**This position is 100% remote, with a M-F 8am-5pm schedule. The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner. The A&G Clinical Specialist is the subject matter expert responsible for all clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The incumbent will manage his/her own caseload and is accountable for investigating and resolving member or provider initiated cases. Manages all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle clinical claim appeals that come from Healthfirst participating and non-participating providers. This is either a remote or on-site position located at either the 100 Church Street location in New York City or the 1101 Greenwood Avenue location, Lake Mary, Florida. This position may require attendance at A&G/ Operations divisional meetings and Town Halls, some of which may require travel to one of the locations (T&E will be covered according to policy). **This position is 100% remote, M-F 8am-5:30pm schedule Duties and Responsibilities: - Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services. The end-to-end process requires the Specialist to independently: - Research issues - Reference and understand HF’s internal health plans policies and procedures to frame decisions - Interpret regulations - Resolve cases and make critical decisions - Update file documentation such as the file notes and case summary - Manage all duties within regulatory timeframes - Communicate effectively to hand-off and pick-up work from colleagues - Work within a framework that measures productivity and quality for each Specialist against expectations - Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case - Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process - Additional duties as assigned Minimum Qualifications: - RN, LPN Preferred Qualifications: - Bachelor’s degree - Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management. - Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines - Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Maces). Experience with care management systems, such as CCMS, TruCare and Hyland. - Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: - Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360 - All Other Locations (within approved locations): $73,400 - $108,160 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

Job Summary: Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members. Essential Functions: - Complete prospective, concurrent and retrospective review of Behavioral Health services - Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care - Engage with medical director when additional clinical expertise if needed - Maintain knowledge of state and federal regulations, including State Contracts and Provider Agreements, benefits, and accreditation standards - Identify and refer quality issues to Quality Improvement - Identify and refer appropriate members for Care Management - Provide guidance to non-clinical staff - Provide guidance and support to LPN staff - Attend medical advisement and State Hearing meetings, as requested - Assist Team Leader with special projects or research, as requested - Perform any other job related duties as requested. Education and Experience: - Associates of Science (A.S) in Nursing required or - Bachelor of Science (B.S) in Social Work required - Three (3) years clinical experience required - Utilization Management/Utilization Review experience preferred - Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: - Proficient data entry skills and ability to navigate clinical platforms successfully - Working knowledge of Microsoft Outlook, Word, and Excel - Effective oral and written communication skills - Ability to work independently and within a team environment - Attention to detail - Proper grammar usage and phone etiquette - Time management and prioritization skills - Customer service oriented - Decision making/problem solving skills - Strong organizational skills - Change resiliency Licensure and Certification: - Current, unrestricted Registered Nurse (RN) Licensure or Licensed Social Worker (LSW) required - MCG Certification is required or must be obtained within six (6) months of hire required Working Conditions: - General office environment; may be required to sit or stand for extended periods of time - Travel is not typically required Compensation Range: $62,700.00 - $100,400.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

