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If you have BI, BI Case Reviewer, Adjudications, or Investigative Federal Law Enforcement experience we're looking for you! If you have BI, BI Case Reviewer, Adjudications, or Investigative Federal Law Enforcement experience we're looking for you.
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The Physician Reviewer will provide an interpretation of the medical necessity of services provided by other healthcare professionals in compliance with client specific policies, nationally recognized evidence-based guidelines, and standards of care.
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Maintains certification for company signature programs (YSIS, Site Reviewer, QIDP, Supervises entry level QA position, if applicable Performs other duties as assignedTravel Required within designated service sites Qualifications Bachelor’s Degree.
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OQA&FI is recruiting for two Principal Administrative Associate II to function as a Quality Control Case Reviewers, who will: -Review POS, HRA One Viewer of imaged/scanned documents, Welfare Management System (WMS) data and other pertinent data in order to obtain information on the current financial status and eligibility criteria of cases in receipt of SNAP benefits.
$53,057 - $61,015Full-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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The Physician Reviewer may work as part of an interdisciplinary care team participating in the coordination of care with social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc.
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Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews; refrains from using case studies, cohorts, and the like to make decisions due to their limited sample sizes.
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MDS, Clinical experience, hospital, nurse auditor, Utilization review, medical fraud, Research Nurse, Nurse reviewer, Prior Authorization, Medicare, Medicaid, Acute Nursing, Hospital Nurse, Travel Nurse.
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If the care or service requested is not meeting initial clinical review criteria, then the case is referred to a peer clinical reviewer. The Utilization Review RN Case Manager shall work in a collaborative fashion to promote the provision of quality care and cost-effective outcomes that will enhance the physical, psychosocial, and vocational health of the plan participants in accordance with the policies and procedures of Lucent Health Care Management, LLC, URAC UM Standards, and the laws and established practices associated with medical management.
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Maintains and coordinates Medicaid state submission forms for presentation to on-site reviewer and files them accordingly or as per facility’s procedure. Knowledge of Discharge Planning/ Utilization Management / Case Management terminology and functions, in both managed care and non-managed care environments.
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Serves as classroom instructor, OJT coach, and quality reviewer. 10 positions will be filled in the Independent Office of Appeals: Case & Operations Support (C&OS)/Acct & Proc Supp/APS. 10 positions will be filled in the Independent Office of Appeals: Case & Operations Support (C&OS)/Acct & Proc Supp/APS (Special Program)/CIT Area 1 Team 2.
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ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services.
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Working from instructions and pre-established guidelines, under general supervision, assigns medical necessity requests to a qualified reviewer and follows-up to ensure timely determination is delivered based on state/URAC guidelines in accordance with Concentra policies, practices and procedures.
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Assuring that all enrollees receive clinically sound triage/referral and ongoing care management services for medical needs Maintains 100% compliance with the laws, standards, rules and regulations of regulatory agencies including but not limited to: URAC, Medicaid, Medicare Consulting with the medical director/peer reviewer on all high-risk and/or complicated cases, re-admissions and stays over six (6) days Provides documentation of enrollee contacts and clinical care as it occurs.
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Assigns cases to appropriate/qualified physician advisor based on case requirements for specific physician specialty, experience, and state licensure requirements. Communicates directly with customer and physician advisor and tracks cases to ensure case is completed and returned to customer within established time requirements.
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Knowledge in discharge planning/utilization management/case management terminology and functions, in both managed care and non-managed care environments. Responsible for the coordination of the various activities of the Case Management Department under the direction of the assigned Case Manager/Social Worker in the development and implementation of the discharge plan.
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