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Reconsideration Analyst I

Medical ReviewerMedical ReviewerFull TimeRemoteMid LevelTeam 201-500

Location

United States

Posted

80 days ago

Salary

$13 - $18 / hour

Seniority

Mid Level

No structured requirement data.

Job Description

Reconsideration Analyst I

J29, Inc

Reconsideration Analyst I (RAI) Overview: J29 is an employee centered healthcare management consulting company that specializes in processing, reviewing, and analyzing medical claims, records, disputes, and audits. Established in 2017, J29 prides itself on its employee centric culture and high employee retention rates that allow us to ensure that we are creating a working environment that prioritizes the employee experience. Our team brings corporate performance that stretches to various areas where we can provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs at the State, Federal, and Commercial levels. Position Purpose: Performs routine appeals work. Serve as a support person for the reconsideration professionals and physician reviewers for second level reconsiderations resolutions. Works under close supervision, with minimal latitude for the use of initiative and independent judgement. Essential Responsibilities: - Coordinates the delivery of appeals case files resolution documents and reconsideration decisions from and to the external entities. - Build a reconsideration case file from evidence submitted or auto forwarded from Plans and analyzes each case to ensure it meets the requirements for a valid reconsideration as mandated by Centers for Medicare and Medicaid Services (CMS) or other customer entities. - Analyzes and makes decisions based on medical vs. non-medical case type, appeal/review categories, validity of appeal. - Inputs appropriate data regarding reconsiderations into the applicable required systems. - Responds to reconsideration from appellants/providers. - Routes or responds to telephonic and/or written inquiries from appellants/ about reconsiderations or about the reconsiderations process from appellants/or their legally designated representatives. - Identifies any suspected instances of fraud and/or abuse and immediately inform management of such issues. - Stays abreast of changes in regulations and practices, policies and procedures. - May submit requests for re-determination files and completed reconsideration and Administrative Law Judge (ALJ) decisions to relevant entities. - May support the processing of reopenings following receipt of ALJ remands. - Participates in special projects and performs other duties as assigned. Minimum Qualifications Education - High School Diploma or equivalent Experience - One (1) year of general office experience College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.) - Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred Knowledge, Skills and Abilities Some Knowledge of - Research techniques - Medicare appeals program - Applicable systems and applications - Applicable laws, rules and regulations Some Skill in - Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency - Prioritizing and organizing work assignments - Researching, analyzing and interpreting policies and state and federal laws and regulations - The use of personal computers and applicable programs, applications and systems Ability to - Meet production and quality standards - Multitask and meet deadlines - Exercise logic and reasoning to define problems, establish facts and draw valid conclusions - Make decisions that support business objectives and goals - Identify and resolve problems or refer issues appropriately - Communicate effectively verbally and in writing - Adapt to the needs of internal and external customers - Show integrity and ethical behavior, respect for confidentiality, business ethics and organizational standards - Assures compliance with company policies, procedures, and guidelines including cybersecurity, regulatory, contractual and accreditation entities J29, Inc. is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity/Affirmative Action Employer, making decisions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, veteran status, disability, or any other protected class. J29, Inc. is a proud Veteran friendly employer.

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Overview Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team! Responsibilities Under minimal direction, the Beaker Analyst will be responsible for the design, build, testing, training, and support of the Electronic Health Record (EHR) system. The Analyst requires little or no supervision as they build, maintain the system and exercise independent judgement and discretion in carrying out day-to-day support related activities. The Analyst performs complex design and analysis tasks related to the hospital business operations. The Analyst will also act as a mentor to other members of the Beaker team. #LI-KT1 #remote Qualifications Required qualifications: - Bachelor's degree in Healthcare Informatics, Nursing, Computer Science, Information Technology, or related field. - Certification in Epic applications (e.g., Epic Beaker, etc.) and any new certifications must be obtained within 3 months of hire. - Two (2) years of experience implementing, configuring, and supporting Epic EHR applications. - Proficiency in system configuration, customization, and optimization within the Epic environment. - Strong understanding of hospital business operations and structure, clinical workflows, general requirements in an integrated delivery system, and use of IT applications in the practicing healthcare environment. - Strong computer skills including Windows, Outlook, Word, Excel, Visio, and PowerPoint - Technical expertise in subject matter areas demonstrated by documented experience in analysis, process design and workflow, research, installation/implementation, and support of EHR systems. - Ability to independently prioritize work assignments, meet deadlines and manage multiple projects and/or priorities. - Customer service oriented and excellent communication and organizational skills. - Able to travel up to 50% and take calls as needed. Preferred qualifications: - Prior experience in EMR implementations and/or support. - Experience with project management methodologies and tools. Pay Transparency Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $68,640.00 to $124,800.00 on an annualized basis. The compensation estimate noted above is specific to California and has not been adjusted for any other geographic location. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure. Employment Status Full Time Shift Days Equal Employment Opportunity Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf Privacy Notice Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf

United States
$68.6K - $124K / year
Full TimeRemoteTeam 501-1,000Since 2011H1B No Sponsor

