Overview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. The QA Home Care Reviewer will facilitate the process of improving clinical documentation through extensive clinical documentation reviews and concurrent interactions with clinicians to fully capture a patients condition, complications and co-morbidities. The QA Home Care Reviewer will educate nurses, clinicians, and staff on documentation improvement opportunities, OASIS compliance, reimbursement and relevant quality and performance improvement opportunities. The QA Home Care Reviewer will identify documentation issues related quality of care and will seek resolution through the appropriate channels. Responsible for review of all clinical records regarding the OASIS and other clinical documentation and ensuring compliance with applicable State and Federal laws and regulations, Medicare guidance, and other policies and procedures. EEO/AA/Disability/Veteran Responsibilities - 1. Performs comprehensive clinical record reviews of start of care, resumptions of care, re-certifications, and discharge for complete and accurate clinical documentation to ensure the OASIS and /or assessment accurately reflects the patients current health status - 1.1 Completes reviews within designated time frames. - 2. Educates on OASIS requirements, clinical documentation, clinician educational training and support, and State and Federal regulatory requirements. Develops and conducts ongoing education including new team members, clinicians, and other staff. - 2.1 Provides in person or virtual training to providers 1:1, or in small groups - 3. Develops and supports strong collaborative professional relationships with peers, coding staff, clinical team members and medical providers. - 4. Utilizes a compliant query process when conducting all clinical queries. Follows each query through to closure including complete documentation on ongoing follow up activities and communication. - 5. Maintains proficiency in OASIS data and data capture best practices according to industry guidelines and CMS instructions. - 6. Prepares periodic reports/dashboards, as requested, that aid in various initiatives often with a direct impact to star ratings/quality reporting. - 7. Works collaboratively with clinical and administrative leadership to ensure positive and compliant program outcomes - 8. Provides ongoing OASIS team learning opportunities through sharing of professional knowledge - 9. Maintains integrity and compliance in all chart reviews, documentation and queries at all times - 10. Supports and implements quality measures as identified by department manager - 11. Identifies opportunities for performance improvement. - 12. Assures home care compliance with OASIS requirements and remains current with regulatory and organization requirements to ensure accurate and thorough quality assurance reviews. Subject matter experts regarding CMS guidelines and OASIS review. - 13. Performs utilization review of existing clinical documents for potential under and over utilization of services - 14. Active participation in staff meetings, and other meetings as requested. - 15. Adheres to the practice of confidentiality regarding patients, staff and the organization - 16. Assists in other monitoring, training, special department projects or initiatives or other needs as determined by the department leadership. Qualifications EDUCATION Registered Nurse with active license, BSN preferred. HCS-D coding certification preferred. LPN with an active license accepted with a minimum of three years experience required in Quality Assurance in Home Health and Hospice . EXPERIENCE At least three (3) years of recent clinical nursing experience required. Home Health and Hospice preferred. Clinical expertise required. At least one (1) year of OASIS QA review experience required. Experience conducting quality assurance and continuous improvement activities. LICENSURE RN license required. LPN with an active license accepted with a minimum of three years experience in Quality Assurance in Home Health and Hospice in lieu of RN license. HCS-D Home Care Coding Certification a plus. COQS (Certified OASIS Quality Specialist) or HCS-O (Certified Home Care Clinical Specialist) required within 12 months of hire. SPECIAL SKILLS Excellent communication, negotiation and organizational skills. Adaptability to a wide variety of interpersonal encounters throughout the health system and community. Comprehensive understanding in use of medical record to extract data. Working knowledge of third party and prospective payment systems relating to home care and hospice. Thorough knowledge of home care quality assurance process. Computer PC literacy required. Must be able to work collaboratively and independently. Must have keen eye to detail. Must be adaptable, flexible, have ability to learn quickly, use critical thinking, and be able to motivate staff. Strong computer skills. PHYSICAL DEMAND Must be capable of standing, walking, and bending. Ability to communicate clearly and confidently to providers the program goals and documentation issues using email, in person communication, telephone and other written and electronic forms of communication. YNHHS Requisition ID 174575

