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Operations Specialist III – Medicaid / Medi-Cal (Epic + Utilization Review
Salary not disclosed
Long Beach, CA 6 days ago

Immediate need for a talented Operations Specialist III – Medicaid / Medi-Cal (Epic + Utilization Review. This is a 06+months contract opportunity with long-term potential and is located in Long Beach, CA(Remote). Please review the job description below and contact me ASAP if you are interested.


Job ID: 26-02810


Pay Range: $30 - $45/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).Traveler benefits as per agency package. (Benefits vary by vendor and assignment.)


Key Responsibilities:


  • Medicaid / Medi-Cal Chart Review
  • Perform comprehensive health chart and administrative chart reviews
  • Ensure documentation completeness and regulatory compliance
  • Identify and escalate quality or utilization concerns
  • Support Medicaid program performance metrics and reporting
  • Utilization Review & Authorizations
  • Conduct Utilization Review activities
  • Support authorization workflows and payor processes (Anthem, Blue Shield, etc.)
  • Review medical necessity documentation
  • Collaborate with clinical and administrative teams to resolve discrepancies
  • Epic & Workflow Execution
  • Navigate and abstract data within Epic (HealthConnect preferred)
  • Manage assigned review queues and documentation workflows
  • Track operational performance metrics
  • Suggest workflow improvements where applicable
  • Operational & Process Support
  • Assist in centralizing and refining hospital/system-wide workflows
  • Support productivity standards and cost-reduction initiatives
  • Contribute to operational efficiency and sustainability projects
  • Schedule: 8:00 AM – 4:30 PM
  • 5 days/week including every other weekend (Saturday & Sunday


Key Requirements and Technology Experience:


  • 1–2+ years healthcare operations experience (3–5 years ideal)
  • Strong Medicaid / Medi-Cal background
  • Experience with Epic EHR (Kaiser HealthConnect highly preferred)
  • Utilization Review exposure (authorization workflows, Tapestry preferred)
  • Experience conducting chart reviews (clinical or administrative)
  • Ability to work independently post-training
  • Stable healthcare employment history
  • Education: High School Diploma required; Associate or Bachelor’s degree preferred.


Our client is a leading Healthcare Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.


Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.


By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy here.

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Hospital RN – Care Coordination & Utilization Review
🏢 Pyramid Consulting, Inc
Salary not disclosed
San Jose, CA 5 days ago

Immediate need for a talented Hospital RN – Care Coordination & Utilization Review . This is a 06+months contract opportunity with long-term potential and is located in San Jose, CA (Onsite). Please review the job description below and contact me ASAP if you are interested.


Job ID: 25-80861


Pay Range: $80 - $95/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).


Key Responsibilities:


  • Conduct utilization reviews using InterQual® / MCG®
  • Support discharge planning and post-acute coordination
  • Communicate with physicians, social work, and external providers
  • Manage authorizations and payer-related workflows
  • Maintain compliance with regulatory standards


Key Requirements and Technology Experience:


  • Key Skills; CA RN License (Active)
  • Acute inpatient hospital experience
  • UM / Case Management / Discharge Planning background


Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.


Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.


By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy here.

Not Specified
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Physician / Infectious Disease / South Carolina / Any / Pacific Companies, Inc. Job
Salary not disclosed
Chicago, Illinois 3 days ago
Good day Are you looking for a change? A way to fill your time while in transition? Or looking for a 1099 independent contractor position? Continue to read below- one of the locum tenens opportunities that we have.

Our firm has a nationwide (locums and permanent) presence so please let me know if you are interested in a different location.The Infectious Disease locum tenens opportunity in South CarolinaLocation: Conway, SCDuration: July 25
- November 25 ( 12 weeks)Reason for coverage: Maternity leaveSchedule: 3 days in clinic + 2 days of inpatient + 1 weekend of callShift: Clinic 3 times a week, Mon/Tues/Wed, half day in the mornings from 9AM to 12PMRounds after clinic (on own patients only)Call: 10 days per month (inpatient days are on the same day as call)Inpatient scope: Rounding and consults on the med surg floor (infectious disease only)Outpatient Scope: Provided antibiotics (no labs on site), infusion lab review, rehab lab (no pharmacist for labs, so this is the physicians responsibility)EMR: CERNER w/ Dragon DictationHospital: Level 3 Trauma, 210 bedsRequirements (boards, license): BC with SC license, Clean NPDBInitial COVID Vaccine Required Travel, Accommodations, and Malpractice
- PAID for locum opportunities Assistance with credentialing provide Call or Email for further details If you (or someone you know) are interested, please let me know your availability, rates, and contact information.

