• Evaluate medical records to determine medical necessity • Perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals • Document decisions using indicated protocol sets or clinical guidelines • Provide support and review of medical claims and utilization practices • Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines • Monitor process's timeliness in accordance with contractor standards • Conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs • Provide education to members and their families/caregivers • Review first level appeal and ensure thorough documentation of each determination and basis for each

• Conduct utilization reviews up to and including the appeal level. This includes chart screen, completing electronic worksheets, entering the required information, and making level one denial decisions when necessary. • Conduct quality and clinical study data collection reviews. • Act as a resource for the administrative staff in training, problem-solving, and clarifying procedures. • Participate in collaborative training specific to clinical study objectives. • You will be using InterQual criteria to review the medical records of inpatient high cost hospital stays for admission and acute level of care. • You'll also review and validate itemized bills and need to have the ability to write up responses to send to the hospital. • Other activities as may be deemed necessary

Registered Nurse/Medicaid Clinical Reviewer - Remote (#25298A) - Location: Remote - Employment Type: Full-time - Hourly Rate: $50/hr About Greenlife Healthcare Staffing: Greenlife Healthcare Staffing is a leading nationwide recruitment agency dedicated to connecting healthcare professionals with top-tier opportunities. We partner with hospitals, clinics, nursing homes, multi-specialty groups, and private practices to match talented individuals with roles that align with their skills and career goals. Position Overview: We are seeking an experienced Registered Nurse to join our team as a Medicaid Clinical Reviewer. This fully remote position involves conducting clinical reviews for Medicaid cases, ensuring compliance with state regulations, and contributing to quality improvement initiatives for a respected non-profit organization. Why Join Us? - Work Schedule: Full-time, Monday to Friday (9:00 AM - 5:30 PM), Fully Remote - Professional Growth: Gain valuable experience in a collaborative, innovative, and supportive environment - Impactful Work: Contribute to a mission-driven organization dedicated to improving patient outcomes through quality Medicaid program oversight Key Responsibilities: This individual will complete the full spectrum of activities related to Medicaid Utilization or Quality reviews as assigned. Thus, conduct final level insurance appeals and review medical records. Responsibilities for Registered Nurse/Medicaid Clinical Reviewer - Remote - Conduct utilization reviews up to and including the appeal level. This includes chart screen, completing electronic worksheets, entering the required information, and making level one denial decisions when necessary. - Conduct quality and clinical study data collection reviews. - Act as a resource for the administrative staff in training, problem-solving, and clarifying procedures. - Participate in collaborative training specific to clinical study objectives. - You will be using InterQual criteria to review the medical records of inpatient high cost hospital stays for admission and acute level of care. - You'll also review and validate itemized bills and need to have the ability to write up responses to send to the hospital. - Other activities as may be deemed necessary Greenlife Healthcare Staffing - Empowering Healthcare Professionals, Enriching Lives.

