Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. Position Summary The Utilization Appeals Review Nurse will be responsible for clinical review of member and provider appeals and/or claims disputes. Collaborating with our team of Medical Directors and internal stakeholders, you will use your clinical expertise to apply Martin’s Point medical policies, CMS and TRICARE regulations to deliver accurate, timely, and compliant appeal or claims disputes decisions. Job Description PRIMARY DUTIES AND RESPONSIBILITIES Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization. - Responsible for the review and resolution of clinical appeals and disputes - Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. - Ensures care delivery aligns with specific line-of-business benefits while maintaining full compliance with contractual and regulatory standards, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. - Stays current with industry regulations and accreditation standards to ensure continuous operational compliance - Consistently delivers high-quality outcomes that meet or exceed established departmental benchmarks and performance standards. Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings. - Independently coordinates the clinical resolution with internal/external clinician support as required. - This position will be accountable for appeals, claims disputes, and QOC review - This is a full-time remote position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time). - Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another. - Assumes extra duties as assigned based on business needs. - Weekend and holiday on-call coverage may be required. POSITION QUALIFICATIONS Education - Associate Degree in Nursing (ADN) - Bachelor’s degree in nursing preferred Licensure/certification - Active, unrestricted Compact Registered Nurse (RN) license. Experience - 3+ years of RN clinical experience, preferably in a hospital setting, along with experience in utilization management in a health plan UM department and in managing appeals or disputes - Coding/CPC preferred Knowledge - Thorough understanding of CMS Medicare Advantage regulations (Parts C & D) and NCQA guidelines - Thorough knowledge of MCG, Interqual of other clinical guidelines - HIPAA & privacy requirements - Concurrent, prior authorization and appeals review - Critical thinking and case analysis - Clinical writing and summarization - Electronic UM systems - Tricare regulation experience preferred - MCQA standards experience preferred - Claims disputes review experience preferred Skills - Ability to extract relevant clinical facts from progress notes, labs, imaging, and treatment plans. - Correct use of MCG, and Martiin’s Point medical policies to determine medical necessity. - Ability to identify inconsistencies, missing information, or red flags in documentation - Understanding appeal levels, timeframes, coverage rules, and documentation requirements. - Ability to produce rationales that meet CMS, TRICARE, and NCQA standards - Ability to write clear, defensible rationales that explain the clinical and regulatory basis for the determination. - Ability to write concise, objective, and compliant appeal rationales Abilities - Ability to analyze data metrics, outcomes, and trends. - Ability to prioritize time and tasks efficiently and effectively. - Ability to manage multiple demands. - Ability to function independently. This position is not eligible for immigration sponsorship. We are an equal opportunity/affirmative action employer. Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. Job Posting Title Initial Review Pharmacy TechnicianJob Description Plays a key role in medical and pharmacy management initiatives critical to the company achieving revenue goals and operational objectives. Responsible for executing utilization management programs on behalf of health plan/payor customers, while utilizing additional clinical knowledge pertaining to a set list of managed medications across all health plans, with additional training for each medication and therapeutic class. Primary activities center on reviewing both prospective and retrospective requests for therapeutic appropriateness using sound clinical criteria. Responsible for making and receiving calls to and from physicians, patients, and pharmacies to gather additional clinical information to determine medication reimbursement. Recommendations will be based on an in-depth understanding of specific specialty medications and industry guidelines, on both pre- and post-service requests. Coordinates with operations, clinical, medical, reporting and other internal departments as needed. Responsibilities - Reviews pertinent patient information and checks appropriateness using clinical criteria. Makes approval recommendations on all services that meet clinical review criteria. Refers all cases not meeting clinical criteria to pharmacist clinical reviewer. - Practices and maintains the principles of utilization management by adhering to the company policies and procedures. Upholds clinical integrity of pharmaceutical solutions by participating in on-going training programs to ensure quality performance in compliance with applicable standards and regulations. Expert within the organization. - Conducts Program Integrity Audits including outreach and review of medical records to audit authenticity of provider response during Prior Authorization and reporting results to client. - Assists with the documentation and implementation of both written and verbal communications to physicians/prescribers and assists in the maintenance of the edits and data elements that support the edits. - Available for consultation in pharmacy related questions to resolve claims submission related to medication edits. - Contacts physicians/prescribers to obtain pertinent clinical history/information. Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plan`s required timeframes. - Regularly reviews and monitors information on pended claims identified as outliers by internal and/or external analysis of pharmacy claims data. - Supports Intake call volume and order entry if necessary. - Determines eligibility for medication reimbursement based upon established clinical criteria and clinical knowledge and enters approvals or denials in the system. - Electronically documents both written and verbal communications with physicians, their staff, cardholders, and pharmacies. - Escalates medical exception requests to nurse, pharmacist or physician on the utilization review clinical team when further review is necessary. - Other duties as assigned. Minimum Qualifications - HS diploma or GED is required - 4 years of Pharmacy Experience - CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy - Must be eligible to work in the United States without the need for work visa or residency sponsorship Additional Qualifications - Must have an active pharmacy technician licensure or registration in accordance with state requirements. - If state does not require an exam for licensure/registration, must possess both active pharmacy technician licensure or - registration in accordance with state requirements AND an active national certification (e.g., PTCB or ExCPT). - In states that do not require licensure or registration, must have an active national certification (e.g., PTCB or ExCPT). - Minimum of 2 years of pharmacy experience without a Bachelors degree OR 2 years of pharmacy experience with a - Bachelors degree in Science, Health, Medical or related field. - Specialty or retail pharmacy experience, previous reimbursement experience, and/or working in a health plan/health care setting. - Experience as Pharmacy Technician, Utilization Management or Customer Service in a high-volume, multi-functional call center environment. - Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems, typing. - Strong team orientation with respect for all members. - Excellent verbal and written communications skills. - People skills are essential that allow for the successful consultation with physicians, prescribers and pharmacists and for successful collaboration with company employees and external vendors who do not directly report to this position. - Analytic skills which can translate into practical and pragmatic recommendations. - In-depth knowledge of specialty injectable prescription drugs, disease states, health plan formulary management techniques and medical terminology. Preferred Qualifications - Oncology pharmacy or other clinical pharmacy experience. - 4 years of pharmacy experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $23.08 - $37.02 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail (https://www.primetherapeutics.com/benefits). Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.   We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays.

