Overview The Medical Director (MD) is a key member of the audit, quality assurance and client team. The Medical Director is responsible for representing the team on all audit and appeals decisions. The Medical Director is also responsible for analyzing, interpreting, and developing additional policies that will allow us to enhance our medical policy library. The Medical Director will guide both internal and external processes as related to CCV inpatient audit, documentation, and communication of results. Responsibilities - Inpatient Audits (Prepayment & Retrospective) - Performs billing and coding audits to ensure charges are supported by the appropriate clinical documentation, review medical records, and document findings in Cotiviti and client systems as necessary. - Conducts reviews of medical records, charges and associated documentation, researching and applying knowledge related to billing and coding guidelines searching for billing, coding and unsupported (or clinical) documentation in provider billing. Analyzes medical record documentation to determine the accuracy and completeness of clinical and coding information in support of correct claim coding and billing guidelines. - Manages the workflow and deadlines to ensure accuracy and timeliness of audit results are consistent with client, federal, and state rules, regulations, and guidelines as applicable. - Upholds HIPAA privacy and security guidelines. - Appeals administration and oversight - Conduct audit of appeals on claims originally recommended for changes by another CCV Auditor to uphold or overturn the original audit decision. - Review new support evidence and/or documentation and gather other information as needed. - Participate in client and provider meetings to review and discuss audit case findings and results. - Research and Development - Assist the Clinical Audit Manager and Research Department to develop medical policy edits. - Develop scorecards for existing rules-based logic to analyze trends in current rules-based audit selection criteria and recommend ongoing optimization. - Quality Assurance Program support - Participate in the design and implementation of the QA program and provide support for ongoing quality assurance audits for interrater reliability and coding accuracy. - Support new sales activity and existing client growth by identifying value creation opportunities for our clients. - Other duties as assigned. Other Related Responsibilities - Delivers personal assignments reliably and on-time through organized personal work processes. - Produces quality work that considers the client’s (internal and external) needs and qualitative self-review process. - Exhibits behaviors consistent with Cotiviti Values. Qualifications RELEVANT EXPERIENCE & EDUCATIONAL REQUIREMENTS: - Must be a licensed physician with 5 + years’ clinical experience (preferrably in an inpatient setting, ER physician or hospitalist). - Experience in private sector/ Health plan operations as a Medical Director, with focus on chart review, medical coding (CPT, ICD-9) or appeals and grievances. - Experience in DRG auditing preferred. - Coding certification (CCS, CPC or CIC) preferred or willingness to obtain / maintain. - 5+ years’ experience using InterQual or MCG/Milliman criteria. - 5+ years’ experience using decision support group software (3M, etc.). SKILLS & COMPETENCIES - Excellent verbal and written communication skills. - Strong analytical and problem solving skills. - Intermediate Microsoft Office skills (Word, Excel, and PowerPoint). - Strong organizational skills and adaptive capacity for rapidly changing priorities and workloads. Mental Requirements: - Communicating with others to exchange information. - Assessing the accuracy, neatness, and thoroughness of the work assigned. Physical Requirements and Working Conditions: - Remaining in a stationary position, often standing or sitting for prolonged periods. - Repeating motions that may include the wrists, hands, and/or fingers. - Must be able to provide a dedicated, secure work area. - Must be able to provide high-speed internet access/connectivity and office setup and maintenance. - No adverse environmental conditions are expected. Base compensation ranges from $225,000 to $275,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. This role is eligible for discretionary bonus consideration. Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page. Date of posting: 3/3/2026 Applications are assessed on a rolling basis. We anticipate that the application window will close on 5/3/2026, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected. #LI-Remote #LI-JB1 #senior

