Job Closed
This listing is no longer active.
Learn More About E-Verify and myE-Verify
Medical Review Analyst
Location
North Carolina
Posted
120 days ago
Salary
$73.7K - $117.9K / year
Seniority
Senior
Job Description
Medical Review Analyst
E-Verify Program
• Identifies, analyzes, and determines medical necessity, pre-existing conditions, benefit eligibility and/or individual consideration reimbursement allowances for novel and complex medical management related claims • Acts as a member advocate to promote and coordinate the delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits • Ensures that review and determinations meet all requirements per line of business by Regulatory and Accrediting bodies • Identifies, documents, and escalates system and process problems • Through analysis, determines root cause and recommends possible solutions • Reviews physician-submitted and member-submitted claims for specified services, utilizing professional knowledge and developed criteria • Refers cases that do not meet criteria to the Medical Director with appropriate clinical analysis and summaries • Issues denials according to department protocols • Documents outcome of reviews • Maintains confidentiality of all PHI in compliance with state and federal laws • Recognizes, documents, and reports inappropriate billing patterns or utilization trends of professional and institutional providers to appropriate business owner • Identifies situations in which claims filing/coding guidelines are not being followed by providers • Communicates with members and providers to obtain additional information • Informs members, providers, and internal customers of claims status and determinations • Performs post adjudication review of claims related to coding, billing and reimbursement
Job Requirements
- RN with a minimum of 3 years previous clinical experience preferably in a variety of clinical settings
- LPN with a minimum of 5 years previous clinical nursing experience preferably in a variety of clinical settings
- Must hold and maintain a valid North Carolina clinical license
Benefits
- The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
- Work-life balance, flexibility, and the autonomy to do great work
- Medical, dental, and vision coverage along with numerous health and wellness programs
- Parental leave and support plus adoption and surrogacy assistance
- Career development programs and tuition reimbursement for continued education
- 401k match including an annual company contribution
Related Guides
Related Categories
Related Job Pages
More Analyst Jobs
IT Vendor – Contract Analyst
Ascent Global LogisticsPremium global logistics solutions for mission-critical supply chain needs.
• The IT Vendor & Contract Analyst supports the PMO and IT delivery teams by managing the end-to-end intake, coordination, and governance process for third-party vendor engagements. • This role ensures vendor requests are appropriate, aligned to approved projects, and routed through the correct procurement, security, and contract review pathways. • The analyst drafts and refines SOW documentation, manages contract workflows, and maintains portfolio visibility into vendor engagements, renewals, and project dependencies. • This role also supports commercial negotiations within established guidelines, especially for staffing and recurring services, and partners with Procurement and IT leadership to negotiate non-standard terms or higher-risk agreements. • Serve as the PMO point of contact for new vendor requests, renewals, SOW changes, and extensions supporting IT projects. • Validate intake requests for completeness and alignment to approved initiatives, including scope summary, vendor justification, timeline, funding/charge codes, and internal owner. • Maintain vendor-to-project traceability across the portfolio: vendor name, service type, project/program, start/end dates, SOW value, renewal dates, and accountable IT owner. • Coordinate vendor onboarding requirements (as applicable), including security intake, access needs, and required documentation. • Draft, assemble, and refine Statements of Work (SOWs) and supporting exhibits to ensure clear: scope, deliverables, milestones, assumptions, acceptance criteria, and roles/responsibilities governance expectations (status cadence, escalation path, change control). • Coordinate routing of SOWs/contracts through the appropriate review and approval steps (Procurement, Legal/Contract team, InfoSec, Finance), ensuring packages are complete and minimizing rework. • Manage change orders, extensions, and amendments by collecting scope/cost impacts, ensuring approvals are obtained, and maintaining documentation integrity. • Support and execute negotiations within approved standards, primarily for staffing and recurring services, including: rate cards, markups, discounts, extension terms, not-to-exceed caps, and payment terms. • Prepare negotiation inputs: rate benchmarking (internal history), option comparisons, and recommendation summaries for IT/Procurement leaders. • Escalate non-standard terms, high-dollar agreements, or elevated-risk vendors to Procurement/Legal/IT leadership for final negotiation and approval. • Track vendor performance issues and work with PMs to document impacts, capture issues/risks, and facilitate escalation to vendor leadership when needed. • Ensure vendor commitments are integrated into project governance (kickoff readiness, milestones, resourcing commitments, renewals that impact schedule). • Support vendor offboarding steps, including end dates, knowledge transfer expectations, and access removal coordination (as applicable). • Provide reporting to PMO and IT leadership such as: vendor/contract pipeline and aging renewals calendar and upcoming decision points vendor engagement inventory by project/program change order log and common contracting bottlenecks. • Maintain standardized templates and checklists (SOW minimum requirements, intake form, renewal readiness checklist, contract routing checklist).
Senior Integrations Analyst
FiservWe aspire to move money and information in a way that moves the world.
• Serve as the primary liaison between business teams, integration developers, architects, QA, and external vendors. • Facilitate workshops, design sessions, and backlog grooming related to integration initiatives. • Communicate complex technical integration concepts in clear business terms and vice versa. • Partner with business stakeholders to understand end‑to‑end business processes and integration needs across multiple systems. • Elicit, analyze, and document functional and non‑functional requirements for system integrations, APIs, and middleware solutions. • Define integration use cases, data flows, message formats, validation rules, and exception handling. • Ensure requirements align with enterprise integration standards, architectural principles, and security guidelines. • Collaborate with integration architects and developers on solutions using middleware platforms (e.g., iPaaS, ESB, message brokers). • Define REST API requirements including endpoints, payloads, error handling, authentication, and performance expectations. • Support API lifecycle activities such as versioning, backwards compatibility, and deprecation strategies. • Participate in API and integration design reviews to ensure business requirements are fully met. • Support agile or hybrid delivery teams by maintaining user stories, acceptance criteria, and integration test scenarios. • Assist with integration testing, data validation, and defect triage. • Support deployment readiness, post‑implementation validation, and continuous improvement efforts.
Senior Director, Analyst Relations
GartnerWe deliver actionable, objective insight that drives smarter decisions and stronger performance.
• Create innovative, thought provoking, and highly leveraged “must-have insights” content • Develop new insights and ideas through thought leadership and offer compelling, actionable approaches to client's needs • Demonstrate thought leadership in establishing Insights positions across a team of analysts • Research, analyze and predict market trends and shifts to provide clients with actionable insights • Create and deliver high value presentation materials on and off stage for Gartner events • Support BTI and Sales: Provide sales support serving as voice of the market and create content
Global Data Cost Analyst
SocureThe leading provider of digital identity verification and fraud solutions. Salesinfo@socure.com
• Develop, analyze, and maintain cost and pricing models for subscription, transactional pay-per-use (API), and enterprise licensing data products. • Partner with Product Managers to analyze, recommend, and test tiered, volume-based, and bundled margin and pricing structures. • Support monthly, quarterly, and annual cost and price reviews and recommend adjustments based on market data and company strategy. • Evaluate data acquisition and licensing costs across vendors and data sources. • Model and monitor gross margins for data products to ensure profitability targets are met. • Analyze vendor and internal data usage patterns against spend and revenue to develop return-on-investment recommendations and decisions. • Benchmark competitive product pricing and margins through market research to ensure competitive positioning. • Monitor cost, margin, and pricing performance against KPIs (revenue, ARPU, conversion rates, and margins).