Overview Ansible Government Solutions, LLC (Ansible) is currently recruiting Remote Medical Support Assistants (Remote Medical Receptionists) that is to support the Oregon VA Healthcare System. Working hours are Mon-Fri, 7am-6pm (8-hour shifts within this window). If you accept employment with Ansible, you must also acknowledge that any assigned schedule is subject to change at the direction of either Ansible or its customers. Ansible Government Solutions, LLC (Ansible) is a Service-Disabled Veteran-Owned Small Business (SDVOSB) providing Federal customers with solutions in many arenas. Our customers face wide-ranging challenges in the fields of national security, health care, and information technology. To address these challenges, we employ intelligent and committed staff who take care of our customers’ success as if it is their own. Responsibilities - Provide front‑line administrative and clerical support for VA clinics and Community Care scheduling - Perform consult intake, patient/provider outreach, appointment scheduling, and follow‑up - Manage appointment schedules, Electronic Wait List, recall lists, and pending consults - Accurately schedule appointments within VA timeliness standards (≤ 7 calendar days from consult entry) - Answer phones professionally, screen calls, and route or resolve inquiries appropriately - Verify patient identity using two VA‑approved identifiers - Update and validate demographic and insurance information during patient interactions - Explain VA insurance collection requirements to Veterans and families - Enter and maintain accurate documentation in CPRS / EHRM - Collaborate with VA clinical staff and interdisciplinary care teams - Assist with clinic access contingency plans, including rescheduling or shifting patients as needed - Escalate scheduling or access issues to VA supervisors per SOP - Maintain high customer service standards when interacting with Veterans, families, and staff - Meet VA performance standards for accuracy (≥98%), responsiveness, and customer service - Participate in required meetings, huddles, reporting, and quality improvement activities - Complete related administrative duties as assigned to support daily operations Qualifications - High School diploma or GED equivalent. - Proficiency in written and spoken English. - Minimum typing speed of 50 words per minute. - Basic computer proficiency, including Microsoft Office applications. - Basic knowledge of medical terminology. - Minimum 6 months of customer service experience. - Ability to work remotely and independently in a professional setting. - Ability to obtain and maintain a favorable VA background investigation (NACI) and PIV credential. - No physical or health restrictions that would interfere with job performance. - Ability to complete all required VA onboarding, security, privacy, and mandatory training prior to and during assignment. - U.S. citizenship required. All candidates must be able to: - Sit, stand, walk, lift, squat, bend, twist, and reach above shoulders during the work shift - Lift up to 50 lbs from floor to waist - Lift up to 20 lbs - Carry up to 40 lbs a reasonable distance - Push/pull with 30 lbs of force All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Job Requisition ID: 2026-225 Requisition Begin Date: 3/17/26 Requisition End Date: 4/30/26 (Posting may close earlier if filled or if business needs change.) Help us Insure it Tokio Marine HCC is a global industry-leading specialty insurance group, backed by the strength and stability of the Tokio Marine Group. Offering over 100 classes of specialty insurance, we empower clients to pursue opportunities confidently through our “Mind Over Risk” philosophy. More than an insurance company, we are an organization built on innovation, unity, and trust. At our core, we are Always Advancing, driven by innovation and an entrepreneurial spirit that keeps us moving forward. Our people are Experts in Tomorrow, using curiosity and smart working to anticipate what’s next. With a culture rooted in Reaching Out, we foster genuine collaboration and support, ensuring every individual has the opportunity to succeed and make a difference. Role Overview Relying on limited experience and knowledge, this role is responsible for accomplishing the following assignments. These assignments are varied in nature. Key Responsibilities - Review issues forwarded from the Underwriting group that includes complex diagnoses and then estimate ongoing costs. Provide this information to the specific Underwriter. - Act as support for renewal underwriting. This includes, but is not limited to, assessing the severity code on on-going claims, adjusting reserves for accuracy, evaluating new referrals if effective within sixty days of notice, and assigning recommended specifics, if requested. - Educate Underwriters on how to recognize specific diagnoses and severe types of diagnoses to ensure these are identified and properly quoted during the underwriting process. What You Bring - 4 Year / Bachelors Degree in a related field or the equivalent education and/or experience - Required Registered Nurse (RN) designation - 5 Years Relevant and progressive clinical experience, preferably in an acute care or manage care/setting - 5 Years Clinical experience, preferably in an acute care setting and/or managed care setting - Strong medical knowledge including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPAA - Strong understanding of operations of third-party