Home Health Care, Hospice Care, Palliative Care, Long Term Care, Rehab No weekends, No afterhours support, No holidays Job Description Job Summary Are you seeking a unique nursing position that gives you a great work/life balance and lets you support people to live the lives that they choose? Then you’ll want to keep reading about this rewarding work opportunity! We are currently looking for a Registered Nurse licensed in Wisconsin to become our next IRIS Self-Directed Personal Care (SDPC) RN. This is a remote position, where you will partner with people in your community who are enrolled in the Wisconsin IRIS program – a Medicaid long-term care option for older adults and people with disabilities. People in the IRIS program who need personal care services have the choice to enroll in the IRIS Self-Directed Personal Care (IRIS SPDC) option. You can learn more about IRIS SDPC on the Wisconsin Department of Health Services website here, and learn about the IRIS program here. While this role is home-based, you will have regularly scheduled visits with people in their homes and communities. As an IRIS SDPC RN, you’ll provide oversight and guidance to the people enrolled in the IRIS SDPC option. You’ll also build relationships with the people you partner with and ensure that they’re getting the most out of the IRIS Self-Directed Personal Care option through assessment, oversight, training and education. IRIS SDPC RNs are responsible for administering the Wisconsin Personal Care Screening Tool; creating person-centered plans of care; providing personal care oversight to a group of people in IRIS, providing education and training for IRIS participants and care providers, and conducting the required documentation and follow-up. As an IRIS SDPC RN, you’ll play an important role in helping people of various backgrounds and abilities live their lives the way they choose. Knowledge/Skills/Abilities - Provides personal care assessments and oversight to the My Cares Groups by administering the Wisconsin Personal Care Screening Tool and addendums as required - Documents assessment as required by individual tool and Department of Health Services policies and by completing oversight visits and calls as required - Oversees a My Cares Groups of participants, develops individual plans of care, ensures physician orders for care are obtained and reviews and revises plan of care as needed - Submits for Prior Authorization for personal care services - Complies with all Department of Health Services policies and SDPC Guidelines, procedures, and practices along with documentation and program regulations - Provides personal care training to participants or care providers as requested and provides educational materials as needed - Completes collateral contacts with IRIS Consultants and Long-Term Care Functional Screeners and physicians to ensure care needs are met - Completes other duties as assigned - Overtime work may be required - May be required to drive 50% of the time during a given day of member home visits - Exposure to members homes which may include navigating stairs, exposure to different environments, and pets Required Qualifications • At least 2 years nursing experience, and at least 1 year of experience serving the target groups of the IRIS program (adults with physical/intellectual disabilities or older adults), or equivalent combination of relevant education and experience. • Active and unrestricted Registered Nurse (RN) license in the state of Wisconsin. • Associate's degree in nursing. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements unless otherwise required by law. • Database operation/maintenance skills and data entry experience. • Teaching and mentoring skills. • Analytical and problem-solving skills. • Strong organizational and time-management skills, and ability to manage tasks independently. • Flexibility in the work environment, and willingness and ability to adapt to changing organizational needs. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Experience providing care through the Wisconsin Medical Assistance Personal Care program (MPAC). • Home care/home health experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Complex Care Navigator LPN *Bi-lingual, Spanish preferred* Location: Houston, Texas Who We Are Tuesday Health launched in 2023 to deliver compassionate, supportive care for patients and caregivers navigating serious illness. We believe that each patient's journey is unique. As such, we deliver member-directed, whole-person care to seriously ill patients in our program, using leading edge supportive care models, including appropriate transitions to hospice when the time is right. This results in dramatically improved quality of life for members and their caregivers, and a meaningful reduction in unproductive medical spend. Our overall mission is to transform serious illness and end-of-life care; our team believes deeply in this mission and puts our members first in all that we do. The Role The Complex Care Navigator LPN plays a key role in delivering coordinated, compassionate care for members with serious illnesses. Working closely with nurse practitioners and registered nurses, the LPN administers clinical assessments and screenings throughout the care journey. They prioritize member needs based on assessment results and collaborate with the interdisciplinary team to develop and execute individualized care plans. The LPN ensures seamless communication, participates in care rounds, and leverages Tuesday Health’s electronic tools to optimize the member experience. Trust-building, empathy, and consistent member engagement are essential to the role, enabling a truly person-centered approach to care. Key responsibilities of this role may include: · Administer multiple assessments and screening tools within the clinical model at different times throughout the care timeline with the support of nurse practitioners and registered nurses · Prioritize needs based on assessment results and task interdisciplinary care team · Be accountable for care plan development within the multidisciplinary care team · Participate in internal and joint rounds to ensure the member experience is optimal and coordinated · Learn the Tuesday Health electronic systems, tools, technology, to