Triage Telephonic Nurse Case Manager Department: Claims Administration & Adjusting Employment Type: Permanent - Full Time Location: Home United States Reporting To: Shaunna Jones Compensation: $66,000 - $67,000 / year Description Our Story Imagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors. Davies North America is seeking a Triage Telephonic Case Manager (RN) to join our medical management team. In this role, you will provide clinical triage and telephonic case management at the initial report of a Workers’ Compensation claim, ensuring injured employees receive appropriate and timely medical care while supporting early return-to-work outcomes. This position requires strong clinical assessment skills, independent decision-making, and excellent communication to coordinate care between injured workers, employers, healthcare providers, and claims professionals. Key Responsibilities - Conduct initial triage and telephonic case management at the outset of Workers’ Compensation claims. - Perform clinical assessments of injured workers to determine appropriate medical care and treatment pathways. - Complete initial assessment and required three-point contact in accordance with State of Florida procedures and emergency protocols. - Develop an initial case management care plan based on clinical findings and information obtained from the injured worker, employer, and medical provider. - Identify potential causation concerns or barriers to recovery and document findings appropriately. - Facilitate communication between injured workers, employers, claims professionals, healthcare providers, and rehabilitation specialists. - Monitor treatment plans to ensure adherence to state-mandated treatment guidelines and evidence-based medical protocols. - Address initial return-to-work capabilities with injured workers and providers, documenting updates in the case management system. - Maintain accurate and timely documentation of all contacts, interviews, and medical information in the claims management system. - Identify opportunities for cost-effective medical management and appropriate utilization of services. - Educate injured workers and their families about recovery expectations and care plans. - Maintain strict patient confidentiality and compliance with state and federal healthcare regulations. - Serve as a patient advocate, ensuring quality care and adherence to ethical and regulatory standards. - Participate in quality assurance initiatives, committees, and department activities as required. - Assist with training claims staff on identifying medical case management opportunities, as needed. Skills, knowledge & expertise - Registered Nurse (RN) with an active and unrestricted state license - Minimum of 3 years of clinical nursing experience (medical-surgical, orthopedic, neurological, ICU/CCU, occupational health, or related specialty). - Workers’ Compensation case management experience preferred. - Prior telephonic case management or triage experience preferred. - Strong understanding of clinical documentation and patient advocacy principles. - Strong clinical assessment and triage skills in a Workers’ Compensation or occupational health environment. - Knowledge of Workers’ Compensation medical case management practices and treatment guidelines. - Ability to identify barriers to recovery and develop appropriate care strategies. - Excellent verbal and written communication skills, with the ability to work collaboratively with multiple stakeholders. - Strong organizational and documentation skills with attention to detail. - Ability to work independently and manage multiple priorities in a fast-paced environment. - Proficiency with computer systems, case management software, and Microsoft Office applications. - Commitment to high-quality patient care, confidentiality, and regulatory compliance. Benefits Benefits At Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes: - Medical, dental, and vision plans to ensure your health and that of your family. - A 401k plan with employer matching to help you build a secure financial future. - Our time-off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment. - Paid holidays. - Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones. Massachusetts Notice It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Diversity and Inclusion Davies is dedicated to fostering a diverse and inclusive workplace that embraces a wide range of perspectives and experiences. We believe that diversity of thought is essential for innovation and creativity, and we actively promote an environment where all voices are valued and heard. Compensation Transparency: The salary range listed reflects the full compensation band for this role across all locations. Actual compensation will be based on factors such as skills, experience, qualifications, and geographic location, which may impact the final offer. We share ranges to remain transparent and consistent with pay equity practices. We do not use sites like Facebook, Craigslist, or Telegram to recruit or interview potential employees or contractors. If you have been asked to provide any information through any method other than our career portal, please email us at recruitment@davies-group.com

Job DetailsJob Location: Mount Vernon, WA 98273Position Type: Full TimeSalary Range: $550,000.00 - $1,000,000.00 Salary/yearJob Shift: DaySkagit Radiology, Inc. / North Star Radiology was established in 1972 and provides specialized diagnostic and interventional radiology services in northwest Washington State, Alaska, and the Olympic Peninsula. Our fiercely independent practice is seeking board-certified or board-eligible Mammography Radiologists to join our collaborative, forward-thinking team in beautiful Washington State and Alaska. This is a shareholder-track opportunity with a clearly defined path to partnership, remote flexibility, and a supportive infrastructure built for physician success. The ideal candidate should: Board-certified or board-eligible Radiologist Fellowship training in Breast Imaging MQSA-qualified with strong experience in screening and diagnostic mammography Experience with breast ultrasound and breast MRI Lucrative, remote internal teleradiology moonlighting is available on your days off. Both shareholder-track (1-year) and employee positions are available. Position Highlights Fast Partnership Track: Just 1 year to partnership for shareholder track High-Value Bonuses: Substantial partnership bonuses available immediately upon partnership – among the highest in Washington Advanced Support: 24/7 IT assistance and a dedicated call center to connect with providers Modern Workflow: Fully staffed credentialing team ensures a smooth onboarding process Imaging Center Ownership: Enjoy direct benefits of our imaging center and a joint venture with our flagship hospital Healthy Payer Mix: Benefit from a stable and profitable payer landscape What Skagit Radiology Offers 401(k) from Day 1: Immediate matching; partners receive max 401(k) with safe harbor CME & Licensure Support: All continuing education and licensure fees fully covered Robust Compensation: Competitive base with partnership bonus potential Work-Life Balance: No overnight shifts, home call coverage, and remote flexibility Comprehensive Benefits: Medical, dental, vision, and more Infrastructure That Works for You: Built-in support systems, cutting-edge technology, and a culture focused on physician success Skagit Radiology is a physician-owned practice committed to clinical excellence and long-term stability. With deep roots in the community and strong hospital and clinic partnerships, we’re proud to provide high-quality imaging services in a supportive and innovative environment. The Skagit Valley offers a unique setting on Puget Sound, nestled in the foothills of the Cascade mountains. It’s close to cosmopolitan attractions in Seattle and Vancouver, providing easy access to oceanfront living, year-round mountain recreation, and everything in between. The region boasts a strong community feel, excellent schools, old growth forests, world-class fishing, and an idyllic semi-rural lifestyle. We provide a generous salary, vacation, and benefits package to support an amazing outdoor lifestyle. Fellows and R-4 residents are encouraged to apply. Qualifications