administrators(TPAs) and managing general underwriters (MGUs) - Knowledge of Carrier and Reinsurer reporting and contractual requirements - Possess and have ability to apply broad knowledge of principles, practices, and procedures - Excellent written and verbal communications skills with an emphasis on confidentiality, tact, and diplomacy - Exceptional organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneously - Knowledgeable of industry changes, legal updates, and technical developments related to applicable area of the Company's business to proactively respond to changing business environment - Intermediate proficiency and experience using Microsoft Office package (Excel, Access, PowerPoint, Word) - Occasional travel (up to 10% of time) What We Offer - Competitive salary and comprehensive benefit package - Strong learning culture with ongoing development opportunities - Opportunities for growth and career advancement - Comprehensive medical, vision, and dental coverage, with eligibility beginning on your first day of employment - Basic life and disability insurance - 401(k) plan with 6% company match - 20 days of PTO, two floating holidays, approximately 11 paid holidays, and volunteer time off - Paid parental leave - Access to our award-winning wellness program, including mental health services, fitness network membership, and a complimentary Headspace subscription - Student loan matching program - Employee discount program - An opportunity to do meaningful work and love what you do Pay Transparency The pay range for this position is $71,000-$156,600, which includes geographic adjustments, where applicable. The pay range is the range THMCC, in good faith, believes is the range of compensation for this role at the time of this posting. The hired applicant will be offered pay within the entire range based on the candidate’s geographic location, qualifications, work experience, education, and/or skill level. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of color, race, sex, national origin, sexual orientation, religion, age, veteran status, disability, pregnancy, citizenship status, genetic information, or any other basis protected by federal, state, or local pay equity laws. Disclaimer WA, NV, IL, MN, OH , NY, CT, D.C., RI, MA, HI, MD, NJ, VT → Use Federal and State Compliance language. As an insurance company, we comply with certain federal, state and local laws such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC § 1033(e)), which restricts our ability to employ individuals with certain types of criminal convictions. Where not restricted by law and for criminal history not covered by this law, the Company will consider qualified applicants with arrest or conviction history in compliance with applicable law. Remote National → Use Conditional Background Check language. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if the Company is concerned about a conviction that is directly related to the job, you will be given the chance to explain the circumstances surrounding the conviction or challenge the accuracy of the background report. The Company will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, such as the Violent Crime Control and Law Enforcement Act of 1994 (18 USC § 1033(e))(the “VCCLEA”), which restricts financial institutions and insurers such as TMHCC from employing individuals with certain types of criminal convictions. Where the hiring and employment of individuals is not restricted by the foregoing, the Company will consider qualified applicants with arrest or conviction history in compliance with applicable law such as the California Fair Chance Act, the Los Angeles Fair Chance Initiative for Hiring Ordinance, the Los Angeles County Fair Chance Ordinance, the San Diego Fair Chance Ordinance, and the San Francisco Fair Chance Ordinance.] About Us Tokio Marine HCC is a leading specialty insurance group with offices in the United States, the United Kingdom, Europe, and other exciting locations. With the strength and stabilitythat comes from being a member of the Tokio Marine Group, and more than fifty years of growth, profitability, and stability, we offer important insurance products that most people don’t even know exist. Every policy we write is special, enabling our clients to do amazing things. TMHCC Stop Loss, a $2 Billion division within TMHCC, leads the way in providing medical stop loss insurance sold to employers. Medical Stop Loss provides an added layer of insurance protection to employers who choose to self-fund their health benefit plans. Self-funding can incur risks from catastrophic claims, and Medical Stop Loss insurance from Tokio Marine HCC is designed to protect employers from that risk. Applying our Mind Over Risk philosophy to writing insurance allows our customers to take on opportunity with confidence. That philosophy defines our way of thinking, unites us as a team, and differentiates us from our competitors. We are much more than just an insurance company; we are a good company. Equal Opportunity Employer TMHCC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, citizenship, color, family or medical care leave, gender identity, genetic information, marital status, medical condition, national origin, physical or mental disability, protected veteran or military status, race, ethnicity, religion, sex (including pregnancy), sexual orientation, or any other characteristic protected by applicable local laws, regulations and ordinances. #LI-CM3 #stoploss1