connections to community-based organizations.
Promote monthly health promotion topics and materials aligned with program priorities.
Expectations & Professional Standards Prioritize client health, safety, dignity, and self-determination.
Communicate with professionalism, tact, and cultural humility.
Demonstrate the ability to work under pressure and manage multiple complex priorities.
Maintain strict confidentiality and ethical standards.
Adapt effectively to change and support continuous improvement.
Model openness, honesty, accountability, and teamwork.
Demonstrate sensitivity to cultural, linguistic, and socioeconomic diversity.
Adhere to organizational safety policies, compliance standards, and guiding principles.
Required Qualifications Active and unrestricted Registered Nurse (RN) license in the State of California, in good standing.
Experience working with vulnerable populations, including individuals with histories of trauma, homelessness, substance use disorders, serious mental illness, or socioeconomic stress.
Strong clinical assessment, critical thinking, and problem-solving skills.
Comfort working autonomously in community-based and outreach settings.
Experience using data to track outcomes and measure performance.
Basic computer proficiency, including email, spreadsheets, and electronic documentation.
Valid California Driver’s License and proof of auto liability insurance meeting state of California minimum requirements.
Knowledge and applied practice of HIPAA compliance and healthcare regulations.
Preferred Qualifications Bilingual in English and Spanish.
Partners in Care Foundation is an equal opportunity employer.
We are committed to complying with all federal, state, and local laws providing equal employment opportunities, and all other employment laws and regulations.
It is our intent to maintain a work environment which is free of harassment, discrimination, or retaliation because of age, race (including hair texture and protective hairstyles, such as braids, locks, and twists), color, national origin, ancestry, religion, sex, sexual orientation, pregnancy (including childbirth, lactation/breastfeeding, and related medical conditions), physical or mental disability, genetic information (including testing and characteristics, as well as those of family members), veteran status, uniformed service member status, gender, gender identity, gender expression, transgender status, arrest or conviction record, domestic violence victim status, credit history, unemployment status, caregiver status, sexual and reproductive health decisions, salary history or any other status protected by federal, state, or local laws.
All qualified applicants will receive consideration for employment and reasonable accommodations may be made to enable qualified individuals to perform the essential functions of the position.
Remote working/work at home options are available for this role.
This role supports interdisciplinary care teams serving individuals with complex medical, behavioral health, and social needs, including people experiencing homelessness, serious mental illness, substance use disorders, chronic disease, and socioeconomic instability.
The Clinical Consultant – RN partners with Care Managers, Behavioral Health clinicians, Primary Care Providers, hospitals, Managed Care Plans, and community-based organizations to ensure high-quality, whole-person, and evidence-based care.
This position plays a critical role in care planning, clinical decision-making, transitions of care, medication management, quality improvement, and staff development while addressing social determinants of health and system barriers to care.
Essential Duties and Responsibilities Clinical Oversight & Consultation Provide clinical support and consultation to Care Managers, and interdisciplinary care teams across care management programs.
Serve as a clinical resource for chronic disease management, medication monitoring, and complex case review.
Guide staff in ensuring member safety and provide immediate consultation and escalation support for high-risk clinical situations.
Ensure clinical services align with evidence-based practices, regulatory standards, and program contracts, including requirements with Managed Care Plans (MCPs).
Care Planning & Coordination Provide clinical oversight and tracking of comprehensive intake assessments.
Participate in the development, review, and approval of patient-centered care plans, including initial plans and required updates.
Monitor progress toward care plan goals and recommend adjustments based on clinical findings and data.
Collaborate with Primary Care Providers, Behavioral Health clinicians, specialists, ACOs, MCOs, hospitals, and community partners to ensure services outlined in care plans are delivered.
Coordinate hospital admissions, discharges, and transitions of care to promote continuity, safety, and prevent avoidable readmissions.
Perform timely medication reconciliation following transitions of care and support medication adherence.
Data, Quality Improvement & Compliance Use data to evaluate outcomes of targeted interventions and assist in modifying care plans and care strategies accordingly.
Participate in quality improvement initiatives, audits, peer reviews, and program evaluations conducted by internal leadership, health plans, or external administrators.
