The physician provides clinical support to the Payment Integrity Office (PIO) to ensure that fraud, waste, and abuse efforts are performed in accordance with the highest and most current clinical standards. Responsible to review cases and evaluate billing and coding accuracy, medical necessity and appropriateness of the treatment service. Responsible for appropriate application of Medical Policy and criteria for reviews, audits, and investigations. Provide necessary support to the anti-fraud program which involves conducting reviews of organization or functional activities related to alleged fraud, waste, and abuse perpetrated by providers, members, facilities, pharmacies, and /or groups. Key Responsibilities: • Overall case guidance and consulting to ensure that fraud, waste, and abuse efforts are performed with the highest and most current clinical standards • Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on services provided to members • Perform reviews and participate in peer-to-peer discussions of inpatient DRG Clinical Validation audits and appeals • Serves as a resource for information and consultation on the issues related to utilization management and clinical services • Approval and direction of consultant reviews. Participation in and support of overpayment recoveries • Support as needed to internal and external agencies in conjunction with these reviews such as but not limited to the Special Investigations Unit • Review of services suspected of being performed for purposes not medically necessary. Appropriate documentation of decisions and follow-up • Comply with all state, federal, and regulatory requirements • Other duties as necessary to ensure progression and completion of reviews • Participate on projects and committees as necessary Key Requirements: • MD or DO with an unrestricted FL medical license • 3+ years of experience in active clinical practice (primary care specialty desirable) • Excellent written and verbal communication skills with the ability to interact with all levels of the organization, external customers and providers • Ability to analyze data, measure outcomes, and develop action plans • Ability to intervene in crisis situations and multi-task • Conversant with most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement. • Experience in utilization management, case review, and/or quality improvement activities in a managed care setting. Preferred: • Board Certification in an American Board of Medical Specialties or Bureau of Osteopathic Specialist recognized specialty, or The National Board of Physicians and Surgeons (NBPS) • Nationally recognized Certification in Inpatient and Outpatient coding, e.g., AHIMA and AAPC credentials • Graduate degree such as a MBA or MPH • Certified Physician Executive (CPE) • American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) General Physical Demands Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. What We Offer: As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities. To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to: Medical, dental, vision, life and global travel health insurance; Income protection benefits: life insurance, short- and long-term disability programs; Leave programs to support personal circumstances; Retirement Savings Plan including employer match; Paid time off, volunteer time off, 10 holidays and 2 well-being days; Additional voluntary benefits available; and A comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ. To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases. Annualized Salary Range: $224,000 - $364,000 Typical Annualized Hiring Range: $224,000 - $280,000 Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Become a part of our caring community and help us put health first The Senior Maternal Health Professional contributes to administration of care management. Provides non-clinical support to the assessment and evaluation of members' needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. The Senior Maternal Health Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. Maternal Health Support Professional Lead Role - Collaborate with Leadership and Associate Director to design and implement short- and long-term Maternal and Child Health action plans with measurable goals - Identify, prioritize, and advance new Maternal and Child Health initiatives to address gaps in care, member needs, and regulatory requirements - Establish and maintain partnerships with community organizations, provider networks, and state agencies to enhance service delivery and strengthen access pathways for Humana members - Represent Humana Maternity at community events, forums, and collaborative workgroups - Be a proxy for the Maternal and Child Health Department in advisory councils, DMAS Maternal workgroups, and other important meetings, such as the Neonatal/Perinatal Collaborations through the VNPC - Travel to and participate in provider and community events to promote Humana's Maternal and Child Health programs - Together with the AD, the lead will support maternity managers in preparing and submitting regulatory reports - Work with leadership to identify access to care challenges, including process improvement, resource building, and collaborations - Develop and maintain tracking systems and methodologies for Maternal and Child Health initiatives, including data collection on outcome measures and program effectiveness and compliance - Analyze and interpret data to assess impact, inform continuous improvement, and fulfill reporting requirements - Be the subject matter expert on maternal child health topics for internal teams, providing guidance on strategy, best practices, and policy interpretation - Collaborate with the Associate Director of Maternal and Child Health to lead internal policy and procedure updates - Collaborate with internal teams and DMAS to improve maternal and behavioral health initiatives, providing recommendations and submitting detailed reports in accordance with DMAS requests. - Advises and guides multiple internal teams, providing advances subject matter expertise and leading the implementation of innovative models for integrates maternal health care. - Ensure that all maternal health operations not only meet, but exceed, regulatory, contractual and accreditation requirements, supporting a culture of continuous improvement and compliance across the organization. - Monitors, analyzes and interprets emerging maternal health equity trends, providing strategic advice to senior executives and commending transformative opportunities across the enterprise. - Leads performance measurement and quality improvement efforts, sponsoring data-driven decision making around network adequacy, utilization, member outcomes, and health equity objectives. - Facilitates strategic advisory councils, learning collaboratives, and community forums, establishing Humana as a trusted partner in maternal health innovation. Use your skills to make an impact Required Qualifications - Must reside in the Commonwealth of Virginia, preferably the Central Region (Richmond, Tidewater) or NOVA - Demonstrated experience in large Care Management and Maternal Health implementation. - Active RN license in the Commonwealth of Virginia, with no disciplinary action OR, LCSW, MSW, BSW, LSW, LPC - 5 years of experience in maternal health, healthcare transformation, integrated care or related disciplines. - 5+ years of technical experience using Microsoft Office, Word, Excel, Outlook - Experience in problem solving and consultation with complex environments. - Strong influencing and process improvement skills - Ability to influence department's strategy - Ability to communicate effectively and deliver presentations to senior leaders. - Demonstrates decision making on moderately complex to complex issues Preferred Qualifications - Bachelor's degree or Master's degree - High-level administrative experience with navigating and/or overseeing state's safety net maternal health programs and services through the LGEs, or a similar infrastructure of state-designated local maternal health organizations. - Knowledge of community resources and behavioral health practices with high-risk populations. - Process knowledge and designed experience. Additional Information - Workstyle: This is a Remote position that requires some travel. - Travel: Up to 25% of the time to Humana Healthy Horizons office in Glen Allen, VA for collaboration and face to face meetings as well as field interactions with providers, members, and their families. Note: Travel may exceed 25% in the initial stages of market implementation. - Typical Workdays and Hours: Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST). - Direct Reports: Up to 15. - Language Proficiency Assessment: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government. Work at Home Internet Statement To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: - At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested. - Satellite, cellular and microwave connection can be used only if approved by leadership. - Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. - Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Interview Format As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. 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.

