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.

Role Description We are currently hiring for a Senior Medical Reviewer to join BlueCross BlueShield of South Carolina. In this role as a Senior Medical Reviewer, you will act as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff and ensure appropriate levels of healthcare services are provided. Location: This position is full-time (40 hours/week) Monday-Friday from 8:00am-5:00pm and will be fully remote. Our ideal candidate must reside in South Carolina and may be required to conduct occasional member-facing patient visits within SC. What You’ll Do: - Functions as team leader/senior-level Medical Reviewer. - Provides leadership/guidance/direction/training to staff. - Maintains working knowledge of unit functions and ability to interpret to new hires, department interworkings and workflow. - Acts as resource for staff/external entities troubleshooting as well as resolving issues. - Keeps manager informed of any problems/issues that need resolving. - Assists management with monitoring workflow and workloads. - Participates in departmental quality reviews. - Follows process to ensure quality plan is adhered to and communicated to all parties. - Gives/receives feedback regarding medical review decision making and technical claims processing issues. - Ensures that quality work instructions/forms/documents are developed/revised as needed. - Provides quality service and communicates effectively with external/internal customers in response to inquiries. - Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems. - Participates in compliance initiatives and other directed activities. - Participates/oversees special projects as requested by management. Qualifications - Required Education: Associates in a job-related field. - Degree Equivalency: Graduate of Accredited School of Nursing. - Required Work Experience: 4 years clinical, OR, 2 years clinical and 2 years medical review/utilization review, OR, combination of health plan, clinical, and business experience totaling 4 years. - Required Skills and Abilities: - Working knowledge of managed care and various forms of health care delivery systems. - Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. - Knowledge of specific criteria/protocol sets and the use of the same. - Working knowledge of word processing and spreadsheet software. - Ability to work independently, prioritize effectively, and make sound decisions. - Good judgment skills. - Demonstrated customer service, organizational, and presentation skills. - Demonstrated proficiency in spelling, punctuation, and grammar skills. - Demonstrated oral and written communication skills. - Ability to persuade, negotiate, or influence others. - Analytical or critical thinking skills. - Ability to handle confidential or sensitive information with discretion. - Ability to lead/direct/motivate others. - Required Software and Tools: Microsoft Office. - Required Licenses and Certificates: If RN, active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area. Requirements - Must have experience of working directly with individuals with mental illnesses. - Preferred Education: Bachelor's degree- Nursing or Graduate of Accredited School of Nursing. - Preferred Skills and Abilities: - Knowledge of database software. - Knowledge of Medicare regulations/policies/instructions/provisions. - Knowledge of home health, and/or system/processing procedures for medical review. - Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software. Benefits - Subsidized health plans, dental and vision coverage. - 401k retirement savings plan with company match. - Life Insurance. - Paid Time Off (PTO). - On-site cafeterias and fitness centers in major locations. - Education Assistance. - Service Recognition. - National discounts to movies, theaters, zoos, theme parks and more.

Building Location: EH North Fargo Clinic Department: 1005400 MEDICAL STAFF OFFICE - EH SS Job Description: Generates data and provides research in support of professional activities and is also responsible for the coordination of the professional practice quality program throughout Essentia Health. Responsible to abstract, aggregate, and analyze data and clinical indicators from the electronic medical record to be used in centralized functions for hospital and clinic peer review, Focused Professional Practice Evaluation (FPPE), and Ongoing Professional Practice Evaluation (OPPE). Provides oversight and recommendations for the development of monitoring processes of physician/APC practice quality, bylaw, accreditation, and regulatory compliance. Education Qualifications: Key Responsibilities: Adding Key Responsibilities: - Provides expert consultation, collaborative development and implementation of all practitioner peer review activities - Promotes and maintains a systemic method to support Ongoing Professional Practice Evaluations and Focused Professional Practice Evaluations (OPPE/FPPE) at a system level to meet Joint Commission accreditation standards - Facilitates interdisciplinary teamwork to ensure OPPE and FPPE quality metrics are meaningful and appropriate for all service specialties - Supports and facilitates the medical staff peer review process through preparing cases for review - Coordinates review activities with medical staff leaders, written and verbal communication with reviewers, management of highly sensitive information and other duties as directed by the Essentia Professional Practice Committee (EPPEC) Co-Chairs, Chief of Medical Affairs and Director of Medical Staff Services - Conducts initial review of clinical indicators which are utilized to supervise and evaluate the quality of care and services rendered by practitioners Educational Requirements: - Bachelor's degree in health education or related field Required Qualifications: - 3-5 years of medical staff peer review or related experience Preferred Qualifications: - Bachelor's degree in Nursing or Health Information Management - 5-10 years of medical staff peer review experience Licensure/Certification Qualifications: FTE: 0.3 Possible Remote/Hybrid Option: Remote Shift Rotation: Day/Eve/Night Rotation (United States of America) Shift Start Time: Shift End Time: Weekends: Holidays: No Call Obligation: No Union: Union Posting Deadline: Compensation Range: $27.57 - $41.36 Employee Benefits at Essentia Health: At Essentia Health, we’re committed to supporting your well-being, growth, and work-life balance. Our comprehensive benefits include medical, dental, vision, life, and disability insurance, along with supplemental options to fit your needs. We offer a 401(k) plan with employer contributions to help you plan for the future, and we invest in your professional development through training, tuition reimbursement, and educational programs. To help you thrive both at work and at home, we provide flexible scheduling, generous time off, and wellness resources focused on your physical, mental, and emotional health. Please note that benefit eligibility may vary. For full details, refer to your benefit summary or contact our HR Service Center at (218) 576-0000.