Followed with an updated CV.

All information is held strictly confidential.Looking forward to hearing from you.

Thank you, Shawn Faucette
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Clinical Reviewer, BH outpatient services
✦ New
Based on experience
Canton, MA 10 hours ago

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

Under the supervision of the Utilization Management Supervisor, the Behavioral Health (BH) Utilization Management (UM) Clinician is responsible for conducting benefit coverage reviews and utilization management according to applicable regulatory guidelines and Enterprise contract requirements. The BH UM Clinician works collaboratively with the Behavioral Health leadership within the Behavioral Health department and other appropriate Point32Health staff to identify and address opportunities to improve service, reduce administrative cost, ensure clinically appropriate delivery of benefit covered services, and support department and organizational business goals. The UM BH Clinician escalates urgent issues and concerns that could potentially impact member needs, program compliance and or acute situations that pose risk. The UM BH Clinician must be committed to clinical and service excellence, including demonstrating the behaviors that support teamwork, collaboration, and professionalism. The BH UM clinician works under the direction of the UM Supervisor and in collaboration with the BH Operation Manager to ensure ongoing competency and learning needs are met that they are performing to applicable regulatory and clinical requirements.

Job Description

Key Responsibilities/Duties - what you will be doing (top five):

  • Adherence to established behavioral and administrative review guidelines and criteria
  • Adherence to timelines, standards, and elements associated with organizational determinations and notifications
  • Daily interactions with UM Support staff and providers to ensure clinical information and support are available and applicable to the review process
  • Appropriate prioritization of authorization requests
  • Achievement of expected productivity goals
  • Review of all assigned prior authorization requests including but not limited to inpatient admissions, specialty referrals, outpatient procedures, VNA or outpatient therapies as specified in the prior authorization list using specified clinical criteria sets.
  • Concurrent review of Behavior Health Services
  • Identification and determination of benefit coverage for behavioral health coverage requests.
  • Identifies and determines medical necessity of out of network requests for services.
  • Effective communication with the Medical Director, regarding identified variances for specific members according to criteria utilized for medical review.
  • Professional growth and development through self-directed learning activities and/or involvement in professional, civic, and community organizations
  • Ongoing referrals to and interactions with the case management team to ensure efficient and safe care transitions and member access to supportive programs and services
  • Works collaboratively with external providers to facilitate member access to high quality cost effective behavioral health services
  • Adheres to all regulatory and contractual requirements
  • Participates in department projects and special assignments as needed.
  • Attends scheduled meetings, training session in both classroom and computer-based required training sessions. Assist in development and updating of department workflows.
  • Other projects and duties as assigned.

Qualifications - what you need to perform the job

Certification and Licensure

  • Current unrestricted Massachusetts license in a behavioral health area of practice

Education

  • Required (minimum): BS Nursing; LICSW, LMHC, or other behavioral health profession qualified to practice independently.
  • Preferred:

Experience (minimum years required):

  • Required (minimum): Direct practice clinical experience in area of credential. Must demonstrate sound knowledge of utilization management and care management principles. Health Plan experience performing utilization review activities. Experience with McKesson's InterQual Clinical Screening Criteria.
  • Preferred: 3 years in a managed care environment in managed care systems and operations.