Telemedicine Physician (Wound Care) At NIVA Health, we believe everyone deserves to live their best life. Our mission is to revolutionize healthcare by providing innovative, high-quality solutions that elevate the well-being of our patients and communities. Join us in shaping a healthier future! Why NIVA Health? At NIVA Health, we are dedicated to leading healthcare innovation by providing patient-centered, insurance-based services that offer long-term solutions. We specialize in personalized care plans incorporating elements of regenerative and functional medicine, aimed at addressing symptoms related to chronic conditions, fatigue, and nutritional deficiencies. Our goal is to offer high-quality care, including wound care services, to meet the diverse needs of our patients. Key Highlights: - Insurance-Based Services: We offer a range of insurance-covered services, ensuring our innovative treatments are accessible to a broader patient base. From wound care to telemedicine, our goal is to provide cost-effective care without compromising quality. - Regenerative Therapies: We utilize regenerative therapies to provide lasting solutions, tailoring our approach to meet the individual needs of each patient, with a focus on improving overall health and quality of life. - Functional Medicine Expertise: Our team integrates functional medicine principles to address health issues such as fatigue, and other chronic conditions, offering holistic care that goes beyond symptom management. - Comprehensive Home-Based Wound Care: As part of our commitment to patient well-being, we offer wound care services in the comfort of patients' homes, ensuring convenience and specialized care for non-ambulatory patients. - Telemedicine and Telehealth Services: We leverage telemedicine to conduct initial patient consultations, follow-up visits, and routine check-ups, allowing us to extend our services to patients regardless of location, providing care in a timely and efficient manner. - Empowerment through Education: We believe in empowering patients by educating them on lifestyle modifications and at-home therapies to promote sustainable, long-term health improvements. Telehealth Supervising Physician Responsibilities: - Provide oversight to Nurse Practitioners, ensuring quality patient care. - Advocate for patients seeking telemedicine solutions for their treatment plans. - Ensure timely and accurate completion of medical records and maintain clinical governance standards. - Foster a compassionate, patient-centered atmosphere. Qualifications: - Must be a licensed Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) with active licensure in Michigan - Must reside in Michigan - Proven leadership experience within a healthcare setting. - Ability to navigate Telehealth technology options. - Available between 8 am and 6 pm for patient consultations and provider oversight. Benefits and Compensation: - Salary: $50,000 base salary with bonus opportunities up to $100,000.  - Malpractice Coverage. - Continuing Education Assistance to support your professional growth. - Employee Discount on NIVA Health services. - No On-Call Requirements, allowing for work-life balance. "Learn more about us at https://nivahealthwoundcare.com/ and become part of NIVA Health’s mission to redefine patient care—one healing wound at a time." Job Type: Part-time Schedule: - Day shift - Monday to Friday - No weekends Work Location: Remote #IND-RHW

Psychiatrist - Bronx, NY (#1654) - Medical, Dental, and Vision insurance - Flexible Spending Account - Paid Time Off, Retirement Savings - Commuter Benefits program - Visa Sponsorship opportunities Location: Bronx, NY Employment Type: Part-Time (Hybrid: Mostly Remote, On-Site 1–2 Days/Month) Salary: $200,000 - $250,000 / yr (pro-rated for part-time) About Impact Recruiting Solutions: Impact Recruiting Solutions is a dedicated recruitment partner connecting healthcare professionals with rewarding opportunities. We collaborate with hospitals, clinics, and multi-specialty facilities to match skilled individuals with roles that align with their expertise and career aspirations. Position Overview: Impact Recruiting Solutions is seeking a Board-Certified or Board-Eligible Psychiatrist to join a collaborative multi-specialty practice in the Bronx, NY. This hybrid role offers flexible remote work with minimal on-site requirements, focusing on delivering patient-centered mental health care to diverse populations. Key Responsibilities: - Conduct psychiatric evaluations and diagnose mental health disorders. - Develop and manage individualized treatment plans (including medication management). - Provide evidence-based therapy for conditions like depression, anxiety, and bipolar disorder. - Collaborate with primary care providers and specialists for integrated care. - Maintain accurate electronic health records (EHR) and ensure HIPAA compliance. - Participate in case conferences and contribute to practice improvement initiatives.