Demandforce Reviews Jobs in Usa
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The challenges of affordable healthcare continue to create new opportunities.
Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs.
These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.
Supervises the assessment of all acute and sub-acute inpatient care for appropriateness of setting and services, according to pre-established criteria and guidelines and ensure a 95% compliance or greater.
Supervises the assessment and coordination of the members physical, psychosocial and discharge planning needs through communication with appropriate hospital staff including treating physician, PCP, utilization managers, social workers, discharge planners.
Assures appropriate staffing to support departmental/agency services.
Ensures all employees are oriented to their department/agency and job and provided with appropriate training, development and continuing education.
Correctly interprets and applies all Human Resources policies and procedures relative to discipline, recruitment and selection, performance appraisals, salary reviews and staffing.
Bachelor's Degree in Nursing.
Minimum one to three years previous management experience preferred.
Previous managed care experience in the areas of utilization management and/or case management required.
Working knowledge of Windows, Word, Excel.
Knowledge of Federal and State regulations, managed care regulations and concepts, and CQI methodologies.
The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.
Care Management Supervisor of Quality Review & Staff Education is responsible for quality assurance, accuracy, and overall integrity of the care management records completed by Care Management staff. This role is to ensure compliance with NYS DOH and CMS regulations through development of auditing tools and data validation. This Supervisor will analyze collected audit data, identify trends for staff re-training, and implement corrective action plans in collaboration with Clinical Management and Staff Education. They will oversee and conduct orientation, training, and education to all members of the Care Management team. Provides support to Director and Managers of Coordinated Care to ensure that all reporting requirements are prepared, submitted, and maintained in a professional and well-coordinated manner.
- Baccalaureate Nursing Degree from an NLN-Accredited School of Nursing
- Experience and knowledge of Managed Care: A minimum of two years nursing experience in Community Health or related field and/or minimum of two years of progressive job-related experience, including care management and coordination, education and supervision
- Demonstrates strong critical-thinking, problem-solving skills, and knowledge of Medicare and Medicaid
- Effective communication skills both written and oral
- Possesses strong critical thinking skills and knowledge of Medicare and Medicaid regulations
- Excellent analytical skills, interpretation of data
- Ability to set priorities and to handle multiple assignments
- Working knowledge of audit techniques and methodologies
- Secures relevant information to identify potential problems and makes recommendations for appropriate solutions
- Work effectively within interdisciplinary team environment
- Computer literate, Windows, Excel, Word, Visio and data base programs required. PowerPoint preferred
- Working knowledge of State and Federal regulations
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.
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.
Job DescriptionAt Boeing, we innovate and collaborate to make the world a better place.
We're committed to fostering an environment for every teammate that's welcoming, respectful and inclusive, with great opportunity for professional growth.
Find your future with us.Job DescriptionThe Boeing Commercial Airplanes Liaison Engineering Organization is seeking Consultant (Level 5) Liaison Engineers to support operations in Everett, Seattle, Auburn, and or Renton Washington .
We are looking for a proactive individual who can make prompt engineering decisions and who want to go beyond their desk and into the factory for hands on engineering.This position requires excellent communication and collaboration skills as the candidate will be partnering closely with production personnel.
The candidate will be the engineering representative on the factory floor transforming design into reality.Position Responsibilities:Analyzes, conducts root cause analysis and develops dispositions for production non-conformances.Applies knowledge of Boeing design principles to assess and resolve product/process issues through the product lifecycle.Applies engineering principles to research technical, operational and quality issues in support of executing final engineering solutions.Identifies documents, analyzes reported problems and communicates deviations that could impact design intent and safety; recommends and manages resolution.Develops and implements product/process improvements.Supports Integrated Product Teams (IPT) and participates in design reviews.Represents the engineering community from initial build through the production and post-production environment.Ensures supplier and build partner compliance with Boeing standards.Develops customer correspondence for continued safe operation and maintenance of equipment.Participates in on-site disabled product repair teams, accident investigation and support teams.Analyzes damage repair or structural modification to determine appropriate jacking and shoring, prevent collateral damage and assure a safe work environment.Designs interim structural repairs and conducts static strength analysis.Develops non-destructive test procedures, tools and standards.This position is fully onsite.
The selected candidate will be required to work onsite at one of the listed locations.
This position involves daily exposure to factory environment which includes stairs, trip hazards, high noise areas, chemical hazards (breathing and handling), and entering airplanes during their many stages of build.This position participates in the approximately 9-month Boeing Company Training Rotation Program, which may involve assignments to the first, second, or third shift, as well as weekend or daily overtime.
The specific requirements for shift assignments and overtime vary between sites and are typically covered on a rotation basis.
