Role Description The Diagnostic Related Groups (DRG) Clinical Supervisor is responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves completing medical review forms, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. This is a remote position. - Supervises all daily activities of the DRG Clinical Auditors - Demonstrated knowledge of ICD-10-CM and PCS codes, and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid with the ability to work independently with minimal supervision and demonstrate initiative - Completes DRG audits as needed - Responsible for the overall integrity of the quality of diagnosis and procedure codes verified by the clinical review nurses, for inpatient records and documentation received with the accompanied claim - Responsible for holding the DRG Clinical Auditors to the quota and error/accuracy rate - Assists with team coverage and provides support when needed - May be required to travel overnight and attend meetings or training - Additional duties as assigned Qualifications - Clinical knowledge of medical necessity rules - Working knowledge of HIPAA Privacy and Security Rules - Ability to build strong working relationships both internally and externally - Strong attention to detail - Must possess problem solving, critical thinking skills - Minimal typing experience - Excellent written and verbal communication skills - Ability to think and work independently, while working in an overall team environment - Ability to work in a fast paced/production environment - Proficient in Microsoft Office applications Requirements - N./L.V.N. preferred - CCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCS - Proficient in Medicare, CMS guidelines and ICD-10 coding guidelines - Minimum of 3-5 years of inpatient/DRG auditing experience in a hospital setting and/or payer setting - A minimum of 2 years of supervisory experience dealing with clinical auditors is required - Experience with claims denials and appeals required Benefits - Comprehensive benefits package for full-time regular employees - 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 Pay Range CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time. For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process. Pay Range: $77,960 – $120,368

Role Description The Medical Review Support Analyst supports clinical audit and claims review processes by triaging claims, requesting and managing medical records, and ensuring accurate documentation within claims systems. This role works closely with claims teams and provider networks to gather required records, track claim review status, and ensure compliance with healthcare regulations and organizational standards. - Perform initial triage of claims selected for review to determine if they meet specific clinical audit criteria. - Request and obtain medical records from healthcare providers based on review requirements. - Prepare and send medical record request letters and follow up on outstanding documentation. - Receive, review, and process medical records received via fax, mail, email, and secure upload systems. - Research claim history and review pre-authorization determinations when necessary. - Enter claim processing instructions and documentation into Facets or other claims systems. - Maintain accurate case notes and required fields in departmental databases. - Communicate claim review status and documentation updates to claims staff and network management teams. - Send detailed provider notifications when records are missing or additional documentation is required. - Maintain production, quality, and compliance standards while adhering to healthcare regulatory requirements. Qualifications - High School Diploma or GED. - 3+ years of experience in a healthcare environment, such as: - Medical office - Claims processing - Medical billing - Healthcare customer service - Strong written and verbal communication skills. - Experience working with medical records, billing, or healthcare documentation. - Ability to research issues, analyze information, and resolve problems independently. - Strong organizational skills with the ability to prioritize tasks and meet deadlines. - Basic understanding of medical terminology. Requirements - Experience using Facets claims system. - Knowledge of medical coding, anatomy, or healthcare claims processes. - Familiarity with BlueCard, ITS processes, FEP Direct, or Salesforce. - Analytical and basic math skills for claims review analysis.

Become a part of our caring community and help us put health first Key Accountabilities - · You will coordinate care for MHS beneficiaries receiving care outside the MTF. Monitor quality of care, identify, and document any potential quality issues regarding the patient's care. Coordinate patient transfers and document in MSR. Review inpatient outlier cases, ensure appropriate and timely discharge planning, and refer to Tier III care management as needed. · You will perform prior authorization reviews according to established HGB contractual requirements and guidelines to include data entry in MSR. · You will perform accurate assessment and concurrent review of outlier admissions using InterQual criteria and document review results in MSR. Pend cases to second level review and follow up with any denial activities as indicated. · You will identify and follow patients requiring Tier II Care Management. Coordinate cases with and refer to tier III Care Manager and Disease Management Programs as appropriate. Use your skills to make an impact Required Qualifications - Our Department of Defense Contract requires U.S. citizenship for this position - Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Service) - HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico. - Registered Nurse with current in-state RN license - At least 3 years of varied clinical RN nursing experience - Current TRICARE experience - Current knowledge of MCG evidence-based criteria or comparable (such as Interqual, etc.) ​Preferred Qualifications - Utilization Review/Quality Management experience - BA/BSN degree Work-At-Home Requirements - WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense. - A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required. - Satellite and Wireless Internet service is NOT allowed for this role. - A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. About us Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. ​ Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Overview Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities Ready to The Utilization Review Nurse will provide professional assessments and review for the medical necessity of treatment requests and plans. The standard work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage required. What You'll Actually Do Essential Functions/Responsibilities/Duties - Provide professional assessment and review for the medical necessity of treatment requests and plans. - Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity; and post claim or post service reviews. Staff are expected to cross train, and provide cross coverage as needed. - Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). - Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. - Refer requests that fall outside of established guidelines to advance review or senior care consultants. - Process appeals for non-certification of services, complete non-certification letters when appropriate. - Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. - Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs. - Complete documentation for all reviews in appropriate documentation software. - Utilize guidelines in appropriate hierarchy. Guidelines include MCG guidelines, internal medical policies, group specific policies, and NCCN. - Ability to meet productivity, quality, and turnaround times daily. - Ability to pass external audits to include URAC and NCQA. - Maintain HIPPA compliance per company’s policy and procedures. - Maintain confidentiality and minimum requirement rules. - Complete all required yearly training per company’s expected time limit. - Complete and pass all annual testing including IRRA at 90% or higher. - Ability to meet productivity, quality, and turnaround times daily. - Ability to pass external audits to include URAC and NCQA. - Maintain HIPPA compliance per company’s policy and procedures. - Maintain confidentiality and minimum requirement rules. - Complete all required yearly training per company’s expected period Qualifications What You Bring to Our Team Education and Experience - Current RN license in the United States or U.S. territory. - Associate’s degree or diploma (Nursing program) required. - 1+ year clinical experience required. - Required Knowledge, Skills, and Abilities Required Knowledge, Skills, and Abilities - Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards. - Ability to maintain regular, punctual attendance. - Ability to sit for 6-8 hours. - Constant use of computer keyboard and mouse; repetitive use of both hands. - Occasional to frequent twisting of neck; occasional bending of neck and at waist. Work Environment At Personify Health we value and celebrate diversity, and we are committed to creating an inclusive environment for all employees. We believe in creating teams made up of individuals with various backgrounds, experiences, and perspectives. Why? Because diversity inspires innovation, collaboration, and challenges us to produce better solutions. But more than this, diversity is our strength, and a catalyst in our ability to change lives for the good. Physical Requirements - Must be able to remain in a stationary position 50% of the time. - The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities. - Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc. - Frequently positions self to maintain files in file cabinets. - Frequently moves boxes or equipment weighing up to 25 pounds. - Must communicate information and ideas so others understand. Must be able to exchange accurate information in these situations. - Must be able to observe details at close range. Disclaimer This job description is not intended to contain a comprehensive list of activities, duties, or responsibilities, but constitutes a general description of the scope and function of the role within the company. Activities, duties, and responsibilities are subject to change at any time with or without notice. Benefits The Highlights: - Competitive base salary and benefits effective day one - Comprehensive medical and dental through our own health solutions (yes, we use what we build) - Paid Time Off—rest and recharge time is non-negotiable - Mental health support, retirement planning, and financial protection - Professional development with clear career progression and learning budgets - Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $30-$38.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.