Role Description In diesem sehr gut ausgestatteten MVZ betreuen Sie Patienten in einem breiten ambulanten neurologischen Spektrum. Sie arbeiten eigenverantwortlich, haben Freiraum für die Setzung eigener Schwerpunkte und profitieren von flexiblen Arbeitszeiten. Die Dokumentation (etwa 20 % der Arbeitszeit) können Sie bequem aus dem Homeoffice erledigen. Auf Wunsch ist eine anteilige Tätigkeit in der Telemedizin möglich. Administrativ werden Sie entlastet, sodass Sie sich auf die Patientenversorgung konzentrieren können. Qualifications - Deutsche Approbation - Facharzttitel in Neurologie - Fachliche Kompetenz und strukturierte Arbeitsweise Requirements - Attraktive Vergütung + leistungsbezogene Vergütungsbestandteile - Betriebliche Altersvorsorge - Eigener Therapieraum, der individuell gestaltet werden kann - Keine Dienste, auch keine KV-Dienste - Flexible Arbeitszeiten – individuell gestaltbar - Vereinbarkeit von Beruf und Privatleben - Die Dokumentation (ca. 20% der Arbeitszeit) kann aus dem Home-Office erledigt werden. Firmen-Laptop wird gestellt. - Auf Wunsch bis zu 30% Telemedizin möglich - Entlastung von bürokratischen Aufgaben - Strukturierte Einarbeitung in den ambulanten Praxisalltag - Gruppeninterne Fortbildungsformate für die Fortbildungspunkte angerechnet werden. - Förderung auch externer Fortbildungen - Jobrad-Leasing möglich Benefits - Attraktive Vergütung + leistungsbezogene Vergütungsbestandteile - Betriebliche Altersvorsorge - Eigener Therapieraum, der individuell gestaltet werden kann - Keine Dienste, auch keine KV-Dienste - Flexible Arbeitszeiten – individuell gestaltbar - Vereinbarkeit von Beruf und Privatleben - Die Dokumentation (ca. 20% der Arbeitszeit) kann aus dem Home-Office erledigt werden. Firmen-Laptop wird gestellt. - Auf Wunsch bis zu 30% Telemedizin möglich - Entlastung von bürokratischen Aufgaben - Strukturierte Einarbeitung in den ambulanten Praxisalltag - Gruppeninterne Fortbildungsformate für die Fortbildungspunkte angerechnet werden. - Förderung auch externer Fortbildungen - Jobrad-Leasing möglich

Workforce Classification: Telecommuter Join Our Team: Do Meaningful Work and Improve People’s Lives Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare. Premera is committed to being a workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development, we’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace. Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.premera.com/. We have an opening for a Utilization Review Nurse! The Utilization Review Nurse performs prospective review (benefit advisory/ prior authorization) admission, concurrent, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of the clinical requests from providers. The incumbent partners with Medical Directors and other Premera Departments such as FEP, National Account Liaisons, Health Care Services, and Claims to ensure appropriate cost-effective care by applying their clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services and procedures, benefit application and provider out of network requests. This work is done for all lines of business and all geographic regions. What you will do: - Performs medical necessity review that includes inpatient review, concurrent review, benefits advisory/prior authorization, retrospective, out of network, and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts - Consults with Medical Directors when care does not meet applicable criteria or medical policies - Documents clinical information completely, accurately, and in a timely manner - Meets or exceeds production and quality metrics - Maintains a thorough understanding of the Plan's provider contracts, member contracts, authorization requirements and clinical criteria including Milliman care guidelines and medical policy - Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management) - Collaborates, educates and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria - Maintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance - Supports the Plan's Quality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies, and projects - Performs other duties as assigned. What you will bring: - Bachelor's degree or 4 years’ work experience - Current State licensure as a registered nurse or behavioral health clinician where licensing is required by State law - 3 years of clinical experience. - CPHM (Certified Professional Health Management) certification, or obtain certification within 36 months of the date of hire - Utilization Management experience (Preferred) - Experience working in the health plan industry. What you will gain: - Deeper expertise in utilization management (prospective, concurrent, and retrospective review) using evidence-based criteria and medical policy - Stronger cross-functional collaboration and clinical influence through partnership with Medical Directors and internal teams to drive appropriate care decisions - Growth in regulatory/accreditation and quality improvement proficiency by applying UM standards, documenting determinations, and supporting process/quality initiatives Premera total rewards Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including: - Medical, vision, and dental coverage with low employee premiums. - Voluntary benefit offerings, including pet insurance for paw parents. - Life and disability insurance. - Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service. - Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few. - Generous paid time off to reenergize. - Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees. - Employee recognition program to celebrate anniversaries, team accomplishments, and more. For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement. - Commuter perks make your trip to work less impactful on the environment and your wallet. - Free convenient on-site parking. - Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable. - Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more. - Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling. - Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus. Equal employment opportunity/affirmative action: Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law. If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785. Premera is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin. The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience. The salary range for this role is posted below; we generally target up to and around the midpoint of the range. National Salary Range: $80,200.00 - $125,600.00 National Plus Salary Range: $84,200.00 - $143,100.00 *National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska. We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all. We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions.