Skill Requirements

  • Ability to work cooperatively as a team member across multiple levels within the organization
  • Results orientation - strives to meet business goals
  • Critical and Analytic thinking, i.e., must understand cause and effect as it relates to workflow design and implications to policies, procedures, and other departmental functions
  • Comfort adapting to changes to business, market, regulatory, and strategic needs
  • Ability to influence others and serve as role model
  • Strong communications skills (formal and informal, written and verbal
  • Ability to handle multiple demands--must be able to balance multiple priorities
  • Regard for confidential data and adherence to corporate compliance policy
  • Proficiency with or ability to learn technology for initiating and participating in web/system-based communications: webinar, instant messaging, thin client, soft phone, or others
  • Proficiency with or ability to learn technology-based programs such as Microsoft Office Word and Excel; other programs as needed

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

  • Fast paced office environment handling multiple demands.
  • Must be able to exercise appropriate judgment when necessary and work and communicate with customers in a telephonic office environment
  • Must be able to work under normal office conditions and work from home as required.
  • Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
  • May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$81,217.85 -$121,826.77

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company's sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

  • Medical, dental and vision coverage

  • Retirement plans

  • Paid time off

  • Employer-paid life and disability insurance with additional buy-up coverage options

  • Tuition program

  • Well-being benefits

  • Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit welcome all
All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact

PDN-a1375fa0-a517-4950-aefd-88a7808245fa
permanent
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Clinical Reviewer (Inpatient), Behavioral Health
✦ New
🏢 Point32Health, Inc.
Based on experience
MA 10 hours ago

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

Under the supervision of the Utilization Management Supervisor, the Behavioral Health (BH) Utilization Management (UM) Inpatient Clinician is responsible for conducting benefit coverage reviews and utilization management according to applicable regulatory guidelines and Enterprise contract requirements. This is VERY IMPORTANT, the schedule for this role is Tuesday - Saturday 8:30 AM - 5 PM The BH UM Clinician works collaboratively with the Behavioral Health leadership within the Behavioral Health department and other appropriate Point32Health staff to identify and address opportunities to improve service, reduce administrative cost, ensure clinically appropriate delivery of benefit covered services, and support department and organizational business goals. The UM BH Clinician escalates urgent issues and concerns that could potentially impact member needs, program compliance and or acute situations that pose risk. The UM BH Clinician must be committed to clinical and service excellence, including demonstrating the behaviors that support teamwork, collaboration, and professionalism. The BH UM clinician works under the direction of the UM Supervisor and in collaboration with the BH Operation Manager to ensure ongoing competency and learning needs are met that they are performing to applicable regulatory and clinical requirements.

Job Description

Key Responsibilities/Duties - what you will be doing (top five):

  • Adherence to established behavioral and administrative review guidelines and criteria
  • Adherence to timelines, standards, and elements associated with organizational determinations and notifications
  • Daily interactions with UM Support staff and providers to ensure clinical information and support are available and applicable to the review process
  • Appropriate prioritization of authorization requests
  • Achievement of expected productivity goals
  • Review of all assigned prior authorization requests including but not limited to inpatient admissions, specialty referrals, outpatient procedures, VNA or outpatient therapies as specified in the prior authorization list using specified clinical criteria sets.
  • Concurrent review of Behavior Health Services
  • Identification and determination of benefit coverage for behavioral health coverage requests.
  • Identifies and determines medical necessity of out of network requests for services.
  • Effective communication with the Medical Director, regarding identified variances for specific members according to criteria utilized for medical review.
  • Professional growth and development through self-directed learning activities and/or involvement in professional, civic, and community organizations
  • Ongoing referrals to and interactions with the case management team to ensure efficient and safe care transitions and member access to supportive programs and services
  • Works collaboratively with external providers to facilitate member access to high quality cost effective behavioral health services
  • Adheres to all regulatory and contractual requirements
  • Participates in department projects and special assignments as needed.
  • Attends scheduled meetings, training session in both classroom and computer-based required training sessions. Assist in development and updating of department workflows.
  • Other projects and duties as assigned.

