Job DetailsJob Location: Rockford, IL 61108Position Type: Full TimeSalary Range: $45.00 - $52.00 HourlyAre you passionate about clinical quality, accuracy, and continuous improvement -and looking for a role that allows you to make a meaningful impact while working from home? We’re seeking a Utilization Review & Quality Assurance Specialist to join our fully remote team. This role offers a consistent 8:00am-4:30pm EST schedule, providing structure and work-life balance while you contribute to high‑quality clinical review operations. In this role, you’ll be at the center of ensuring excellence - reviewing clinical documentation, upholding regulatory and client standards, and driving quality across medical review processes. If you thrive in a peer review environment, have a sharp analytical mindset, and take pride in delivering precise, compliant, and thoughtful work, this is an exciting opportunity to grow your expertise and help shape best practices in utilization review and quality assurance. Responsibilities may include: Evaluate clinical information received, write and/or review various reports including, but not limited to: Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements. Perform quality assurance reviews of peer review reports, correspondences, addendums or supplemental reviews to ensure they meet company standards for content, clarity, evidence-based rationale, formatting, and professional presentation. Ensure all client instructions and specifications have been followed, all questions have been answered, and all recommendations or determinations are supported by clear, concise, and evidence-based rationales. Verify that each review includes appropriate clinical citations when applicable, and ensure all references cited are current and obtained from reputable medical journals and publications. Identify inconsistencies within reports and contact the reviewer to obtain clarifications, modifications, or corrections needed. Assist in the resolution of customer complaints and quality assurance issues as appropriate. Ensure all federal ERISA and applicable state mandates are adhered to. Provide ongoing feedback and recommendations to management regarding consultant performance, quality trends, and compliance with internal and client specific requirements. Participate in the development and implementation of policies and procedures to improve efficiency and quality across operations. Develop and lead formal and informal training sessions -individually or in groups -that promote high-quality utilization review practices and reinforce company standards. Develop and document new or improved operational processes to support continuous improvement. Promote effective and efficient utilization of company resources across all responsibilities. Participate in or lead various continuing education and training activities related to clinical knowledge, industry standards, and company processes. Perform other duties as assigned. Qualifications Must hold and maintain a Registered Nursing License, or license or certification in related field. Experience in the insurance industry and/or utilization management preferred. Must have strong understanding of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values. Must be proficient in Microsoft Office Suite, Outlook, internet navigation and general office equipment. Must have the ability to follow instructions and respond to upper managements’ directions accurately. Ability to work independently, prioritize tasks, and manage time efficiently in a fast-paced environment. Ability to demonstrate accuracy, thoroughness, and commitment to producing high quality work; actively monitor own performance and seek opportunities for improvement. Ability to demonstrate flexibility and remain composed under pressure or in stressful conditions; adapts well to change and promotes a positive team environment. Must be able to maintain confidentiality. Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time. ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services. Our clients include property and casualty insurance carriers, law firms, third-party claim administrators and government agencies that use independent services to confirm the veracity of claims by sick or injured individuals under automotive, disability, liability and workers' compensation insurance coverages. Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws. Equal Opportunity Employer - Minorities/Females/Disabled/Veterans ExamWorks offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.

Job DetailsJob Location: Rockford, IL 61108Position Type: Full TimeSalary Range: $45.00 - $52.00 HourlyAre you passionate about clinical quality, accuracy, and continuous improvement -and looking for a role that allows you to make a meaningful impact while working from home? We’re seeking a Utilization Review & Quality Assurance Specialist to join our fully remote team. This role offers a consistent 8:00am-4:30pm EST schedule, providing structure and work-life balance while you contribute to high‑quality clinical review operations. In this role, you’ll be at the center of ensuring excellence - reviewing clinical documentation, upholding regulatory and client standards, and driving quality across medical review processes. If you thrive in a peer review environment, have a sharp analytical mindset, and take pride in delivering precise, compliant, and thoughtful work, this is an exciting opportunity to grow your expertise and help shape best practices in utilization review and quality assurance. Responsibilities may include: Evaluate clinical information received, write and/or review various reports including, but not limited to: Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements. Perform quality assurance reviews of peer review reports, correspondences, addendums or supplemental reviews to ensure they meet company standards for content, clarity, evidence-based rationale, formatting, and professional presentation. Ensure all client instructions and specifications have been followed, all questions have been answered, and all recommendations or determinations are supported by clear, concise, and evidence-based rationales. Verify