deliver a coordinated approach to ensure the members have a unique experience · Build a strong, trusting relationship with every member, where listening and empathy are the foundation of every interaction · Serve as the quarterback of the multidisciplinary team transforming care for members with serious illness A strong candidate will demonstrate the following: · Active and unrestricted licensed practical nurse license in the State of Texas without any board action · Experience in clinical/medical setting preferred · Experience in a multi-disciplinary care model working across network providers, health plan care management support, and employed clinicians · Strong communication and organization skills · Ability to multitask and work under pressure without sacrificing a positive member experience · Ability to know when to escalate and potentially act professionally in an emergent situation · Strong technical skills to navigate different documentation systems and tools; as well as ability to learn new systems as the company grows and evolves · Strong written skills · Ability to drive during daytime, nighttime, or inclement weather · Valid driver's license with safe driving record · State minimum automobile insurance coverage · Comfort with change and ambiguity; you understand that rapid changes to the business, strategy, organization, and priorities will come with rapid evolution of our business What We Offer - Competitive compensation, reflecting our commitment to attracting, retaining, and motivating the best talent in the industry - Comprehensive benefits including medical, dental, vision, and life insurance, paid time off and holidays, employer 401(K) match, etc. - Remote work with multiple onsite sessions each year to maximize collaboration and team building - A dynamic and inclusive team environment where you can lean on your teammates, offer candid feedback, bring your true self to work each day, and deliver tremendous impact while having fun along the way - Meaningful work each day; we care deeply about our mission, our patients, and each other If you are passionate about improving the quality of care for seriously ill individuals and their caregivers through innovative solutions, we would love to hear from you. Tuesday Health seeks to recruit and retain staff from diverse backgrounds and encourages qualified candidates to apply. Tuesday Health is an equal opportunity employer and does not discriminate on the basis of age, sex, gender identity/expression, sexual orientation, color, race, creed, national origin, ancestry, religion, marital status, political belief, physical or mental disability, pregnancy, military, or veteran status.

Description Psychiatric Mental Health Nurse Practitioner (PMHNP) – Mental Health Clinic We are seeking a compassionate and experienced Psychiatric Mental Health Nurse Practitioner (PMHNP) to join our dedicated team at our Mental Health Residential Clinic. This role offers an opportunity to make a meaningful difference in the lives of individuals seeking mental health support in a supportive and collaborative environment. If you are committed to providing high-quality, patient-centered care, we encourage you to apply. Key Responsibilities: - Conduct comprehensive psychiatric assessments and develop individualized treatment plans for patients - Prescribe and manage medications in accordance with state and federal regulations - Provide psychotherapy and counseling to patients as appropriate - Collaborate with multidisciplinary team members to coordinate care and ensure optimal patient outcomes - Monitor patient progress and adjust treatment plans as necessary - Educate patients and their families about mental health conditions and treatment options - Maintain accurate and timely documentation of patient interactions and treatment plans - Adhere to all clinical protocols, ethical standards, and confidentiality requirements Skills and Qualifications: - Valid and current Nurse Practitioner license with certification as a Psychiatric Mental Health Nurse Practitioner (PMHNP) - Proven experience working in mental health settings, preferably in residential or outpatient clinics - Strong knowledge of psychiatric medications, therapeutic modalities, and evidence-based practices - Excellent communication and interpersonal skills - Ability to work independently and as part of a team - Compassionate, patient-focused approach to care - Ability to handle sensitive situations with professionalism and discretion Our clinic fosters a supportive and inclusive environment that values professional growth and continuous learning. We offer competitive compensation, comprehensive benefits, and opportunities for advancement. Join us in making a positive impact on the mental health and well-being of our community. Requirements - See 10-15 patients (17 yo +) per day in our mental health urgent care and our residential treatment facility - Lead four 60 min lectures per month in person - Participate in Family Education Sessions 1 Saturday per month for 2 hours as the Facilitator of recovery education virtual care - License in both CA and TX - ok to start with just Texas license as long as you are licensed in CA within 6 mo of hire - PMHNP experience for 7+ years in SUD and mental health - Hours: 3 days per week are 5P-10P * Note position is In Person or Virtual. Virtual care hourly rate is 15% less * Bonus for 5 star reviews and successful graduations from the program