Company Description At EVERSANA, we are proud to be certified as a Great Place to Work across the globe. We’re fueled by our vision to create a healthier world. How? Our global team of more than 7,000 employees is committed to creating and delivering next-generation commercialization services to the life sciences industry. We are grounded in our cultural beliefs and serve more than 650 clients ranging from innovative biotech start-ups to established pharmaceutical companies. Our products, services and solutions help bring innovative therapies to market and support the patients who depend on them. Our jobs, skills and talents are unique, but together we make an impact every day. Join us! Across our growing organization, we embrace diversity in backgrounds and experiences. Improving patient lives around the world is a priority, and we need people from all backgrounds and swaths of life to help build the future of the healthcare and the life sciences industry. We believe our people make all the difference in cultivating an inclusive culture that embraces our cultural beliefs. We are deliberate and self-reflective about the kind of team and culture we are building. We look for team members that are not only strong in their own aptitudes but also who care deeply about EVERSANA, our people, clients and most importantly, the patients we serve. We are EVERSANA. Job Description THE POSITION: Medical Communications is part of our integrated commercial services. This position is fundamental to building credibility and strengthening relationships with healthcare providers, patients, and industry clients. The position delivers industry-leading services, which include call center staffing for responding to product information requests, identifying and in-taking of adverse events and/or product quality issues, and medical writing. The role is home office based, (full-time position), ideally located in Poland, Ireland, the UK, Italy, Portugal, Germany or Spain and the job holder must be legally eligible to work in the European Union or in the UK Working hours: US hours, working 9 hour shifts between 2pm and 2am CET Mon-Fri. ESSENTIAL DUTIES AND RESPONSIBILITIES: Our employees are tasked with delivering excellent business results through the efforts of their teams. These results are achieved by: - Translation of English documents into the target language or vice-versa, and delivering these translated responses either on the phone or in writing. - Triage and respond to drug information inquiries from physicians, pharmacists, nurses, other health care professionals, and consumers/patients. - Disseminate drug information either verbally or by written correspondence. - Identify adverse events and product complaints during interactions with customers. Perform intake sufficient to generate initial adverse event and product complaint reports in compliance with EVERSANA-Medical Communications and client SOPs. Fulfill local Regulatory Authority regulations and requirements for post-marketing adverse event reporting. In addition to being fluent in safety terminology, the individual should be able to make accurate assessments regarding what information needs to be obtained and level or depth of information to be collected. - Utilise writing skills for adverse event and product complaint narratives during intake as well as medical inquiry custom responses. - Coordinate processes necessary for responding to quality-related complaints. This process may involve interactions with personnel in the following departments: Quality Assurance, Regulatory Affairs, and the complainant. - Utilise drug information skills to critically evaluate medical literature in researching and developing information for written dissemination to healthcare professionals. - Miscellaneous projects including market and competitive product research, system development, sales training projects, and field liaison support. - Medical Writing - On-call responsibilities on an as assigned basis. - All other duties as assigned. EXPECTATIONS OF THE JOB: - Customer Services: Maintain and improve customer services associated with activity of the Medical Communications Call Centre. - Place of Work: Home Office or European Hub Office - Working hours: US hours, working 9 hour shifts between 2pm and 2am CET Mon-Fri. - Metrics: Maintain and contribute toward process improvement which positively impacts metrics associated with activities of the Medical Communications Call Centre; metrics are subject to change annually or more often as deemed necessary. - Travel: In general, this position does not travel; however, the incumbent will need to be able to travel up to 10%. Qualifications MINIMUM KNOWLEDGE, SKILLS AND ABILITIES: - The requirements listed below are representative of the experience, education, knowledge, skill and/or abilities required. - Education: Life Sciences or healthcare degree or equivalent - Experience and/or Training: Strong clinical background and excellent verbal/written communication skills. - Language: English C1 level is obligatory. In addition to mother tongue fluency in Spanish is essential. - Strong translation skills. PREFERRED QUALIFICATIONS: - Education: Preferred Pharma D / M Pharma but other degrees such as BSc. or MSc. in Pharmacy also considered. - Experience and/or Training: Call Center, Medical Information, pharmaceutical industry, and clinical experiences including medical writing. - Language skills: fluent English along with Native Spanish. - Technology/Equipment: Computer proficiency in Microsoft Word, Excel, and other Window applications. The utilization of Medical Information Management Systems, Safety Databases, or equivalent. - Positive Attitude and Energy: Exhibits an upbeat attitude, a genuine interest in others, and a sense of humor. Energises others and heightens morale through her/his attitude. - Communication Skills: Possesses the ability to develop and articulate ideas and information that generate understanding and create a climate that motivates and encourages others to participate. - Innovator: Transforms creative ideas into original solutions that positively impact the company’s performance. - Highly Principled: Proves to be a professional of unquestionable integrity, credibility, and character who demonstrates high moral and ethical behavior Additional Information Patient Minded I act with the patient’s best interest in mind. Client Delight I own every client experience and its impact on results. Take Action I am empowered and hold myself accountable. Embrace Diversity I create an environment of awareness and respect. Grow Talent I own my development and invest in the development of others. Win Together I passionately connect with anyone, anywhere, anytime to achieve results. Communication Matters I speak up to create transparent, thoughtful, and timely dialogue. Always Innovate I am bold and creative in everything I do. Our team is aware of recent fraudulent job offers in the market, misrepresenting EVERSANA. Recruitment fraud is a sophisticated scam commonly perpetrated through online services using fake websites, unsolicited e-mails, or even text messages claiming to be a legitimate company. Some of these scams request personal information and even payment for training or job application fees. Please know EVERSANA would never require personal information nor payment of any kind during the employment process. We respect the personal rights of all candidates looking to explore careers at EVERSANA. From EVERSANA’s inception, Diversity, Equity & Inclusion have always been key to our success. We are an Equal Opportunity Employer, and our employees are people with different strengths, experiences, and backgrounds who share a passion for improving the lives of patients and leading innovation within the healthcare industry. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion, and many other parts of one’s identity. All of our employees’ points of view are key to our success, and inclusion is everyone's responsibility. Follow us on LinkedIn | Twitter - Department: Clinical & Medical - Job Family: Medical & Regulatory Affairs