that each review includes appropriate clinical citations when applicable, and ensure all references cited are current and obtained from reputable medical journals and publications. Identify inconsistencies within reports and contact the reviewer to obtain clarifications, modifications, or corrections needed. Assist in the resolution of customer complaints and quality assurance issues as appropriate. Ensure all federal ERISA and applicable state mandates are adhered to. Provide ongoing feedback and recommendations to management regarding consultant performance, quality trends, and compliance with internal and client specific requirements. Participate in the development and implementation of policies and procedures to improve efficiency and quality across operations. Develop and lead formal and informal training sessions -individually or in groups -that promote high-quality utilization review practices and reinforce company standards. Develop and document new or improved operational processes to support continuous improvement. Promote effective and efficient utilization of company resources across all responsibilities. Participate in or lead various continuing education and training activities related to clinical knowledge, industry standards, and company processes. Perform other duties as assigned. Qualifications Must hold and maintain a Registered Nursing License, or license or certification in related field. Experience in the insurance industry and/or utilization management preferred. Must have strong understanding of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values. Must be proficient in Microsoft Office Suite, Outlook, internet navigation and general office equipment. Must have the ability to follow instructions and respond to upper managements’ directions accurately. Ability to work independently, prioritize tasks, and manage time efficiently in a fast-paced environment. Ability to demonstrate accuracy, thoroughness, and commitment to producing high quality work; actively monitor own performance and seek opportunities for improvement. Ability to demonstrate flexibility and remain composed under pressure or in stressful conditions; adapts well to change and promotes a positive team environment. Must be able to maintain confidentiality. Ability to follow all company policies and procedures in effect at time of hire and as they may change or be added from time to time. ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services. Our clients include property and casualty insurance carriers, law firms, third-party claim administrators and government agencies that use independent services to confirm the veracity of claims by sick or injured individuals under automotive, disability, liability and workers' compensation insurance coverages. Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws. Equal Opportunity Employer - Minorities/Females/Disabled/Veterans ExamWorks offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.

Company Navitus About Us Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other._____________________________________________________________________________________________________________________________________________________________________________________________________________. Current associates must use SSO login option at https://employees-navitus.icims.com/ to be considered for internal opportunities. ____________________________________________________We are committed to providing equal employment opportunity to all applicants and employees and comply with all applicable nondiscrimination regulations, including those related to protected veterans and individuals with disabilities. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or handicap. Pay Range USD $105,271.00 - USD $131,588.00 /Yr. STAR Bonus % (At Risk Maximum) 7.50 - Pharm, Supvr, AsMgr, SrCSEII, PrgMgr, SrPrgMgr, SrProdMgr Work Schedule Description (e.g. M-F 8am to 5pm) Monday-Thursday: Three shifts of 9:00 AM to 5:30 PM CT; one shift 10:30 to 7 PM CT. Friday: 8:30 AM to 5 PM CT Remote Work Notification ATTENTION: Navitus is unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming. Overview Navitus Health Solutions is seeking a Pharmacist, Telehealth to join our team! The Pharmacist, Telehealth will be a key contributor to the success of a newly launched Clinical Engagement Center (CEC) focused on improving member’s health and wellness via tele-pharmacy and wellness coaching. This pharmacist is responsible for the delivery of the Medication Therapy Management (MTM) services for commercial and Medicare members. In addition, the Telehealth Pharmacist will assist in the development and execution of additional clinical outreach program to exceed client expectations. Is this you? Find out more below! Responsibilities How do I make an impact on my team? - Conduct medication therapy management (MTM) and expanded clinical programs in accordance with the Centers for Medicare & Medicaid Services (CMS). - Develop appropriate clinical algorithms, pathways, and call scripts to support pharmacy staff in delivering MTM services. - Review and update all algorithms and call scripts at least yearly and with updated clinical guidelines. - Develop documentation standards for all clinical outreach. - Collaborate with other CEC staff to develop and maintain a high quality and consistent MTM product. - Assist CEC leadership to develop programs to support STAR ratings outreach. - Facilitate communication and education to clients, providers, and internal staff regarding MTM programs and program outcomes. - Provide clinical outreach to members, prescribers, and pharmacy providers in order to enhance care coordination. - Provide Medicare Part D clinical, operational and educational support by maintaining knowledge of all existing updates and regulations regarding the MTM program and Medicare Part C and D performance measures (STAR ratings). - Stay current with new guidelines, literature, recommendations, and medications, and integrate that information into the MTM and STARs programs, such that our clinical outreaches remain up to date. - Serve as a preceptor for APPE students within the CEC department. - Maintain open lines of