Monitor continuous quality improvement measures through documentation review, clinical consultation, and chart audits.
Oversee charting and documentation standards to ensure compliance with contracts, program requirements, and organizational policies.
Documentation & Systems Complete and review care plans, assessments, and case notes using required systems (e.g., Salesforce, EHRs, or health plan platforms).
Maintain accurate, timely, and compliant documentation using SMART format where applicable.
Ensure confidentiality and compliance with HIPAA and all applicable federal and state regulations.
Staff Development & Team Collaboration Provide staff development training, coaching, and clinical guidance for care management staff.
Participate in weekly, bi-weekly, and monthly interdisciplinary care team meetings to review client progress, evaluate program effectiveness, and develop strategies to enhance care delivery.
Present cases and clinical insights during scheduled case conferences.
Attend required trainings, webinars, meetings, and conferences to maintain clinical excellence and program knowledge.
Support and expand programming that addresses social determinants of health and strengthens connections to community-based organizations.
Promote monthly health promotion topics and materials aligned with program priorities.
Expectations & Professional Standards Prioritize client health, safety, dignity, and self-determination.
Communicate with professionalism, tact, and cultural humility.
Demonstrate the ability to work under pressure and manage multiple complex priorities.
Maintain strict confidentiality and ethical standards.
Adapt effectively to change and support continuous improvement.
Model openness, honesty, accountability, and teamwork.
Demonstrate sensitivity to cultural, linguistic, and socioeconomic diversity.
Adhere to organizational safety policies, compliance standards, and guiding principles.
Required Qualifications Active and unrestricted Registered Nurse (RN) license in the State of California, in good standing.
Experience working with vulnerable populations, including individuals with histories of trauma, homelessness, substance use disorders, serious mental illness, or socioeconomic stress.
Strong clinical assessment, critical thinking, and problem-solving skills.
Comfort working autonomously in community-based and outreach settings.
Experience using data to track outcomes and measure performance.
Basic computer proficiency, including email, spreadsheets, and electronic documentation.
Valid California Driver’s License and proof of auto liability insurance meeting state of California minimum requirements.
Knowledge and applied practice of HIPAA compliance and healthcare regulations.
Preferred Qualifications Bilingual in English and Spanish.
Partners in Care Foundation is an equal opportunity employer.
We are committed to complying with all federal, state, and local laws providing equal employment opportunities, and all other employment laws and regulations.
It is our intent to maintain a work environment which is free of harassment, discrimination, or retaliation because of age, race (including hair texture and protective hairstyles, such as braids, locks, and twists), color, national origin, ancestry, religion, sex, sexual orientation, pregnancy (including childbirth, lactation/breastfeeding, and related medical conditions), physical or mental disability, genetic information (including testing and characteristics, as well as those of family members), veteran status, uniformed service member status, gender, gender identity, gender expression, transgender status, arrest or conviction record, domestic violence victim status, credit history, unemployment status, caregiver status, sexual and reproductive health decisions, salary history or any other status protected by federal, state, or local laws.
All qualified applicants will receive consideration for employment and reasonable accommodations may be made to enable qualified individuals to perform the essential functions of the position.
Remote working/work at home options are available for this role.
Not Specified
A
Clinical Data Review Pharmacist (onsite)
Salary not disclosed
A-Line Staffing is now hiring a Clinical Data Review Pharmacist in West Jordan, UT 84084.
The Clinical Data Review Pharmacist would be working for a Major Fortune 500 Company and has career growth potential.
Clinical Data Review Pharmacist Highlights: Schedule: ??? 6am to 2pm Monday to Friday ??? Sunday 3-11pm and Monday-Thursday 1-9pm OFF Friday/Saturday Pay Rate: $65/hr Clinical Data Review Pharmacist Responsibilities: Process prescription orders and perform clinical verification Consult with patients and providers as needed Support pharmacy programs that improve patient health outcomes, medication adherence, and prescription accuracy Clinical Data Review Pharmacist Qualifications: BS in Pharmacy or Doctor of Pharmacy (PharmD) Active Pharmacist License (RPh) Minimum 1 year of experience in a pharmacy environment If you are interested in this Clinical Data Review Pharmacist position, please apply to this posting with Luke H.
at A-Line!
