Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. Position Summary The Utilization Appeals Review Nurse will be responsible for clinical review of member and provider appeals and/or claims disputes. Collaborating with our team of Medical Directors and internal stakeholders, you will use your clinical expertise to apply Martin’s Point medical policies, CMS and TRICARE regulations to deliver accurate, timely, and compliant appeal or claims disputes decisions. Job Description PRIMARY DUTIES AND RESPONSIBILITIES Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization. - Responsible for the review and resolution of clinical appeals and disputes - Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. - Ensures care delivery aligns with specific line-of-business benefits while maintaining full compliance with contractual and regulatory standards, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. - Stays current with industry regulations and accreditation standards to ensure continuous operational compliance - Consistently delivers high-quality outcomes that meet or exceed established departmental benchmarks and performance standards. Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings. - Independently coordinates the clinical resolution with internal/external clinician support as required. - This position will be accountable for appeals, claims disputes, and QOC review - This is a full-time remote position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time). - Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another. - Assumes extra duties as assigned based on business needs. - Weekend and holiday on-call coverage may be required. POSITION QUALIFICATIONS Education - Associate Degree in Nursing (ADN) - Bachelor’s degree in nursing preferred Licensure/certification - Active, unrestricted Compact Registered Nurse (RN) license. Experience - 3+ years of RN clinical experience, preferably in a hospital setting, along with experience in utilization management in a health plan UM department and in managing appeals or disputes - Coding/CPC preferred Knowledge - Thorough understanding of CMS Medicare Advantage regulations (Parts C & D) and NCQA guidelines - Thorough knowledge of MCG, Interqual of other clinical guidelines - HIPAA & privacy requirements - Concurrent, prior authorization and appeals review - Critical thinking and case analysis - Clinical writing and summarization - Electronic UM systems - Tricare regulation experience preferred - MCQA standards experience preferred - Claims disputes review experience preferred Skills - Ability to extract relevant clinical facts from progress notes, labs, imaging, and treatment plans. - Correct use of MCG, and Martiin’s Point medical policies to determine medical necessity. - Ability to identify inconsistencies, missing information, or red flags in documentation - Understanding appeal levels, timeframes, coverage rules, and documentation requirements. - Ability to produce rationales that meet CMS, TRICARE, and NCQA standards - Ability to write clear, defensible rationales that explain the clinical and regulatory basis for the determination. - Ability to write concise, objective, and compliant appeal rationales Abilities - Ability to analyze data metrics, outcomes, and trends. - Ability to prioritize time and tasks efficiently and effectively. - Ability to manage multiple demands. - Ability to function independently. This position is not eligible for immigration sponsorship. We are an equal opportunity/affirmative action employer. Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ***POSITION IS REMOTE FOR 8-5 EST WORK SCHEDULE*** ***COMPACT LICENSURE REQUIRED*** ***ROTATIONAL WEEKEND AND HOLIDAY WORK SCHEDULE REQUIRED FOR ROLE** Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. - Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care - Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member - Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered - Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines - Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings - Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members - Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines - Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities - Collaborates with care management on referral of members as appropriate - Performs other duties as assigned. - Complies with all policies and standards. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: - LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Role Description - Review patient insurance policies to determine specific prior authorization requirements based on CPT codes for all upcoming surgical procedures. - Initiate prior authorization requests through provider portals, phone communication, or fax submission. - Track and follow up on submitted authorization requests, ensuring approvals are obtained and properly attached and linked to the patient’s scheduled appointment. - Prepare and submit appeals when authorization requests are denied or require reconsideration. - Communicate with patients when necessary to explain the prior authorization process or request additional required information. - Accurately document all prior authorization activities in patient charts to ensure the care team is informed prior to the patient’s appointment. - Monitor Microsoft Teams chats for questions, clarifications, or appointment updates that may impact prior authorization status in real time. Qualifications - Strong attention to detail and organizational skills. - Effective verbal and written communication skills. - Proficiency with Microsoft Teams, Outlook, and Excel preferred. - Strong problem analysis and resolution skills. - Ability to effectively multitask while working across multiple computer-based information systems. - Capacity to work independently and remain productive in a self-directed environment. Requirements - This is a full time role. - Up to $6/hr. Important Notice By submitting your application, you acknowledge and provide your explicit consent to the collection, processing, storage, and use of the personal information contained in your application. You agree that Remote Raven may contact you using the details provided for recruitment and talent management purposes. You further authorize Remote Raven to retain your information within its database for consideration in current and future employment opportunities, in compliance with applicable data protection and privacy regulations.

About Prep Network Prep Network (www.prepnetwork.com) operates websites -- 100+ in total -- aimed at maximizing visibility and value for high school athletes at all levels. Our scouts provide content, player rankings, and event coverage year-round. Prep Network operates Prep Hoops, Prep Girls Hoops, Prep Redzone, Prep Dig, and Prep Lacrosse. Combined, Prep Network websites have over 300 scouts nationwide that produce 2,500+ articles each month on prep basketball, football, and volleyball. Prep Network also operates 100+ tournaments and showcases that host hundreds of teams and thousands of prospects across the country each year. Job Description As a scout, you will create written and social media content. You will attend high school and club games, watch game film, and publish player-driven analysis on Prep Network's website. You will utilize your existing network with high school and college coaches in your community to grow the Prep Network footprint. We are a rapidly growing sports-focused company where your voice will be heard and you can make a real impact. Aside from helping high school players get recruited, we want someone who fits our culture, work ethic, and, most importantly, our passion for learning and improving. Responsibilities and Duties - Attend high school and club games and publish written and social media content - Promote players at all levels of collegiate recruitment - Work with other Prep Network contributors to maximize the value added to teams, players, and coaches in your state - Network with coaches at all levels to grow the Prep Network brand We Are Looking For Someone Who Is - Entrepreneurial. Help us build the fastest-growing high school sports network in the country - A Great Teammate. No job is too small. We need someone willing to do whatever is needed to build something great - Driven. You are self-motivated and perform without direct supervision - A Strong Communicator. You need excellent interpersonal, verbal, and written skills - Experienced with Microsoft & Google. You are proficient with Microsoft Office (Word, Excel, and PowerPoint), as well as Google Apps (Gmail, Google Calendar, Google Docs) Benefits and Perks - Flexibility. We care more about the quality of your work than your location. - Awesome Co-Workers. Company culture is important to us. We love hiring curious, self-motivated people who work hard and have a blast doing it. - Potential for Growth. Make an impact, and earn the opportunity for an expanded role. Join the Prep Network team, selected as a 2020 recipient of the Best Employers in Sports Award by Front Office Sports as well as 2023 and 2023 Minneapolis St. Paul Best Places to Work.