Durasein Solid Surface Reviews Jobs in Usa

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.

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!

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

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.

Provides quality, cost-effective care to all members through the direct supervision of staff responsible for the management and coordination of the member's care through the incorporation of interdisciplinary strategies, medicare regulations, and medically accepted standards of care.

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.

POSITION SUMMARY AND RESPONSIBILITIES

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.

POSITION SUMMARY AND RESPONSIBILITIES

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.

POSITION SUMMARY AND RESPONSIBILITIES

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.