Qualifications - what you need to perform the job

Certification and Licensure

  • Current unrestricted Massachusetts license in a behavioral health area of practice

Education

  • Required (minimum): BS Nursing; LICSW, LMHC, or other behavioral health profession qualified to practice independently.
  • Preferred:

Experience (minimum years required):

  • Required (minimum): Direct practice clinical experience in area of credential. Must demonstrate sound knowledge of utilization management and care management principles. Health Plan experience performing utilization review activities. Experience with McKesson's InterQual Clinical Screening Criteria.
  • Preferred: 3 years in a managed care environment in managed care systems and operations.

Skill Requirements

  • Ability to work cooperatively as a team member across multiple levels within the organization
  • Results orientation - strives to meet business goals
  • Critical and Analytic thinking, i.e., must understand cause and effect as it relates to workflow design and implications to policies, procedures, and other departmental functions
  • Comfort adapting to changes to business, market, regulatory, and strategic needs
  • Ability to influence others and serve as role model
  • Strong communications skills (formal and informal, written and verbal
  • Ability to handle multiple demands--must be able to balance multiple priorities
  • Regard for confidential data and adherence to corporate compliance policy
  • Proficiency with or ability to learn technology for initiating and participating in web/system-based communications: webinar, instant messaging, thin client, soft phone, or others
  • Proficiency with or ability to learn technology-based programs such as Microsoft Office Word and Excel; other programs as needed

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

  • Fast paced office environment handling multiple demands.
  • Must be able to exercise appropriate judgment when necessary and work and communicate with customers in a telephonic office environment
  • Must be able to work under normal office conditions and work from home as required.
  • Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
  • May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$76,114.60 -$114,171.90

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company's sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

  • Medical, dental and vision coverage

  • Retirement plans

  • Paid time off

  • Employer-paid life and disability insurance with additional buy-up coverage options

  • Tuition program

  • Well-being benefits

  • Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit welcome all
All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact

PDN-a0f4fed4-a922-4f8f-a976-d7aff0bf7640
permanent
View & Apply
Medical Promotional Review Specialist I -- SAHDC5737160
Salary not disclosed
Plainsboro, NJ 6 days ago

Job Summary:

The Medical Promotional Review Specialist ensures the scientific accuracy, clinical appropriateness, and regulatory validity of promotional materials from a medical and scientific perspective. This role serves as a member of the Promotional Review Board (PRB), collaborating with cross-functional stakeholders including Marketing, Legal, Regulatory Affairs, and Medical Affairs. The specialist reviews promotional content, evaluates supporting scientific data, and provides recommendations to ensure compliance with approved labeling, regulations, and company policies while supporting safe and effective product use.


Key Responsibilities:

  • Review promotional materials to ensure medical accuracy, scientific validity, and clinical appropriateness
  • Verify alignment of promotional content with approved labeling, scientific evidence, regulations, and company policies
  • Evaluate the appropriateness of data, references, and claims used in marketing materials
  • Provide recommendations for alternative data, references, or language when needed
  • Collaborate with PRB reviewers and commercial teams to address concerns related to promotional materials
  • Engage with business partners early in promotional material development to improve efficiency
  • Work with Medical Directors for assigned products or therapeutic areas to ensure alignment and mitigate risk
  • Document review comments and verdicts within the PRB workflow system within assigned timelines
  • Participate in Promotional Review Board meetings as required
  • Stay current with medical literature and scientific data in assigned therapeutic areas
  • Attend internal and external meetings and training related to regulations, scientific updates, and marketing strategy


Required Skills:

  • Demonstrated expertise in reviewing medical literature and evaluating scientific validity of promotional content
  • Ability to clearly and concisely communicate complex scientific information
  • Proven ability to build and maintain collaborative cross-functional relationships
  • Strong understanding of the US pharmaceutical industry, healthcare landscape, and promotional review compliance requirements
  • Detail-oriented with strong editorial and analytical skills
  • Strong organizational and prioritization abilities
  • Ability to work effectively within cross-functional teams
  • Ability to critically analyze and apply scientific data in a customer-focused manner
  • Strong verbal and written communication skills
  • Effective negotiation and influencing skills


Education:

  • PharmD, MD, DO, or NP required
  • Minimum 2 years of relevant professional experience (academic, clinical, or industry)
  • Post-doctoral fellowship may substitute for professional experience where appropriate
Not Specified
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Medical Reviewer
✦ New
Salary not disclosed
Bronx, NY 1 day ago

Medical Reviewer


As a Medical Reviewer in the Healthcare sector, you play a crucial role in ensuring the accuracy, compliance, and quality of medical content and documentation. Your work directly impacts patient safety, regulatory adherence, and the overall success of the company.