Patient Support Supervisor Location: Stoughton and Phoenix Area Preferred (other locations considered based on unique situations) Shields is seeking an experienced person who loves to work with and lead people, has strong management skills, who is highly motivated self-starter who is looking for a challenging career with a fast-growing company in specialty pharmacy management services. Applicants should be results-oriented with a positive outlook and a clear focus on high quality. A natural forward planner who critically assesses their own performance. The ideal candidate should have front-line employee management experience with a background in pharmacy or healthcare. Applicant should be service-oriented, motivational in their style and have a clear focus on performance accountability and employee development. The applicant must be able to work as a member of a close-knit team. A Patient Support Supervisor is a key leadership position supporting Shields Health Solutions Patient Support team. This position will provide day-to-day leadership for a significant portion of Patient Support Center and will be responsible for leading a team of Patient Support team members. This person is primarily responsible to ensure either/both of the following: Manage all responsible work of assigned sites/clinics and ensure service level metrics are reached in accordance with contract requirements. The leader is responsible for ensuring the adoption and continuity of best practices, providing ongoing support, coordinating coverage, coaching, performance management and professional development of the team, and any other support team members. 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BeiGene logo

Manager, Clinical Pharmacology & Pharmacometrics

BeiGene

BeOne is committed to fair and equitable compensation practices. Actual compensation packages are determined by several factors that are unique to each candidate, including but not limited to job-related skills, depth of experience, certifications, relevant education or training, and specific work location. We are proud to be an equal opportunity employer. BeOne does not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, disability, national origin, veteran status or any other basis covered by appropriate law. In order to ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, Title I of the Americans with Disabilities Act of 1990, and any other applicable federal, state or local laws, applicants who require reasonable accommodation in the job application process may contact accommodationsus@beonemed.com.

Medical Reviewer80 days ago
Full TimeRemoteTeam 2,862Since 2010

BeOne continues to grow at a rapid pace with challenging and exciting opportunities for experienced professionals. When considering candidates, we look for scientific and business professionals who are highly motivated, collaborative, and most importantly, share our passionate interest in fighting cancer. General Description: We are seeking a highly motivated candidate to join our Clinical Pharmacology and Pharmacometrics (CPP) group. The successful candidate will support a variety of Clinical Pharmacology activities, including tasks related to non-compartmental analysis (NCA), data visualization, table generation, quality control (QC) of results, and data curation to support novel small molecules and biologics assets in the company portfolio. This role requires a strong STEM background and proficiency in data manipulation tools such as R and/or Phoenix WinNonlin (WNL). Exposure to clinical pharmacology and pharmacometric approaches for characterizing pharmacokinetic profiles; assessing drug/food interaction potential; characterizing QT prolongation potential, etc is desirable but not required. 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Supervisory Responsibilities: - Assist with and/or lead internal trainings periodically Computer Skills: - Proficiency in using R for data manipulation, visualization, and basic statistical analyses is required. - Hands-on experience in performing NCA using Phoenix WinNonlin is preferred. - Experience or exposure with one or more of the following is desirable: NONMEM, Berkeley Madonna, Simcyp, Gastroplus, Matlab. - Exposure to working with and manipulating large datasets Education Required: - A B.S. with 5+ years relevant work experience, a M.S. with 4+ years relevant work experience, or PhD with 2+ years relevant work experience. - Education: Pharmacokinetics, Pharmaceutical Sciences/Pharmacy, Biomedical Engineering, Bioinformatics, Data Sciences, Mathematics, or related STEM discipline Other Qualifications: - Demonstrated commitment to problem solving and developing creative solutions - Detail oriented to ensure accuracy and thoroughness of work - Ability to multi-task - Ability to adapt to fast-moving timelines and quick turnaround times - Strong written and oral communication skills - Strong drive to learn and apply emerging technologies such as AI, ML, or other tools to improve daily task efficiencies Travel: N/A Global Competencies When we exhibit our values of Patients First, Driving Excellence, Bold Ingenuity and Collaborative Spirit, through our twelve global competencies below, we help get more affordable medicines to more patients around the world. - Fosters Teamwork - Provides and Solicits Honest and Actionable Feedback - Self-Awareness - Acts Inclusively - Demonstrates Initiative - Entrepreneurial Mindset - Continuous Learning - Embraces Change - Results-Oriented - Analytical Thinking/Data Analysis - Financial Excellence - Communicates with Clarity Salary Range: $120,100.00 - $160,100.00 annuallyBeOne is committed to fair and equitable compensation practices. 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United States
$120K - $160K / year
CVS Health logo

Utilization Management Nurse Consultant - Medical Review (Remote)

CVS Health

Bringing our heart to every moment of your health.

Medical Reviewer80 days ago
Full TimeRemoteTeam 10,001+Since 1963H1B No Sponsor

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Information Schedule: Monday–Friday 8:00am-5:00pm EST Location: 100% Remote (U.S. only) About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. Position Summary Join a team that’s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Medical Review, you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect. Key Responsibilities - Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases. - Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client. - Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. - Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback. - Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs. - Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction. - Must be able to work independently without personal distractions to meet quality and metric expectations. Remote Work Expectations - This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. - Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications - Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed. - Minimum 3 years of clinical experience. - 5 years demonstrated to make thorough independent decisions using clinical judgement. - 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems. - 1+ Year of Utilization Review Management and/or Medical Management experience. - Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications - Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity. - MCG Milliman, CPB or other criteria guideline application experience is preferred. Education - Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: - Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. - No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. - Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/28/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

United States
$26 - $56 / hour
Job Closed