This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The CERIS Professional Review Nurse provides analysis of medical services to determine appropriateness of charges on multiple types of medical bills and review of medical reports to determine appropriateness of medical care. Clinical and/or technical expertise is utilized to address the provision of medical care and to identify inappropriate billing practices and errors inclusive of, but not limited to: - Duplicate billing - Unbundling of charges - Services not rendered - Mathematical and data entry errors - Undocumented services - Reusable instrumentation - Unused services and supplies - Unrelated and/or separated charges - Quantity and time increment discrepancies - Inconsistencies with diagnosis - Treatment frequency and duration of care - DRG validation - Service/treatment vs. scope of discipline - Use of appropriate billing protocols This is a remote position. Qualifications - Must maintain current licensure as a Registered Nurse in the state of employment with a minimum of 4 years clinical experience - A minimum of an Associate Degree in Nursing is preferred - Thorough knowledge of both C.P.T. and I.C.D.10 codes is preferred - Medical bill auditing experience preferred - Experience in the clinical areas of O.R., I.C.U., C.C.U., E.R., and orthopedics preferred - Prospective, concurrent and retrospective utilization review experience preferred Requirements - Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and/or direct reporting manager - Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans - Completely document work and final conclusions in designated computer program - Adhere to regular and consistent work attendance - Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP) and other requirements as outlined in the Employee Handbook - Responsive to additional Professional Review job duties as assigned by management or determined by legislative changes and/or market changes Benefits - Medical (HDHP) w/Pharmacy - Dental - Vision - Long Term Disability - Health Savings Account - Flexible Spending Account Options - Life Insurance - Accident Insurance - Critical Illness Insurance - Pre-paid Legal Insurance - Parking and Transit FSA accounts - 401K - ROTH 401K - Paid time off Company Description CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!). CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

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. Centene is seeking a Clinical Review Nurse to join our Arizona Medicaid team in a fully remote role. Position Overview: The ideal candidate will have experience with prior authorizations for outpatient services and be available to work Arizona hours, Monday through Friday, 8:00 AM – 5:00 PM. Qualifications: - Active RN or LPN license in Arizona or a multistate compact license. - Candidates located in New Mexico, Nevada, Washington, or Oregon will be considered if they hold an active Arizona license. Prior authorization experience with outpatient services preferred. - Strong clinical assessment and communication skills. - Ability to work Arizona business hours remotely. Join Centene and help us deliver high-quality care and support to our Medicaid members across Arizona. Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. - Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria - Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care - Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member - Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care - Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities - Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines - Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members - Provides feedback on opportunities to improve the authorization review process for members - 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. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service 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