Importance of the Role:

Medical Reviewers are the gatekeepers of medical information, ensuring that all materials meet high standards of accuracy and integrity.

Impact on Team Collaboration: By collaborating with medical writers, researchers, and regulatory affairs teams, Medical Reviewers contribute to seamless teamwork and project success.

Industry Trends: Medical Reviewers must stay abreast of evolving regulations, digital health innovations, and data privacy laws to uphold best practices in medical content creation.

Key Stakeholders: This role interacts closely with medical writers, regulatory bodies, compliance officers, and project managers, playing a vital role in the company’s content development pipeline.

Success Measurement: Performance is gauged based on adherence to regulatory guidelines, accuracy of medical content, timely completion of reviews, and feedback from stakeholders.


Key Responsibilities

As a Medical Reviewer, your responsibilities encompass a range of critical tasks:

Project Planning and Execution: You will be involved in planning, scheduling, and executing medical content reviews to ensure timely delivery and accuracy.

Problem-Solving and Decision-Making: Medical Reviewers analyze complex medical data, resolve discrepancies, and make informed decisions to maintain content integrity.

Collaboration with Cross-Functional Teams: You will collaborate with medical writers, researchers, and regulatory teams to align content with medical and regulatory standards.

Leadership and Mentorship: Mentoring junior team members, providing guidance on medical writing best practices, and leading by example in quality assurance processes.

Process Improvement and Innovation: Constantly seeking ways to enhance efficiency, streamline review processes, and innovate in medical content creation and review.

Technical or Customer-Facing Responsibilities: Engaging with clients, healthcare professionals, or regulatory bodies to address queries, clarify medical information, and ensure compliance.


Required Skills and Qualifications

To excel as a Medical Reviewer, candidates must possess the following skills and qualifications:

Technical Skills:

Proficiency in medical terminology, knowledge of medical writing software, familiarity with regulatory guidelines, understanding of clinical trial protocols.


Educational Requirements:

A degree in Pharmacy, Medicine, Life Sciences, or a related field. Certification in Medical Writing or Regulatory Affairs is a plus.


Experience Level:

Minimum 3-5 years of experience in medical reviewing, pharmaceutical industry experience, familiarity with FDA and EMA regulations.

Soft Skills:

Excellent communication skills, attention to detail, critical thinking, ability to work under pressure, and a collaborative mindset.

Industry Knowledge:

In-depth knowledge of medical content regulations, pharmacovigilance processes, adverse event reporting, and medical device documentation requirements.

Not Specified
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Physician / Orthopedics / Georgia / Locum tenens / Telemedicine Physician Opportunity with Great Inc
✦ New
Salary not disclosed
Augusta, Georgia 1 day ago
Quivvy Tech is currently hiring telemedicine physicians!Quivvy Tech is the fastest growing national telemedicine network in the U.S.

We have a triage call center where all patients are pre-screened for medical necessity and to confirm compliance with legal and regulatory standards all while ensuring a positive patient experience.Telemedicine Physician Responsibilities Include: Evaluate patients medical conditions (review patient chart); Determine medical necessity of products requested by the patient; Electronically sign Rx prescriptions upon consult completion; Your contact information will remain private at all times Telemedicine Physician Requirements: Must be a commercial insurance provider and/or Medicare provider; Maintain all appropriate licensure to prescribe medications under applicable state and federal laws; Maintain familiarity with our state of the art portalTelemedicine Physician Benefits: Competitive compensation; No billing insurance companies; Reliable volume; Work from anywhere; Flexible hoursPlease contact me for more information at
Not Specified
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Physician / Orthopedics / Arizona / Locum tenens / Telemedicine Physician Opportunity with Great Inc
✦ New
🏢 Quivvy Tech
Salary not disclosed
Tucson, Arizona 1 day ago
Quivvy Tech is currently hiring telemedicine physicians!Quivvy Tech is the fastest growing national telemedicine network in the U.S.

