Prior Authorization/Concurrent Review Nurse RN (Remote in Texas only, TX RN license required)
Location
United States
Posted
49 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Prior Authorization/Concurrent Review Nurse RN (Remote in Texas only, TX RN license required)
Central Health
Overview Works with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Mentors and trains new team members. Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. This position also trains and mentors new team members as well as assesses services for Sendero members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Utilizes clinical skills to review and monitor members' utilization of health care services with the goal of maintaining high quality cost-effective care for members that are hospitalized in acute, skilled and long-term care settings. Performs telephonic reviews of inpatient hospital admissions and assist with the coordination ofdischarge planning needs. Obtains the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs. Evaluates the options and services required to meet the member's health needs, in support and collaboration with disease management interventions. Performs prospective, concurrent & retrospective review of inpatient, outpatient, ambulatory & ancillary services requiring clinical review including all levels of appeal requests. Hours of operation are Monday through Friday 8 am to 5 pm to include extended hours that may occur on a weekend and/or holidays as required by State and Federal regulations in order to maintain operational compliance. This position is considered Remote, which means that individuals in this position may work at an approved Offsite location; however, they may be required to occasionally visit a Central Health office in Austin, Texas. Remote work not available for residents of California, Colorado, New York, New Jersey, Hawaii, Maryland, Montana, Pennsylvania, Virginia, or Washington. Responsibilities Essential Duties (at least 5 that are non-negotiable duties and are absolutely pertinent to successfully completing the job without accommodations): - Provides concurrent review and prior authorizations (as needed) according to policy. - Perform concurrent and retrospective reviews on all inpatient, facility and appropriate home health services. - Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures. - Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and cost. - Completes assigned work plan objectives and projects on a timely basis. - Collect pertinent documentation and conduct medical services review applying appropriate national standardized medical criteria, Sendero medical policy, and state and federal guidelines. - Perform discharge planning activities in coordination with facility or provider case manager. - Act as a member/family advocate in coordinating and accessing medical necessity of health care services within the benefit plan. - Consult with a Medical Director as appropriate for all requests requiring MD approval or not meeting criteria for approval. - Maintain open communication flow with to other care management staff to facilitate smooth transition and - follow-up as member is transitioned from one level of care and/or service to another. - Seek out opportunities to improve HEDIS, NCQA, URAC or general accreditation and QIA activities. - Perform other related tasks as assigned by supervisor or manager and maintains department productivity and quality measures. - Attends regular staff meetings, conducts self in a professional manner at all times, and completes assigned work objectives and projects in a timely manner. Knowledge/Skills/Abilities: - Knowledge of Managed Care principles and practices, involving medical and behavioral case management, disease management, utilization and pharmaceutical management. - Skilled with clinical knowledge and experience in the treatment of human injuries, diseases, and deformities including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditions and preventive health guidelines. - Demonstrated ability to lead, communicate, problem solve, and work effectively with people. - Excellent organizational skill with the ability to manage multiple priorities. - Work independently and handle multiple projects simultaneously. - Knowledge of applicable state, and federal regulations. - In depth knowledge of InterQual and other references for length of stay and medical necessity determinations. - Subject matter expert with NCQA requirements. - Ability to take initiative and see tasks to completion. - Computer Literate (Microsoft Office Products). - Computer Literate (Microsoft Office Products). - Excellent verbal and written communication skills. - Ability to abide by Sendero’s policies. - Ability to maintain attendance to support required quality and quantity of work. - Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). - Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers. Qualifications MINIMUM EDUCATION: High School Diploma or equivalent Required and Completion of an accredited (RN) or an accredited (LVN) program Required MINIMUM EXPERIENCE: One (1) year clinical practice experience Required AND Two (2) years managed care experience with utilization management and/or case management REQUIRED CERTIFICATIONS/LICENSURE: Holds and maintains these certifications as a professional. Lapsing/expiration of these certifications/licensure will result in suspension of work:1. Active, unrestricted State Registered Nursing license in good standing
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Technical Report Reviewer, FLEX (BVTA)
Bureau VeritasAt Bureau Veritas, we are driven by our values of Trusted, Responsible, Ambitious & Humble, and Open & Inclusive. If this resonates with you, we’d love to hear from you.
