• Review and analyze Medicare claims sampled by the Department of Justice, using associated medical records, to make payment determinations based on coverage, coding and utilization of services and practice guidelines. • Conducts medical record claims review to determine correct coding, utilizing ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II coding principles. • Review medical documentation for medical necessity utilizing clinical knowledge and CMS policies and guidelines, as well as other state and board regulations. • Conducts in-depth claims analysis of suspected over-utilizers who are suspect of fraudulent billing practices. • Completes summary report upon completion of the records review, summarizing claim determinations, clinical observations and other information requested by the DOJ. • Reviews and completes the required number of claims reviews in accordance to pre-established production standards for the project. • Produces and submits required reports according to established content and timeframes. • Communicates internally with all levels of the group. • Participates in Quality Assurance (QA) and IRR monitoring as requested. • Complies with departmental policies and procedures. • Complies with Medicare and DOJ guidelines and CMS directives, policies and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information. • Attends departmental and required education and training programs. • Reviews information contained in Standard Claims Processing System to determine provider billing patterns and detect fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies. • Utilizes the Medicare/Medicaid guidelines for coverage determinations. • Performs in-depth research and investigation utilizing the Internet and other tools, including data analysis tools. • Maintains chain of custody on all documents, follows all confidentiality and security guidelines.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Triage LPN answers, monitors, and returns calls/communications related to Caris Healthcare patients working under the supervision of an RN and/or in consultation with or under the direction of Physicians or Nurse Practitioners. Must recognize physical, psychosocial, and spiritual aspects of care. Accurately identify patients with at-risk conditions, while supporting all triage processes, works within the LPN scope of practice as defined by the Board of Nursing and Caris Healthcare policies and procedures. The LPN may contribute to nursing assessment and development of plan of care but may not independently assess or make clinical decisions based on their singular clinical judgment. This will be a remote position. Flexible schedule - however must be available to work Nights and Weekend shifts. - Addresses patient calls after hours concerning a wide range of symptom/side effect related and other patient care in a timely manner. - Asks appropriate questions to assist in the collection/identification of patient’s symptom and side effect management inquiries. - Recognizes changes in the patient's status and need for care. - Identifies urgency of patient symptoms/side effects and addresses them appropriately, aggressively managing to prevent unnecessary emergency department and hospital use. - Responds to emergency situations/calls and coordinates care/EMS response, as necessary. - Collaborates with Physicians, Nurse Practitioners, and Registered Nurses to discuss patient care needs that cannot be independently and appropriately addressed using current orders. - Completes on call log and distributes to appropriate Caris branch locations by end of shift each night. - Provides clear education to patients and caregivers including verifying understanding of plan of care within LPN scope of practice. - Counsels patients, family, and/or caregiver about side effects of medication (within LPN scope), applicable referrals, as well as available community resources. - Assists with obtaining prescription refills if needed. - Performs charting and updating of records in the EMR as expected. - Acts as a resource for healthcare team, patients, caregivers, and external agencies/organizations. - Participates in and initiates performance improvement activities as requested. Qualifications - Current Compact state LPN licensure or licensure for the following states: TN, SC, MO, VA, GA. - Home Health and or Hospice Experience, required. - Graduate of an accredited school of Licensed Practical/Vocational Nursing. - 2-years of relevant experience in nursing and/or telephone triage. - Post-acute provider experience preferred. Requirements - Must be available to work Nights and Weekend shifts. Benefits - Competitive Salary. - Bonus Eligibility. - Eligible for benefits within 60 days. - Health Benefits (Medical, Dental, Vision); health savings account. - Earned Time Off. - 401 (K) plan with company match. - Paid Training. - Mileage Reimbursement. - Tuition Reimbursement. - Flexible Scheduling. - Career Advancement Opportunities.

Role Description Job Title: Temporary Dental Hygienist Location: Schaumburg, IL 60194 Schedule: Flexibility to pick up shifts that work with you - hours may vary from 4-12 hours shifts Monday-Saturday. Qualifications - At least one year of experience working in general dentistry. - Expected to perform routine hygiene duties, including: - Scaling and root planning - FMDs - Probing - Arestin application - Taking digital x-rays - Online charting is a plus but not required. - Must have active hygiene license. - CPR certified preferred. Requirements - One year of experience in general dentistry. - Active hygiene license. - CPR certification preferred. Benefits - Health, Dental, Vision - Telehealth - Prescription Rx - Hospital Indemnity - Short Term Disability - Emergency Assistance while Traveling

Role Description CorVel Corporation is hiring a full time caring, self-motivated, energetic and independent registered nurse to fill a Medical Case Manager position in the Springfield, MO area. *Must live in the locations of Jefferson City and Columbia, MO* Work from home, and on the road. As a Medical Case Manager you will make a meaningful difference in the lives of injured workers and their families. Your responsibilities include: - Working closely with injured workers to facilitate their recovery. - Collaborating with the patient, their family, medical providers, members of our team, and others. - Managing a caseload of workers compensation injured workers within a defined jurisdiction. Essential Functions and Responsibilities: - Provides Medical Case Management to individuals through in person and telephonic communications with the patient, physician, other health care providers, employer and others. - Utilizes their medical and nursing knowledge to discuss the current treatment plan with the physician and discuss alternate treatment plans. - Evaluates patient’s treatment plan for appropriateness, medical necessity, and cost effectiveness. - Provides assessment, planning, implementation and evaluation of patient’s progress. - Attends doctors, other providers, home and in some cases, attorney’s visits. - Attends hospital and/or long-term facility discharge planning conferences for the purpose of determining appropriateness of care and developing an effective long-term care strategy. - Initial home visit for initial evaluation. - Implements care such as negotiation the delivery of durable medical equipment and nursing services. - This role requires regular travel, dependent on the injured worker’s injuries and needs, with local travel up to approximately 60% of the work week/month. - This role may require overnight travel. Qualifications - Effective communication and multi-tasking skills in a high-volume, fast-paced, team-oriented environment. - Experience as a RN, Medical Case Manager is ideal, or a clinical background in orthopedics, neurology, or rehabilitation is preferred. - Ability to meet with the patient, their physicians, other healthcare providers, attorneys, and advisors/clients and coworkers. - A cost containment background, such as utilization review or managed care is helpful. - Strong interpersonal, time management and organizational skills. - Computer proficiency and technical aptitude with the ability to utilize MS Office including Excel spreadsheets. - Ability to work both independently and within a team environments. Requirements - Graduate of accredited school of nursing. - Current RN Licensure in state of operation. - Certification as a CCM, CIRS, or other Case Management certifications are preferred. - A valid driver’s license, reliable transportation, and ability to travel to assigned locations is required. Benefits - Comprehensive benefits package for full-time regular employees including: - 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 and ROTH 401K - Paid time off - Medical Case Managers are eligible for bonus and will be provided state-of-the-art technological devices to ensure ready access to CorVel’s proprietary Case Management application.