We have a triage call center where all patients are pre-screened for medical necessity and to confirm compliance with legal and regulatory standards all while ensuring a positive patient experience.Telemedicine Physician Responsibilities Include: Evaluate patients medical conditions (review patient chart); Determine medical necessity of products requested by the patient; Electronically sign Rx prescriptions upon consult completion; Your contact information will remain private at all times Telemedicine Physician Requirements: Must be a commercial insurance provider and/or Medicare provider; Maintain all appropriate licensure to prescribe medications under applicable state and federal laws; Maintain familiarity with our state of the art portalTelemedicine Physician Benefits: Competitive compensation; No billing insurance companies; Reliable volume; Work from anywhere; Flexible hoursPlease contact me for more information at
Not Specified
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Physician / Orthopedics / Wyoming / Locum tenens / Telemedicine Physician Opportunity with Great Inc
✦ New
🏢 Quivvy Tech
Salary not disclosed
Cheyenne, Wyoming 1 day ago
Quivvy Tech is currently hiring telemedicine physicians!Quivvy Tech is the fastest growing national telemedicine network in the U.S.

We have a triage call center where all patients are pre-screened for medical necessity and to confirm compliance with legal and regulatory standards all while ensuring a positive patient experience.Telemedicine Physician Responsibilities Include: Evaluate patients medical conditions (review patient chart); Determine medical necessity of products requested by the patient; Electronically sign Rx prescriptions upon consult completion; Your contact information will remain private at all times Telemedicine Physician Requirements: Must be a commercial insurance provider and/or Medicare provider; Maintain all appropriate licensure to prescribe medications under applicable state and federal laws; Maintain familiarity with our state of the art portalTelemedicine Physician Benefits: Competitive compensation; No billing insurance companies; Reliable volume; Work from anywhere; Flexible hoursPlease contact me for more information at
Not Specified
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Physician / Orthopedics / Montana / Locum tenens / Telemedicine Physician Opportunity with Great Inc
✦ New
🏢 Quivvy Tech
Salary not disclosed
Billings, Montana 1 day ago
Quivvy Tech is currently hiring telemedicine physicians!Quivvy Tech is the fastest growing national telemedicine network in the U.S.

We have a triage call center where all patients are pre-screened for medical necessity and to confirm compliance with legal and regulatory standards all while ensuring a positive patient experience.Telemedicine Physician Responsibilities Include: Evaluate patients medical conditions (review patient chart); Determine medical necessity of products requested by the patient; Electronically sign Rx prescriptions upon consult completion; Your contact information will remain private at all times Telemedicine Physician Requirements: Must be a commercial insurance provider and/or Medicare provider; Maintain all appropriate licensure to prescribe medications under applicable state and federal laws; Maintain familiarity with our state of the art portalTelemedicine Physician Benefits: Competitive compensation; No billing insurance companies; Reliable volume; Work from anywhere; Flexible hoursPlease contact me for more information at
Not Specified
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Physician / Orthopedics / Alabama / Locum tenens / Telemedicine Physician Opportunity with Great Inc
✦ New
🏢 Quivvy Tech
Salary not disclosed
Quivvy Tech is currently hiring telemedicine physicians!Quivvy Tech is the fastest growing national telemedicine network in the U.S.