Additionally, there may be travel involved between Boeing Puget Sound sites during the training rotation.Basic Qualifications (Required Skills/Experience):Bachelor's or Masters of Science Degree from an ABET OR ABET equivalent accredited course of study in Engineering14+ years of experience in structures, systems, design, or production engineeringPreferred Qualifications (Desired Skills/Experience):Hands-on experience with materials and manufacturing processes.Prior BCA Engineering Material Review Board (MRB) CertificationConflict of Interest:Successful candidates for this job must satisfy the Company's Conflict of Interest (COI) assessment processDrug Free Workplace:Boeing is a Drug Free Workplace where post offer applicants and employees are subject to testing for marijuana, cocaine, opioids, amphetamines, PCP, and alcohol when criteria is met as outlined in our policies.Shift:This position is for multiple shifts and may require off shift, weekend, and travel assignments.The candidate may periodically be assigned to first, second, or third shift as well as weekend or daily overtime.
This requirement varies from site to site and is typically covered on a rotation basis.Union:This is a union represented position.In locations where SPEEA representation applies, this job family will be covered by the terms of the collective bargaining agreement.
Applicable and appropriate educational/certification credentials from an accredited institution and/or equivalent experience is required.Pay and Benefits:At Boeing, we strive to deliver a Total Rewards package that will attract, engage and retain the top talent.
Elements of the Total Rewards package include competitive base pay and variable compensation opportunities.The Boeing Company also provides eligible employees with an opportunity to enroll in a variety of benefit programs, generally including health insurance, flexible spending accounts, health savings accounts, retirement savings plans, life and disability insurance programs, and a number of programs that provide for both paid and unpaid time away from work.The specific programs and options available to any given employee may vary depending on eligibility factors such as geographic location, date of hire, and the applicability of collective bargaining agreements.Pay is based upon candidate experience and qualifications, as well as market and business considerations.
Summary pay range for Expert (level 5): $165,750
- $224,250 Applications for this position will be accepted until Mar.
20, 2026Export Control Requirements:This position must meet U.
S.
export control compliance requirements.
To meet U.
S.
export control compliance requirements, a "U.
S.
Person" as defined by 22 C.
F.
R.
§120.62 is required.
"U.
S.
Person" includes U.
S.
Citizen, U.
S.
National, lawful permanent resident, refugee, or asylee.Export Control Details:US based job, US Person requiredRelocationThis position offers relocation based on candidate eligibility.Visa SponsorshipEmployer will not sponsor applicants for employment visa status.ShiftThis position is for 1st shiftEqual Opportunity Employer:Boeing is an Equal Opportunity Employer.
Employment decisions are made without regard to race, color, religion, national origin, gender, sexual orientation, gender identity, age, physical or mental disability, genetic factors, military/veteran status or other characteristics protected by law.
Essential Functions of the job:
- Review and validate QC data and test records.
- Support investigations related to Out of Specification (OOS), Out of Trend (OOT), and Out of Expectation (OOE) results.
- Ensure compliance with current Good Manufacturing Practices (cGMP) in the laboratory.
- Assist in the technical documentation of investigations and change control assessments to evaluate the impact on product quality, in alignment with FDA/EU regulations, international standards
- Undertake other duties as required.
This position is ideal for candidates who are detail-oriented and committed to quality assurance in the pharmaceutical industry.
Education/Experience Required:
- Bachelor’s Degree or above in Chemistry, Biochemistry, or Biotechnology related scientific discipline. Scientific degree (ideally chemistry, biochemistry, biotechnology or related).
- Minimum 4 years working experience in an FDA-regulated biotechnology or pharmaceutical company is required.
- Working knowledge and experience with chemistry analytical methods such as HPLC, GC, TOC, Capillary Electrophoresis (CGE-Reduced, CGE-Non-Reduced, and Capillary Zone Electrophoresis), etc.
- Strong working knowledge with USP/EP and cGMP/EU GMP.
- Technical writing experience.
- Familiar with instrument and equipment validation.
- Impressive, demonstrable track record and skills/experience gained within a similar position(s), at a similar level.
- Credible and confident communicator (written and verbal) at all levels.
- Strong analytical and problem-solving ability.
- Hands-on approach, with a ‘can do’ attitude.
- Ability to prioritize, demonstrating good time management skills.
- Excellent attention to detail, with the ability to work accurately in a busy and demanding environment.
- Self-motivated, with the ability to work proactively using own initiative.
- Committed to learning and development
- Self-motivated, with the ability to work proactively using own initiative.
Computer Skills:
- Strong PC literacy required; MS Office skills (Outlook, Word, Excel, PowerPoint).
Travel:
- Must be willing to travel approximately 10%.
- Ability to work on a computer for extended periods of time.
Summary:
The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services “CMS” Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and guidelines related to UM. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.
Responsibilities:
- Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
- The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary.
- Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines.
- Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination.
- Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary’s member’s health care for behavioral health care management.
- Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI).
- Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines.
- Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities.
- Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up.
- Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
- Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate.
- Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities.
- Must be able to take after hour calls to meet business requirements as needed.
Job Requirements:
Education/Skills
- Graduate of an accredited school of vocational nursing or equivalent required
- Associate’s (ADN) or Bachelor’s (BSN) in Nursing preferred
Experience
- 3 – 5 years of nursing experience preferred
- Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required
- General computer knowledge and capability to use computers required
Licenses, Registrations, or Certifications
- LVN license in the state of employment or compact required
- RN license in state of employment or compact preferred
Work Schedule:
5 Days - 8 Hours
Work Type:
Full Time