The Clinical Data Review Pharmacist would be working for a Major Fortune 500 Company and has career growth potential.
Clinical Data Review Pharmacist Highlights: Schedule: ??? 6am to 2pm Monday to Friday ??? Sunday 3-11pm and Monday-Thursday 1-9pm OFF Friday/Saturday Pay Rate: $65/hr Clinical Data Review Pharmacist Responsibilities: Process prescription orders and perform clinical verification Consult with patients and providers as needed Support pharmacy programs that improve patient health outcomes, medication adherence, and prescription accuracy Clinical Data Review Pharmacist Qualifications: BS in Pharmacy or Doctor of Pharmacy (PharmD) Active Pharmacist License (RPh) Minimum 1 year of experience in a pharmacy environment If you are interested in this Clinical Data Review Pharmacist position, please apply to this posting with Luke H.
at A-Line!
Not Specified
C
Care Review Clinician I
✦ New
Salary not disclosed
Job Title: Care Review Clinician I Location: 100% Remote Duration: 3 Months+ (temp to hire) Schedule: Wednesday
- Sunday 8 – 5 pm PST Pay Range: $43
- $44/hr.
on W2 Description: · The Care Review Clinician is responsible for performing utilization management (UM) reviews, including prior authorization of outpatient services, to ensure medical necessity, appropriate level of care, and compliance with regulatory and organizational guidelines.
· The clinician will review clinical documentation, apply evidence-based criteria, and collaborate with providers to facilitate timely and appropriate care for members.
· This role supports Client’s commitment to quality, cost-effective care and regulatory compliance within the California health plan.
Must Have Skills: · Knowledge of California delegation requirements · Strong understanding of utilization management processes · Experience with prior authorization review (outpatient preferred) · Ability to apply clinical guidelines (e.g.
MEDICAID, MCG) Day to Day Responsibilities: · Process outpatient prior authorization referrals · Review clinical documentation for medical necessity · Apply established UM criteria and guidelines · Communicate with providers for additional clinical information · Ensure compliance with state, federal, and Client policies · Document determinations accurately and timely Required Years of Experience: · Active, unrestricted California RN or LVN license required · Minimum of 3 years of clinical experience in utilization management
- Sunday 8 – 5 pm PST Pay Range: $43
- $44/hr.
on W2 Description: · The Care Review Clinician is responsible for performing utilization management (UM) reviews, including prior authorization of outpatient services, to ensure medical necessity, appropriate level of care, and compliance with regulatory and organizational guidelines.
· The clinician will review clinical documentation, apply evidence-based criteria, and collaborate with providers to facilitate timely and appropriate care for members.
· This role supports Client’s commitment to quality, cost-effective care and regulatory compliance within the California health plan.
Must Have Skills: · Knowledge of California delegation requirements · Strong understanding of utilization management processes · Experience with prior authorization review (outpatient preferred) · Ability to apply clinical guidelines (e.g.
MEDICAID, MCG) Day to Day Responsibilities: · Process outpatient prior authorization referrals · Review clinical documentation for medical necessity · Apply established UM criteria and guidelines · Communicate with providers for additional clinical information · Ensure compliance with state, federal, and Client policies · Document determinations accurately and timely Required Years of Experience: · Active, unrestricted California RN or LVN license required · Minimum of 3 years of clinical experience in utilization management
Not Specified
Sterile Processing Quality Review Tech Mid Shift
Salary not disclosed
Hourly Pay Range:
$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.
$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.
Not Specified
M
Professional, Prospective Review RN
✦ New
$33.36 - 44.36
Join Us in Shaping the Future of Health Care
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 .
permanent
Physician / Non Clinical Physician Jobs / New York / Permanent / Utilization Review Physician
✦ New
Salary not disclosed
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.
permanent
I
Proofreader/Document Reviewer
✦ New
Salary not disclosed
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.
Not Specified
S
Medical Reviewer
Salary not disclosed
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.
Not Specified
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Clinical Review Clinician - Appeals
🏢 Spectraforce Technologies
Salary not disclosed
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)
Not Specified
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