A WORLD LEADER IN TESTING, INSPECTION & CERTIFICATION SERVICES Bureau Veritas offers dynamic, exciting employment opportunities with an attractive salary/benefit package and an opportunity to play a vital role with a global organization. If you would enjoy working in a dynamic environment and are looking for an opportunity to become part of a stellar team of professionals, we invite you to apply online today. Bureau Veritas is an Equal Opportunity Employer, and as such we recruit, hire, train, and promote persons in all job classifications without regard to race, color, religion, sex, national origin, disability, age, marital status, citizen status, sexual orientation, gender identity, genetics, status as a protected veteran, or any other non-job-related characteristics. This position is responsible to ensure equal opportunity in employment in that all persons are treated equally and on the basis of merit, in decisions regarding selection, placement, promotions, training, work assignments, transfers and other personnel actions. City: Remote State: Remote SUMMARY: Reviews Environmental Site Assessment (ESA), Property Condition Assessment (PCA), Property Condition Equity (PCE), and/or Facility Condition Assessment (FCA) reports and/or Seismic Reports (including Seismic Risk Assessments, Tier 1 Reports, and Structural Building Systems Assessments. Communicates with the field staff and provides feedback on quality of written report. Helps instruct the field staff and provides “redlined” versions of reports to field staff when the submitted report requires changes or improvements that should have been completed by the field staff. 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Other job-related duties may be assigned in conformance with state and federal regulations. - Responsibilities include serving as technical reviewer for Equity and BSA (Building Systems Analysis) reports, including but not limited to reviews of: Acquisition/Investor grade Property Condition Assessments (PCEs), Building Systems Analysis assessments (MEP, Structural, Roofing, Façade, etc.), Site Investigation, ESG, and Property/Climate Resiliency reporting, as well as provide support and complete other technical services requested by clients in conjunction with the reports discussed above - Familiar with current Property Condition and other Equity or BSA program-related ASTM standards - Optimize workflow efficiency, ensuring on-time delivery of due diligence reports within fast-paced investment cycles. - Travel by Plane, Motor Vehicle, Train (50% of workweek) to client sites across the U.S. Common patterns of travel include one to two day on-site followed by one to two days at home. 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Certificates, Licenses, Registrations: - Valid driver's license required with no significant MVA points/violations (clean driving record). - Employees who incur $2,000 or more per year in company-related travel expenses will be required to obtain a Corporate Credit Card. Employees who incur less than $2,000 per year in company-related travel expenses will be required to have sufficient personal credit to cover their business travel costs. Language Ability: Ability to write reports, business correspondence, and standard operating procedures. Ability to effectively present information and respond to questions from clients, peers, and technical field staff. Reasoning Ability: Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of instructions and deal with several abstract and concrete variables. 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While performing the onsite/field duties of the Project Assessor (field), the employee is required to: - Walk (material part of an 8-hour workday, up to 3 to 4 continuous hours at one time.) - Stand (material part of an 8-hour workday, up to 3 to 4 continuous hours at one time.) - Sit, Stoop, kneel, crouch, or crawl to observe basement and grade-level crawl spaces, and/or to read equipment data plates when necessary (at least once for each building assessed) - Climb and balance Stairs (at least once for each building assessed) - Climb and balance various types of ladders to access flat roofs/hatch access (at least once for each building assessed) - Repetitive use of hands/fingers for keyboard interaction (frequently) - Reach with hands and arms - Talk and hear (communicate with onsite contact) - Vision (close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus) - Lift and or move (occasionally up to 40 pounds) - Operate an electronic tablet in the field for live data collection. - Operate a computer (up to 100% of workweek) - Operating a motor vehicle - Travel by Plane, Motor Vehicle, Train to client sites across the U.S. - Onsite visits can occur up to one continuous week at a time. 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We are happy to assist you and encourage you to consider Bureau Veritas for your next great career opportunity! If you would like additional information regarding Bureau Veritas' federal obligations in regards to equal employment opportunity, please click the link below: https://www.dol.gov/agencies/ofccp/posters
Clinical Reviewer – (Remote in California)
Acentra Health, LLCAcentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact. Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes. You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.
