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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 WeCARE Physician is the role of Review Physician supports the Medical Director in the implementation of standard operation policies and procedures to ensure that UBA WeCARE complies with all New York City's HRA contractual requirements.
Key Responsibilities are:-To conduct medical reviews of Clinical Assessments/Clinical Reassessments for finalization, complete Wellness Plans dispositions for UBA WeCARE clients, and act as a clinical support for UBA WeCARE staff in the fulfillment of funder, (NYC HRA), contracted goals.
-Conduct medical reviews of Clinical Assessments completed by Qualified Health Professionals -Displays knowledge of medical conditions and SSA disability criteria.-Review prior WeCARE documentation, documentation provided by the client, prior and current Clinical Assessment/Clinical Reassessments, previous Medical Evaluation and Substance Use Assessment (when indicated).-Review, address, and correct any inconsistencies in the history obtained by the QHP-Order and review additional specialty assessments as indicated -Review and update Reasonable Accommodations and work limitations.-Determine appropriate medical diagnoses.
Assess the stability of client's medical issues.-Obtain medical documentation from EPIC, PSYCKES, and Bronx RHIO.-Enter information/complete appropriate forms in HRA (funder) database (SEAMS).
-Complete off-line/paper when medical record system SEAMS, is not functioning completely or is partially working.
-Ensure all off-line paper documents and medical records obtained from outside sources are scanned into SEAMS within 24 hours.
-Review the SSA sequential evaluation process conducted by the QHP to ensure accuracy.-Review provided wellness documentation from treatment providers -Check for medical documentation in EPIC, PSYCKES, and Bronx RHIO-Update and review reasonable accommodations and limitations-Ensure the FCO is correct and that the FCO justification contains relevant information -Review Wellness extensions with Medical Director and provide summary justifications for same-Able to assist and motivate clients to comply with WeCARE process.
Able to assist clients to access services to reduce barriers to compliance with WeCARE appointments.
-Knowledge of medical and behavioral health diagnoses.-Knowledge of various software systems including SEAMS, EPIC, PSYCKES, Bronx RHIO, etc.
-Possess strong computer skills with knowledge of Microsoft Office applications.
-Knowledge of SSA disability application process is preferred.Experience with NYC HRA preferred.Two years of professional experience in medical or clinical practice.Complete Wellness Enhancement Forms as indicated for Wellness track clients Medical and computer software (SEAMS, EPIC) and medical depository information databases (example PSYCKES, Bronx RHIO)In addition to a competitive salary of $180,000-220,000, we offer LTD, STD, paid malpractice, health, dental, vision and a 403(b).
Interested candidates should have a current unrestricted NYS Doctor of Medicine license to practice and American Board of Medical Specialties or American Osteopathic Association Board Certification and send an updated CV to Senior Recruiter, Desiree Aulet at Montefiore is an equal employment opportunity employer.
Montefiore will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.
At Dollar General, our mission is Serving Others! We value each and every one of our employees. Whether you are looking to launch a new career in one of our many convenient store locations, distribution centers, store support center or with our private fleet team, we are proud to provide a wide range of career opportunities. We are not just a retail company; we are a company that values the unique strengths and perspectives that each individual brings. Your difference truly makes a difference at Dollar General. How would you like to Serve? Join the Dollar General journey and see how your career can thrive.
Dollar General Corporation has been delivering value to shoppers for more than 80 years. Dollar General helps shoppers Save time. Save money. Every day. by offering products that are frequently used and replenished, such as food, snacks, health and beauty aids, cleaning supplies, basic apparel, housewares and seasonal items at everyday low prices in convenient neighborhood locations.
Job DetailsGeneral Summary:
Function as a cashier and/or stocker and act in a lead capacity in the absence of the store manager or assistant store manager. Assist in setting and maintaining plan-o-grams and programs. Provide exemplary customer service. Perform other duties as necessary to maximize profitability, customer satisfaction, and teamwork, while protecting company assets and reducing losses.
Duties and Essential Job Functions:
- Unload trucks according to the prescribed process for the store.
- Follow company work processes to receive, open and unpack cartons and totes.
- Stock merchandise; rotate and face merchandise on shelves and build merchandise displays.
- Restock returned and recovered merchandise.
- Order zones and drop shipment categories, following prescribed ordering practices, as assigned by the store manager.
- Assist in plan-o-gram implementation and maintenance.
- Assist customers by locating merchandise.
- Bail cardboard and take out trash; dust and mop store floors; clean restroom and stockroom.
- Greet customers as they enter the store.
- Maintain register countertops and bags; implement register countertop plan-o-grams.
- Operate cash register and flatbed scanner to itemize and total customer's purchase; bag merchandise.
- Collect payment from customer and make change.
- Clean front end of store and help set up sidewalk displays.
- Help to maintain a clean, well-organized store and facilitate a safe and secure working and shopping environment.
- Provide superior customer service leadership.
- Follow company policies and procedures as outlined in the standard operating procedures manual, employee handbook, and company communications.
- Open and/or close the store under specific direction of the area manager.