We have a triage call center where all patients are pre-screened for medical necessity and to confirm compliance with legal and regulatory standards all while ensuring a positive patient experience.Telemedicine Physician Responsibilities Include: Evaluate patients medical conditions (review patient chart); Determine medical necessity of products requested by the patient; Electronically sign Rx prescriptions upon consult completion; Your contact information will remain private at all times Telemedicine Physician Requirements: Must be a commercial insurance provider and/or Medicare provider; Maintain all appropriate licensure to prescribe medications under applicable state and federal laws; Maintain familiarity with our state of the art portalTelemedicine Physician Benefits: Competitive compensation; No billing insurance companies; Reliable volume; Work from anywhere; Flexible hoursPlease contact me for more information at
Not Specified
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Physician / Orthopedics / Indiana / Locum tenens / Telemedicine Physician Opportunity with Great Inc
✦ New
🏢 Quivvy Tech
Salary not disclosed
Quivvy Tech is currently hiring telemedicine physicians!Quivvy Tech is the fastest growing national telemedicine network in the U.S.

We have a triage call center where all patients are pre-screened for medical necessity and to confirm compliance with legal and regulatory standards all while ensuring a positive patient experience.Telemedicine Physician Responsibilities Include: Evaluate patients medical conditions (review patient chart); Determine medical necessity of products requested by the patient; Electronically sign Rx prescriptions upon consult completion; Your contact information will remain private at all times Telemedicine Physician Requirements: Must be a commercial insurance provider and/or Medicare provider; Maintain all appropriate licensure to prescribe medications under applicable state and federal laws; Maintain familiarity with our state of the art portalTelemedicine Physician Benefits: Competitive compensation; No billing insurance companies; Reliable volume; Work from anywhere; Flexible hoursPlease contact me for more information at
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Physician / Orthopedics / Vermont / Locum tenens / Telemedicine Physician Opportunity with Great Inc
✦ New
🏢 Quivvy Tech
Salary not disclosed
Quivvy Tech is currently hiring telemedicine physicians!Quivvy Tech is the fastest growing national telemedicine network in the U.S.

We have a triage call center where all patients are pre-screened for medical necessity and to confirm compliance with legal and regulatory standards all while ensuring a positive patient experience.Telemedicine Physician Responsibilities Include: Evaluate patients medical conditions (review patient chart); Determine medical necessity of products requested by the patient; Electronically sign Rx prescriptions upon consult completion; Your contact information will remain private at all times Telemedicine Physician Requirements: Must be a commercial insurance provider and/or Medicare provider; Maintain all appropriate licensure to prescribe medications under applicable state and federal laws; Maintain familiarity with our state of the art portalTelemedicine Physician Benefits: Competitive compensation; No billing insurance companies; Reliable volume; Work from anywhere; Flexible hoursPlease contact me for more information at
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Utilization Review Nurse Health Plans-HP Utilization Mgmt (Hiring Immediately)
Salary not disclosed
Irving, TX 5 days ago
Description

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

permanent
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Product Review Engineer (Liaison Engineering) Consultant (Level 5)
🏢 Boeing
Salary not disclosed
AUBURN, WA 3 days ago

Job Description

At 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 Description

The 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 Engineering
  • 14+ years of experience in structures, systems, design, or production engineering

Preferred Qualifications (Desired Skills/Experience): 

  • Hands-on experience with materials and manufacturing processes.
  • Prior BCA Engineering Material Review Board (MRB) Certification

Conflict of Interest:

 Successful candidates for this job must satisfy the Company’s Conflict of Interest (COI) assessment 
process

Drug 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, 2026


Export 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 required

Relocation

This position offers relocation based on candidate eligibility.

Visa Sponsorship

Employer will not sponsor applicants for employment visa status.

Shift

This position is for 1st shift


Equal 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.

permanent
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Remote Personal Finance Content Reviewer
$32 per hour - monthly

We are hiring remote contributors to review consumer finance content focused on budgeting and money-saving strategies.

Your role will involve reading short financial guidance pieces and providing feedback on their usefulness for people managing tight budgets. You may also identify which tips are the most practical for everyday situations.

This position is ideal for people interested in personal finance, budgeting, or improving financial literacy.

The work is flexible and completed online.


Remote working/work at home options are available for this role.
temporary
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RN Clinical Review Nurse {167271}
Salary not disclosed
Alameda 5 days ago
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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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.
Not Specified
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Clinical Data Review Pharmacist (onsite)
Salary not disclosed
West Jordan 2 days ago
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!
Not Specified
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