Company Overview Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact. Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector. Job Summary and Responsibilities Job Summary Acentra Health is seeking a dedicated and experienced Clinical Reviewer to join our growing and mission-driven team. This role offers the opportunity to make a meaningful impact by supporting high-quality healthcare decisions that improve outcomes for patients and communities. In this position, you will leverage your clinical expertise to review medical records, ensuring alignment with established clinical criteria, evidence-based guidelines, and contractual requirements. Your work will play a critical role in supporting informed healthcare decisions, improving health outcomes, promoting quality care, and ensuring regulatory and contractual compliance. We currently have four Clinical Reviewer openings. Available schedules include one position with a Sunday–Thursday, 8:00 AM–5:30 PM schedule; one position with a Tuesday–Saturday, 8:00 AM–5:30 PM schedule; and two positions with a Monday–Friday, 10:00 AM–6:30 PM schedule. This is a remote, work-from-home position, and candidates must reside in California and must hold an active, unrestricted California LMFT or LCSW license. Job Responsibilities - Ensure the accuracy, quality, and timeliness of all assigned review cases in accordance with contractual and regulatory requirements. - Proactively assess, prioritize, and manage daily workloads and review queues, adjusting work schedules as needed to effectively meet departmental demands. - Collaborate with the Supervisor to support and participate in ongoing quality monitoring and performance improvement initiatives. - Maintain current knowledge of clinical practices, evidence-based guidelines, and internal review processes to ensure high-quality, compliant reviews. - Serve as a liaison to healthcare providers by addressing customer service inquiries and facilitating effective problem resolution. - Perform all applicable types of clinical reviews as dictated by workload volume and business needs. - Build and sustain positive, professional working relationships with both internal teams and external stakeholders. - Participate in required training sessions and scheduled meetings to remain informed of process updates, policy changes, and organizational initiatives. - Cross-train across functions to support a flexible workforce and ensure continuity in meeting client and customer needs. - Read, understand and adhere to all corporate policies and procedures, including full compliance with HIPAA Privacy and Security regulations. 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Best of luck in your search! ~ The Acentra Health Talent Acquisition Team EEO AA M/F/Vet/Disability Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law. Benefits Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more. 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Medical Records Retrieval Specialist - A289
PearlPearl provides tools for overqualified and overlooked jobseekers. Come find your next opportunity.
Work Arrangement: Fully Remote Job Type: Independent Contractor, Full-time Work Schedule: US time zone - 40 hours per week (9:00 AM – 5:00 PM CST) Locations: - Philippines - LATAM: Mexico City (Mexico), Bogotá (Colombia), São Paulo (Brazil), Buenos Aires (Argentina), CMDX (Mexico), Santo Domingo (Dominican Republic), Caracas (Venezuela) About Pearl Talent Pearl works with the top 1% of candidates from around the world and connects them with the best startups in the US and EU. Our clients have raised over $5B in aggregate and are backed by companies like OpenAI, a16z, and Founders Fund. They’re looking for the sharpest, hungriest candidates who they can consistently promote and work with over many years. Candidates we’ve hired have been flown out to the US and EU to work with their clients, and even promoted to roles that match folks onshore in the US. Hear why we exist, what we believe in, and who we’re building for: WATCH HERE Why Work with Us? At Pearl, we’re not just another recruiting firm—we connect you with exceptional opportunities to work alongside visionary US and EU founders. Our focus is on placing you in roles where you can grow, be challenged, and build long-term, meaningful careers. About the Company Our client is a healthcare operations platform that supports law firms by enabling fast, accurate, and compliant medical records retrieval. The company operates at the intersection of healthcare and legal services, helping improve operational efficiency, provider compliance, and client satisfaction through structured processes and high-quality execution. Role Overview The Medical Records Retrieval Specialist plays a critical role as the first step in the medical records request lifecycle. This position is responsible for ensuring that every request is complete, accurate, and compliant before moving downstream. The role requires strong attention to detail, experience with legal medical records requests, and the ability to resolve ambiguity through research and proactive communication. This is an execution-heavy, process-driven role with direct impact on retrieval speed and service quality. Candidates who thrive here are highly organized, precise, and comfortable working in detail-intensive environments. Your Impact: You will directly influence the speed and accuracy of medical records retrieval by ensuring requests are correctly prepared from the start. Your work will reduce provider rejections, minimize downstream rework, and improve overall turnaround times. You will contribute to higher client satisfaction by maintaining compliance and documentation quality. Your attention to detail and proactive issue resolution will help scale operations while maintaining high accuracy standards. Core Responsibilities Provider Research & Identification – 40% - Identify all medical providers involved in a client’s treatment beyond the initially submitted facility. - Research billing providers and related entities using provider portals, historical requests, and direct outreach. - Accurately document and add all identified providers into internal admin systems. Request Creation & Quality Control – 35% - Review incoming Release of Information (ROI) forms and correct missing or incorrect information. - Create clean, accurate base forms prior to generating submission packets. - Perform detailed QA checks to ensure provider-specific compliance and completeness. Request Assignment & Workflow Coordination – 15% - Assign requests to appropriate records team members based on workload and utilization. - Ensure smooth handoff to downstream teams with clear and complete documentation. Edge Case Management & Escalation – 10% - Identify non-standard provider requirements and escalate issues appropriately. - Resolve conflicting or missing information through coordination with law firm case managers and internal teams.
