The Utilization Management Nurse Reviewer plays a crucial role in healthcare systems by ensuring that medical services are used efficiently and appropriately. They review medical records, treatment plans, and patient information to determine the necessity and appropriateness of medical procedures, tests, and treatments. Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their responsibilities include assessing medical necessity, coordinating care, conducting utilization reviews, providing recommendations for care plans, and ensuring adherence to regulations and guidelines. This role requires strong clinical knowledge, critical thinking skills, communication abilities, and the ability to make informed decisions regarding patient care pathways. MAJOR DUTIES & RESPONSIBILITIES - Conduct assessments of medical services to validate their appropriateness using established criteria and guidelines, ensuring the medical necessity of treatments (e.g., CMS, Milliman Care Guidelines, InterQual, or health plan specific guidelines/criteria). - Examine and evaluate patient records to verify the quality of patient care and the necessity of provided services. - Offer clinical expertise and serve as a clinical reference for non-clinical staff members. - Input and manage essential clinical details within various medical management platforms. - Keep up-to-date with regulatory prerequisites (such as URAC) and state standards for utilization review. - Apply clinical reasoning to determine the suitable evidence-based guidelines. - Foster efficient and high-quality patient care by effectively communicating with management teams, physicians, and the Medical Director. Requirements - Proficient in both written and spoken communication. - Capable of maintaining professional communication with physicians and clients. - Skilled at handling multiple tasks and adjusting swiftly in a dynamic office setting. - Possesses a keen organizational sense and pays close attention to details. - Adept at resolving intricate and multifaceted problems. - Experienced with Microsoft tools such as Word, Excel, PowerPoint, and Outlook. - Background in medical or clinical practice through education, training, or professional engagement. - Holds an unrestricted LVN/RN license from an accredited vocational nursing program (for LVNs) or a nursing degree from an accredited college (for RNs). Additional Duties - May provide oversight to the work of the team members. - Continuously improves processes that help to facilitate better turnaround time, peer to peer success rates and lessens returned reports by clients for clarification purposes, ultimately resulting in higher client satisfaction. - Responsible for the final approval on cases for release to the client. - Will act as a liaison and coordinate quality issue reports along with all new reviewer reports with the VP of Clinical Operations. - EDUCATION/CREDENTIALS: Licensed Practical/Vocational Nurse with an active and unrestricted license to practice. JOB RELEVANT EXPERIENCE: 2 yrs minimum clinical nursing experience is required. One year of previous experience in Utilization Management is required. JOB RELATED SKILLS/COMPETENCIES: Demonstrate strong abilities in both spoken and written communication, along with effective interpersonal skills. Possess a proficient understanding of computer operations, particularly the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows. Show the capability to acquire new skills and competencies to address the evolving requirements of systems, software, and hardware. WORKING CONDITIONS/PHYSICAL DEMANDS: Any lifting, bending, traveling, etc. required to do the job duties listed above. Long periods of sitting and computer work. WORK FROM HOME TECHNICAL REQUIREMENTS: Supply and support their own internet services. Maintaining an uninterrupted internet connection is a requirement of all work from home position. Beginning compensation will depend on several factors including the candidate's experience, education, and specific skills. In addition to the base salary, we offer a comprehensive benefits package including health insurance, retirement plans, and performance bonuses. Our Commitment: We are committed to providing fair and competitive compensation that reflects each employee's contributions and performance. We value diversity and strive to create an inclusive environment for all employees. Salary: $45,000 - $70,000 USD Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additionally, we offer voluntary life insurance options for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace.  ABOUT DANE STREET: A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.