In the Absence of the Store Manager or Assistant Store Manager:
- Authorize and sign for refunds and overrides; count register; make bank deposits.
- Assist in maintaining strict cashier accountability, key control, and adherence to company security practices and cash control procedures.
- Monitor cash levels and make appropriate drawer pulls as directed by the store manager.
- Monitor cameras for unusual activities (customers and employees), if applicable.
- Supply cashiers with change when needed.
- Complete all required paperwork and documentation according to guidelines and deadlines as assigned.
Knowledge and Skills:
- Ability to perform mathematical calculations such as addition, subtraction, multiplication, division, and percentages.
- Knowledge of cash handling procedures including cashier accountability and deposit control.
- Ability to perform IBM cash register functions.
- Knowledge of cash, facility and safety control policies and practices.
- Effective interpersonal and oral & written communication skills.
- Understanding of safety policies and practices.
- Ability to read and follow plan-o-gram and merchandise presentation guidance.
Work Experience and/or Education:
- High school diploma or equivalent and six months of supervisory experience (or related experience/training) preferred.
Relocation assistance is not available for this position.
Dollar General Corporation is an equal opportunity employer.
Jump start your career with Benedictine!
Our Certified Nursing Assistants (CNA) are amazing and dedicated professionals that provide high-quality, compassionate care to our residents daily. As a CNA-NAR you operate on the front lines and ensure our residents are treated with dignity and respect, as well as choices within their lives.
ResponsibilitiesThe CNA provides direct resident care and report condition changes to RN or LPN while also charting in POC system.
The CNA demonstrates time management and prioritization of tasks.
QualificationsMust be in good standing on the State Nursing Assistant registry or appropriate entity.
Must have good communication skills.
Must be able to read, write and communicate in English.
BLS Certification.
Benedictine and our Ministry partners are a non-profit senior care organization founded by the sisters of St. Scholastica that operates on four core values: Hospitality, Stewardship, Respect, and Justice. We pride ourselves on having an extraordinary team of associates, with outstanding hearts. Our focus is to provide a comforting and empowering culture for our residents and our team members, to help you grow and succeed. With opportunities available throughout the upper Midwest, we need big hearts like yours!
EEO/AA/Vet Friendly
Salary Range$22.48 - $26.08
Benefits StatementA robust benefits package is available to eligible associates, designed to meet the needs of every stage of life, including paid time off (PTO), retirement, medical, dental, vision, education assistance, and a variety of additional voluntary benefits.
Established Internal Medicine clinic looking for a BC/BE Internist for a busy clinic in Coastal Northwestern California.
Hospitalist program supports primary care physicians.
Generous compensation package available.
Live life on the Pacific Coast! If you are interested in hearing more about this opportunity, please call HDA at , or text to .
You can also reach us through email at .
Please reference Job ID # j-4020
OBGYN Near Reno, Nevada! In scenic Northern California, just over an hour from Reno, Nevada, a rural health clinic is seeking an OBGYN to join their established practice.
The health clinics provide a full range of services, all connected with the hospital.
This position is Monday through Friday normal business hours.
Visa candidates are welcome to apply.
This position includes PTO, CME, health insurance, retirement, and more.
If you are interested in hearing more about this opportunity, please call HDA at , or text to .
You can also reach us through email at .
Please reference Job ID # j-4681
ObGyn physician is needed in a health center in Northern California 2 hours from Tahoe.
It has Level II NICU and da Vinci.
10 days of call per month.
Relocation, sign on and student loan repayment.
MGMA standard.
4 weeks of vacation.
10 days Holiday.
1 week CME If you are interested in hearing more about this opportunity, please call HDA at , or text to .
You can also reach us through email at .
Please reference Job ID # MW7065
New Pediatric Opportunity in Northern California! Join a clinic 2 hours from Tahoe whose mission is to provide quality, comprehensive, preventive, and accessible health care services, regardless of ability to pay; and to meet the changing needs of their communities with creativity and innovation.
Salary plus an on-call compensation, sign on , relocation If you are interested in hearing more about this opportunity, please call HDA at , or text to .
You can also reach us through email at .
Please reference Job ID # 7067
Family Practice Physician with emphasis in OB with C-section to join a provider team.
Physicians can expect to see 25-27 patients per day and share the hospital on call duties.
Experience with electronic medical record (NextGen) and electronic practice management software functionality preferred.
BLS/CPR certification.
If you are interested in hearing more about this opportunity, please call HDA at , or text to .
You can also reach us through email at .
Please reference Job ID # 7066
Family Practice Near Reno, Nevada! 80 miles outside of Reno, in beautiful northern California, a rural clinic is seeking an additional family practice or internal medicine physician.
There are currently 7 providers in the clinic and it is a traditional office practice.
Office hours are normal Monday through Friday, with call only 1 in 6.
Physicians are credentialed through the critical access hospital next door.
This position offers a competitive salary plus full benefits, PTO, CME, retirement, and more! If you are interested in hearing more about this opportunity, please call HDA at , or text to .
You can also reach us through email at .
Please reference Job ID # j-5840