Opportunity Overview: We are looking for Doctors of Physical Therapy (DPT) who have expertise in Physical Therapy to deliver on Cohere’s musculoskeletal and orthopedic programs by determining the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines. Reporting to the Medical Director MSK Spine and Ortho for Cohere Health, and part of the review team that includes non-clinical intake specialists and nurses. This is a fast-paced environment that favors people who are able to learn quickly, be hands-on, handle ambiguity, and communicate effectively with people of different backgrounds and perspectives. What you’ll do: - Provide timely medical reviews that meet Cohere’s stringent quality parameters - Provide clinical determinations based on evidence-based criteria while utilizing clinical acumen - Clearly and accurately document all communication and decision-making in Cohere workflow tools, ensuring a member and provider can easily reference and understand your decision - Use correct templates for documenting decisions during case review - Meet the appropriate turn-around times for clinical reviews - Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research - Demonstrate the highest level of professionalism, accountability, and service in your interactions with Cohere teammates and providers - Support projects specific to building the team's clinical expertise and efficiency, as delegated - Support the team on operational improvements and member/provider experience involving clinical review tasks, as delegated What you’ll need: - Doctor of Physical Therapy (DPT) from a CAPTE-accredited physical therapy program - Active, unrestricted Physical Therapist license in the state of practice (or eligibility for licensure) - 5+ years of direct clinical patient care experience - Familiarity with facilities rendering care in PT, OT, SLP - 1+ years of managed care utilization review experience, preferably in an utilization management organization within a Medicare, Commercial or Medicaid payor organization preferred - Membership in national and/or regional specialty societies preferred Pay & Perks: 💻 Fully remote opportunity with about 5% travel 🩺 Medical, dental, vision, life, disability insurance, and Employee Assistance Program 📈 401K retirement plan with company match; flexible spending and health savings account 🏝️ Up to 184 hours (23 days) of PTO per year + company holidays 👶 Up to 14 weeks of paid parental leave 🐶 Pet insurance  The salary range for this position is $95,000 to $105,000 annually; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment. Interview Process*: - Connect with Talent Acquisition for a Preliminary Phone Screening - Meet your Hiring Manager! - Behavioral Interview(s) *Subject to change About Cohere Health: Cohere Health’s clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. Cohere Health works with over 660,000 providers and handles over 12 million prior authorization requests annually. Its responsible AI auto-approves up to 90% of requests for millions of health plan members. With the acquisition of ZignaAI, we’ve further enhanced our platform by launching our Payment Integrity Suite, anchored by Cohere Validate™, an AI-driven clinical and coding validation solution that operates in near real-time. By unifying pre-service authorization data with post-service claims validation, we’re creating a transparent healthcare ecosystem that reduces waste, improves payer-provider collaboration and patient outcomes, and ensures providers are paid promptly and accurately. Cohere Health’s innovations continue to receive industry wide recognition. We’ve been named to the 2025 Inc. 5000 list and in the Gartner® Hype Cycle™ for U.S. Healthcare Payers (2022-2025), and ranked as a Top 5 LinkedIn™ Startup for 2023 & 2024. Backed by leading investors such as Deerfield Management, Define Ventures, Flare Capital Partners, Longitude Capital, and Polaris Partners, Cohere Health drives more transparent, streamlined healthcare processes, helping patients receive faster, more appropriate care and higher-quality outcomes. The Coherenauts, as we call ourselves, who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles. We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone. We can’t wait to learn more about you and meet you at Cohere Health! Equal Opportunity Statement: Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal. #LI-Remote #BI-Remote

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Dane Street is expanding our physician panel! This is a telework opportunity for supplemental income for physicians providing a caseload customized to your schedule. Our physician panel is comprised of independent contract reviewers (1099) compensated on a per-case basis. As a Physician Reviewer/Advisor for Disability Peer Review, you will utilize clinical expertise to: - Review medical records provided and return an independent, professional opinion on the claimant’s functionality and restrictions or limitations as it relates to an application for disability benefits or the current status of disability. - Accept cases on a contract basis, as individual schedule permits, review all medical records, and address each question posed utilizing client-specific criteria or other nationally recognized evidence-based criteria, and opine on disability status. - Ensure a clear rationale for the determination that is concise and contains adequate supporting documentation to substantiate the decision. - Identify and employ current criteria and resources, such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews; refrain from using case studies, cohorts, and the like to make decisions. - Provide a report and copies of any criteria utilized within the review promptly. - Return cases on or before the due date and time specified. - Complete peer-to-peer calls/call attempts as required based on client-specific protocol with the goal of obtaining information not included in medical records as well as any necessary clarification. - Perform other duties as assigned, including addressing any necessary clarification, providing addendum as required (with additional compensation), identifying and responding to potential quality assurance issues, complaints, and regulatory issues. Board certification required, active practice preferred. PLEASE BE AWARE: In the interest of the security of all parties, Dane Street will never conduct interviews via text or request checks from candidates for any reason, including the purchase of equipment. Qualifications - Board certification required. - Active practice preferred. Requirements - Robust opportunity for supplemental income. - Schedule flexibility and predictable work hours - You choose services and case types, dictate volume, and conduct exams and reviews based on your schedule availability. - No doctor/patient relationship is established, and no treatment is provided. These are advisory-only opinions. - Enhanced industry expertise, strengthening your medical practice with medical necessity and utilization review/management expertise. - Expanded credentials as an expert in Independent Medical Exams and physician advisor services. - Fully prepped cases, streamlined case flow, transcription services at no cost, and a user-friendly work portal. - Dane Street supports all referral processes, scheduling, preps cases extensively, prepares all medical records, provides transcription services as applicable, facilitates all client communications, and ensures the quality and timeliness of all reports and report delivery.