div.content { background: #6c6f70 } div.joqReqDescription { background: #FFF repeat-y; !important; font family: Century Gothic; !important text-align: left; color: #000; width: 900px !important; margin: 0 auto !important; position: relative; -webkit-column-count: 1; -moz-column-count: 1; padding-top: 480px; padding-left: 5px; padding-bottom: 50px; } div.joqReqDescription strong{ font family: Century Gothic !important; font-size: 14px; color: #000; } div.joqReqDescription p{ font family: Century Gothic !important; padding-left:0px; width: 892px; } div.joqReqDescription div.image-box { width: 900px; text-align: center; display: block; top: 0px; left: 5px; position: absolute; height: 150px; } div.joqReqDescription div.header-box { background-color: #0043FA; position: absolute; top: 380px; display: block; font-family: Century Gothic !important; font-size: 30px; color: rgb(255, 255, 255); font-weight: bold; width: 883px; left: 5px; height: 72px; padding-left: 17px; padding-top: 15px; } The Clinical Nurse Reviewer plays a crucial role in Comfort Medical by evaluating and assessing medical records, progress notes, and healthcare Certificates of Medical Necessity (also known as CMN’s or Prescriptions) to ensure compliance with industry standards, federal and state regulations, and quality of care. This position requires a strong understanding of medical terminology, healthcare protocols, and attention to detail to maintain the highest standards of patient care and safety. Major Areas of Accountability - Review and analyze patient medical records, ensuring accuracy, completeness, and compliance with relevant regulations and guidelines. - Collaborate with healthcare professionals, including physicians, nurses and appropriate staff, to ensure receipt of proper documentation. - Responsible for understanding and adhering to all Medicare Local and National Coverage Determinations (LCD’s and NCD’s), policy articles, government rules and regulations, and contracted payor policies pertaining to services and products provided. - Will work closely with the department Manager and external resources to accurately interpret and explain policy documentation requirements to all company stakeholders. - Responsible for navigating between multiple computer-based systems to accurately review audits/appeals as assigned - Will identify and communicate deficiencies/discrepancies in documentation while complying with company policies & procedures. - Ensure audit/appeal packets are assembled and submitted correctly according to department policies and procedures within the defined timeframe. - Effectively communicates with Comfort Medical internal stakeholders clinical need qualifications and regulatory requirements. - Serve as a clinical resource for non-medical staff. - Support training and education on clinical need qualifications, justification, and regulatory requirements when knowledge gaps are identified for internal associates. - Participate in peer review processes to assess the quality of care provided by other clinicians, offering constructive feedback and recommendations for improvement. - Analyze and provide feedback to Comfort Medical stakeholders with respect to trends in clinical patient care and identify opportunities for quality improvement. - Responsible for keeping Manager informed of deficient audits/appeals, patterns, errors, or other systematic problems identified. - Responsible for understanding and adhering to all company and department policies, procedures, and process documents. - Comfort Medical employees are required to conduct business to the highest ethical and professional standards; comply with applicable laws and regulations, the MedTech Code of Conduct, and company policies. - Responsible for additional duties assigned by the department’s management. Basic Qualifications - College Degree in healthcare, nursing, or related fields. - Minimum of 2 years’ experience working as a clinical nurse reviewer or in utilization management. - Must have active LPN or RN Certification in the state in which they reside (must maintain certification). - Ability to work collaboratively and independently and stay on task. - Strong background knowledge in healthcare regulatory, government policy, and contracted payer policy. - Excellent medical terminology skills. - Excellent written and verbal communication skills. Preferred Qualifications - 5+ years’ DME industry experience (urological/ostomy) - EHR system experience - Certified Professional in Healthcare Quality (CPHQ) At Coloplast, we believe in recognizing and rewarding the contributions of our employees. Our total rewards package is designed to support your well-being, foster your professional growth, and ensure a healthy work-life balance. Here is some of what you can expect: - Health and Wellness: Comprehensive medical, dental, and vision insurance plans to keep you and your family healthy. Plus, access to company sponsored wellness programs and mental health resources, paid leave of absence for qualifying events and generous paid parental leave for both birthing and non-birthing parents. - Financial Security: A competitive 401(k) plan with company match that vest immediately, financial planning services to help you secure your future, and corporate discount programs for goods and services. - Work-Life Balance: Generous paid time off, flexible work hours, and flexible work arrangement options to help you balance your personal and professional life may be available. - Professional Development: Opportunities for continuous learning and career advancement through training programs, mentorship, and tuition reimbursement. - Recognition and Rewards: Recognition programs to celebrate achievements and contributions, including peer recognition, bonuses, awards, and special events. - Community and Culture: A supportive work environment where everyone feels valued and has a sense of belonging. Participate in team-building activities, volunteer opportunities, and company-sponsored events. Sustainability strategy that outlines our ambitions for how to run our company in a more sustainable way. - • Competitive Compensation: The compensation range for this position is $80,740 - $100,000. Actual compensation is influenced by a variety of factors including but not limited to skills, experience, qualifications, and geographic location. Hired candidates may be eligible to receive additional compensation in the form of bonuses and/or incentives. div.joqReqDescription { background :#FFF repeat-y !important; color:#000; } Comfort Medical provides an extensive selection of name brand catheter and ostomy supplies to thousands of customers nationwide. Our attention to detail, unmatched customer service, and dedication to helping our customers live happier, healthier lives are just a few of the many reasons we are one of the fastest growing catheter and ostomy supply companies in the nation!​ Comfort Medical employees are required to conduct business to the highest ethical and professional standards; comply with applicable laws and regulations, the Advamed Code of Ethics on Interactions with Healthcare Professionals, and company policies. Comfort Medical is committed to a policy of Equal Employment Opportunity (EEO) which means we employ and promote individuals based on their merits, regardless of race, color, religion, sex, national origin, age, disability, veteran status, pregnancy, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status, status with regards to public assistance or any other protected classification. 60909 #LI-CM #LI-REMOTE