Medical Records Retrieval Specialist - A289
PearlPearl provides tools for overqualified and overlooked jobseekers. Come find your next opportunity.
Work Arrangement: Fully Remote Job Type: Independent Contractor, Full-time Work Schedule: US time zone - 40 hours per week (9:00 AM – 5:00 PM CST) Locations: - Philippines - LATAM: Mexico City (Mexico), Bogotá (Colombia), São Paulo (Brazil), Buenos Aires (Argentina), CMDX (Mexico), Santo Domingo (Dominican Republic), Caracas (Venezuela) About Pearl Talent Pearl works with the top 1% of candidates from around the world and connects them with the best startups in the US and EU. Our clients have raised over $5B in aggregate and are backed by companies like OpenAI, a16z, and Founders Fund. They’re looking for the sharpest, hungriest candidates who they can consistently promote and work with over many years. Candidates we’ve hired have been flown out to the US and EU to work with their clients, and even promoted to roles that match folks onshore in the US. Hear why we exist, what we believe in, and who we’re building for: WATCH HERE Why Work with Us? At Pearl, we’re not just another recruiting firm—we connect you with exceptional opportunities to work alongside visionary US and EU founders. Our focus is on placing you in roles where you can grow, be challenged, and build long-term, meaningful careers. About the Company Our client is a healthcare operations platform that supports law firms by enabling fast, accurate, and compliant medical records retrieval. The company operates at the intersection of healthcare and legal services, helping improve operational efficiency, provider compliance, and client satisfaction through structured processes and high-quality execution. Role Overview The Medical Records Retrieval Specialist plays a critical role as the first step in the medical records request lifecycle. This position is responsible for ensuring that every request is complete, accurate, and compliant before moving downstream. The role requires strong attention to detail, experience with legal medical records requests, and the ability to resolve ambiguity through research and proactive communication. This is an execution-heavy, process-driven role with direct impact on retrieval speed and service quality. Candidates who thrive here are highly organized, precise, and comfortable working in detail-intensive environments. Your Impact: You will directly influence the speed and accuracy of medical records retrieval by ensuring requests are correctly prepared from the start. Your work will reduce provider rejections, minimize downstream rework, and improve overall turnaround times. You will contribute to higher client satisfaction by maintaining compliance and documentation quality. Your attention to detail and proactive issue resolution will help scale operations while maintaining high accuracy standards. Core Responsibilities Provider Research & Identification – 40% - Identify all medical providers involved in a client’s treatment beyond the initially submitted facility. - Research billing providers and related entities using provider portals, historical requests, and direct outreach. - Accurately document and add all identified providers into internal admin systems. Request Creation & Quality Control – 35% - Review incoming Release of Information (ROI) forms and correct missing or incorrect information. - Create clean, accurate base forms prior to generating submission packets. - Perform detailed QA checks to ensure provider-specific compliance and completeness. Request Assignment & Workflow Coordination – 15% - Assign requests to appropriate records team members based on workload and utilization. - Ensure smooth handoff to downstream teams with clear and complete documentation. Edge Case Management & Escalation – 10% - Identify non-standard provider requirements and escalate issues appropriately. - Resolve conflicting or missing information through coordination with law firm case managers and internal teams.