The job profile for this position is Business Project Senior Analyst, which is a Band 3 Senior Contributor Career Track Role. Excited to grow your career? We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position you see is right for you, we encourage you to apply! Our people make all the difference in our success. POSITION SUMMARY The Business Project Senior Analyst works with the Plan Automation team to assist with the review of various Plan Automation inventory types; internal/external remediation projects, automation enhancement testing, etc. You will help provide process-oriented support based on inquiries from the front-line analysts and/or leads, provide root cause analysis for claim reviews, Problem Resolution Form (PRF) resolutions and high-profile account service issues. Primary Responsibilities: - Serve as the lead on Proclaim Plan Automation remediation projects and system reviews. - Support the area RMG with managing TAT on quality inspections by assisting with escalated error correction requests. - Assist in the development of frontline analysts through effective coaching feedback and reporting analytics. - Collaborate with management teams on process improvement initiatives. - Effectively communicates with and influence business partners and systems personnel regarding cross-functional process enhancements. - Foster and maintain a collaborative relationship with all matrix partners to ensure internal and external customer satisfaction and overall enterprise profitability. Key Qualifications - High school diploma or GED; Bachelor’s degree preferred. - 2+ years of Proclaim Plan Automation experience preferred. - Proficient knowledge of Plan Specs, ePro, Leg tool, Proclaim Claim System required. - Experience with Client Operations inventory management. - Experience working with mid-level and senior management required. - Excellent communication (oral and written) listening, and organization skills. - Ability to work independently and meet target completion dates. - Proficient MS Office product knowledge required, MS Word, OneNote PowerPoint; advanced proficiency with MS Excel preferred. - Drive for results in a fast-paced environment. - Ability to develop solid working relationships and establish a high level of credibility across functions, geographies, and lines of business required. If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. For this position, we anticipate offering an annual salary of 64,900 - 108,100 USD / yearly, depending on relevant factors, including experience and geographic location. This role is also anticipated to be eligible to participate in an annual bonus plan. At The Cigna Group, you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, click here. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description We're looking for a Quality Analyst who will own testing quality across 1-2 digital products at Viewrail. You'll design and execute test strategies, identify and track defects, and collaborate with cross-functional teams in an agile environment to ship high-quality software. The right person is detail-oriented, proactive about process improvement, and comfortable working alongside developers, UX designers, analysts, and business stakeholders to resolve issues and deliver results. - Design, implement, and maintain test strategies, plans, and cases for assigned digital products - Execute functional, regression, integration, and performance testing across development cycles - Identify, document, and track defects in Jira, communicating findings clearly to developers and product teams - Analyze test results and deliver reports that inform release decisions - Collaborate with engineers, UX designers, project teams, and business stakeholders on defect resolution and quality standards - Leverage AI tools and automation to accelerate testing workflows, improve defect detection, and increase overall QA productivity - Contribute to task estimation, sprint planning, and timeline commitments within SAFe agile practices - Proactively identify opportunities to improve QA processes, tools, and testing coverage - Maintain proficiency with current QA tools, frameworks, and testing methodologies - Demonstrate intellectual curiosity by continuously exploring new tools, techniques, and approaches to improve quality outcomes - All other job duties and responsibilities as assigned Qualifications - 2+ years experience ensuring quality for digital products - Proficiency with test management and defect tracking tools (Jira preferred) - Working knowledge of the software development lifecycle (SDLC) and Agile methodologies - Demonstrated curiosity and willingness to adopt AI-assisted tools and workflows to enhance productivity - Basic SQL skills for data validation and application data analysis - Strong analytical thinking and problem-solving abilities - Effective written and verbal communication skills - Ability to work both independently and collaboratively within a team Requirements - Experience working within SAFe or other scaled agile frameworks - Familiarity with test automation concepts or tools - Experience using AI tools (e.g., Claude, Copilot, or similar) to support testing, documentation, or analysis tasks - Relevant QA certification(s) (ISTQB, CSTE, or similar) - Experience with API testing or performance testing tools - Hands-on experience building or maintaining test automation scripts or frameworks - Exposure to CI/CD pipelines and how testing integrates into them Benefits - Medical Insurance - PPO and HDHP options - Dental Insurance - Vision Insurance - Voluntary Life Insurance - Short Term Disability Insurance - 401k with Company match of up to 4% - Paid Holidays - Paid Time Off

• Manage HTS and ECCN classification • Qualify goods under FTAs such as USMCA and GSP • Ensure compliance with EAR and ITAR export control requirements • Respond to CBP inquiries (CF-28/CF-29) • Conduct import audits for duty recovery opportunities • Oversee ACE portal management and denied party screening • Work cross-functionally with Supply Chain, Finance, and Engineering