communication with other functional areas/departments. - Develop a full understanding of Navitus Clients’ member experience and how the engagement center contributes to improved health and wellness. - Adhere to compliance and HIPAA regulations. - Other duties as assigned. Qualifications What our team expects from you? - Pharm.D. degree with unrestricted licensure - Minimum of two years clinical experience including direct consultation experience. - Experience as a clinical call center lead is preferred. - Experience as a member of a multi-disciplinary team is preferred. - Professional PBM industry work experience is preferred. - Knowledge of applicable data privacy practices and laws is preferred. - Knowledge of healthcare industry practices and HIPAA regulations - Spanish-speaking is preferred. - Participate in, adhere to, and support compliance program objectives - The ability to consistently interact cooperatively and respectfully with other employees What can you expect from Navitus? - Top of the industry benefits for Health, Dental, and Vision insurance - 20 days paid time off - 4 weeks paid parental leave - 9 paid holidays - 401K company match of up to 5% - No vesting requirement - Adoption Assistance Program - Flexible Spending Account - Educational Assistance Plan and Professional Membership assistance - Referral Bonus Program – up to $750! #LI-Remote Location : Address Remote Location : Country US

Huron helps its clients drive growth, enhance performance and sustain leadership in the markets they serve. We help healthcare organizations build innovation capabilities and accelerate key growth initiatives, enabling organizations to own the future, instead of being disrupted by it. Together, we empower clients to create sustainable growth, optimize internal processes and deliver better consumer outcomes. Health systems, hospitals and medical clinics are under immense pressure to improve clinical outcomes and reduce the cost of providing patient care. Investing in new partnerships, clinical services and technology is not enough to create meaningful and substantive change. To succeed long-term, healthcare organizations must empower leaders, clinicians, employees, affiliates and communities to build cultures that foster innovation to achieve the best outcomes for patients. Joining the Huron team means you’ll help our clients evolve and adapt to the rapidly changing healthcare environment and optimize existing business operations, improve clinical outcomes, create a more consumer-centric healthcare experience, and drive physician, patient and employee engagement across the enterprise. Join our team as the expert you are now and create your future. The Health Informatics Analyst supports the Client program by analyzing, documenting, and optimizing healthcare application functionality to ensure compliance with Federal and Client policies. This role partners closely with the Client Interagency Office to align stakeholders, translate business needs into technical requirements, and support governance efforts that drive efficient, coordinated decision-making across agencies. In this role, you will leverage your clinical informatics expertise to support the implementation and sustainment of a large-scale electronic health record (EHR) system through activities such as terminology mapping, testing, prototyping, and architecture design. The role involves coordinating cross-functional teams, addressing usability and interoperability challenges, and developing interagency standards and executive-level communications. This position offers the flexibility of virtual work, though it is based in Washington, DC. As the Health Informatics Analyst, you will: - Analyze and document the functionality, integration, and architecture of current and planned software applications to ensure compliance with Federal and Client policies - Support interagency governance by enabling structured collaboration across Client partner organizations - Act as a liaison between business, technical, and governance stakeholders to align requirements, outcomes, and performance constraints - Contribute to the development and oversight of governance strategies that support efficient, interagency decision-making - Provide clinical informatics expertise to translate business and functional requirements into technical solutions, including architecture, terminology mapping, prototyping, and testing - Coordinate cross-functional teams to ensure interoperability, healthcare semantics, usability, and platform compatibility across EHR systems - Develop interagency standards and executive-level communication materials to support alignment and shared objectives Requirements: - Bachelor’s degree required; advanced degrees (e.g., MBA) or equivalent experience are valued - Experience with Oracle Health Electronic Health Record (EHR) systems, particularly large-scale implementations and deployments - Expertise in governance strategies, interagency collaboration and healthcare informatics - Experience with tools and processes such as terminology mapping, system testing, and cross-platform integration will further enhance your ability to succeed - Strong communication skills and the ability to navigate complex stakeholder environments will be critical as you work to align technical and business objectives - Previous Federal consulting or experience working within the DoD, Veteran’s Health Administration (VHA) or Military Hospital System (MHS) - Must be a United States Citizen - Candidates must comply with applicable client requirements, such as immunization and occupational health mandates The estimated base hourly rate range for this job will vary based on multiple factors, including but not limited to specific skills or certifications, years of experience, market changes, and required travel. The job is also eligible to participate in Huron’s benefit plans which include medical, dental and vision coverage and other wellness programs. The rate range information provided is in accordance with applicable state and local laws regarding salary transparency that are currently in effect and may be implemented in the future. Position Level Consultant Country United States of America