Title: Clinical Reviewer, Inpatient RN Location: Remote Worker Home Office (MA) Job Description: Who We Are Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health. Job Summary The Clinical Reviewer, Inpatient RN, is a licensed professional that is expected to function independently in his/her role and is responsible for managing clinically complex caseload of members for one or more lines of business for such as the inpatient settings; acute, subacute, acute rehabilitation, LTAC (Long-Term Acute Care). . The Clinical Reviewer, Inpatient RN is responsible for making the determination of medical necessity and, therefore, benefit coverage for multiple products / lines of business, such as Commercial (FI, SI, and exchange products), state specific Medicaid programs, or Federal programs or in and out of area. The Clinical Reviewer, Inpatient RN is expected to demonstrate the ability to work collaboratively within a team environment. The Clinical Reviewer, Inpatient RN will be expected to demonstrate clinical judgement and health plan business knowledge in their decision-making processes, on behalf of the health plan. A working understanding of departmental workflows, policies, and procedures, and understanding of the corporate business goals and objectives. Accountability for outcome measures is critical to the Clinical Reviewer, Inpatient RN’s success in this role. Provides timely, clinically appropriate, and cost-effective utilization management and discharge planning activities for Point32Health members receiving services at her / his assigned facilities and may be required to float to provide coverage at unassigned facilities. Inpatient management functions include but are not limited to; application of clinically relevant criteria sets to determine medical necessity, level of care and/or readiness for transition to a lesser level of care setting. The Clinical Reviewer, Inpatient RN will develop effective working relationships with providers to facilitate the transition of the member through their continuum of care following department work processes and policies. The Clinical Reviewer, Inpatient RN will be expected to have direct experience with evidence based clinical criteria sets (such as InterQual or MNGs), Point32Health proprietary Medical Necessity Guidelines and product specific payment policies. The Clinical Reviewer, Inpatient RN may have responsibility for multiple types of service reimbursement models, depending upon the LOB (Line of Business) and/or assigned facilities contractual arrangements. Examples include but may not be limited to DRG, and/or per diem reimbursement models. The Clinical Reviewer, Inpatient RN works under the general direction of the Inpatient Manager of the team/s and the Director of the Department. Job Description Key Responsibilities/Duties – what you will be doing (top five): - Provide a range of utilization management (UM) activities for members in an inpatient setting. - Utilize industry standard / plan proprietary criteria for determining the appropriateness of the inpatient setting on an initial and concurrent review basis, both acute and post-acute (as noted above). - Determines reimbursement methodology and schedules concurrent review appropriately. - Reviews inpatient admissions, continued stays, t by fax or other electronic means for length of stay (LOS), medical necessity, discharge planning. - identifies and determines medical necessity for out of network requests. - Performs discharge planning for both acute and post-acute admissions. - Identifies complex members and refers members to case management or disease management programs based on member specific diagnoses, circumstances or psychosocial needs, and product / LOB program requirements. - s - Redirects members and providers to in network or in network preferred providers, including transition back to the Point32Health Plans service area. - Identifies potential High Risk High Needs members and presents at Consultive Rounds for inclusion of additional interventions. - May be required to conducts preauthorization of transplant requests. - Performs case documentation according to Department standards including but not limited to timely completion of daily tasks, timely management of assigned UM events and same day case data entry. - Mentor new and existing staff in process and system changes/updates - Facilitate UM/CM (Consultive Rounds. - Become subject matter expert (SME’s) to support the Inpatient Management Initiatives MedHOK, Case Trakker, Jiva, - Assist the Team Manager in day-to-day activities/assignments to the team as needed. - Develop effective and collaborative relationships with key customers: - , - With partner departments in / across Point32Health to coordinate and expedite clinical and administrative processes as needed - Prepares cases for presentation at and actively participates in weekly UM/CM Consultive Rounds. - Participates in committees or as team liaison as needed. - Maintains professional growth and development through self-directed learning activities and/or involvement in professional, civic, and community organizations. - Performs additional related duties as assigned. Qualifications – what you need to perform the job. Certification and Licensure - Registered nurse with current, unrestricted Massachusetts RN license Education - Required (minimum): Associate degree - Preferred: BSN (Bachelor of Science in Nursing) Experience (minimum years required): - Required (minimum): 3 years of clinical nursing experience; 3 years of Utilization Management experience. Skill Requirements - Strong people skills to form positive and collaborative relationships. - Effective communication skills - Strong t negotiation skills - Ability to multitask and utilize clinical judgment to identify issues and escalate accordingly to a Manager. - Ability to apply Evidence Based Criteria and/or P32H Medical Necessity Guidelines to support utilization management. - Ability to mentor - Ability to assume additional responsibilities such as special projects, while managing a case load, flexibility - Ability to use a laptop to accurately document utilization management activities adhering to department documentation standards. - Ability to work independently; initiative-taking and self–directed with strong time management skills. - Proficiency with or ability to learn technology for initiating and participating in web/system-based communications: online seminar, instant messaging, or others. - Proficiency with or ability to learn technology-based programs such as Microsoft Word and Excel; other programs as needed. Working Conditions and Additional Requirements fast-paced business environment that requires the balancing of multiple demands. - Must be able to exercise sound judgment and make evidence based clinical and business decisions. - Requires skill in responding to inquiries from providers. Must be able to work under normal office conditions and work from home as required. - Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations. - May be required to work additional hours beyond standard work schedule. Disclaimer The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time. Salary Range $94,136.62 -$141,204.92 Compensation & Total Rewards Overview The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law. Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes: - Medical, dental and vision coverage - Retirement plans - Paid time off - Employer-paid life and disability insurance with additional buy-up coverage options - Tuition program - Well-being benefits - Full suite of benefits to support career development, individual & family health, and financial health We welcome all All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates.

Role Description We are seeking a talented individual for a Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including: - Analyzing and responding appropriately to appeals from providers. - Reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately. - Preparing case files and case summaries for hearings. - Participating in virtual and on-site hearings. Your role in our mission includes: - Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. - Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. - Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. - Assists management with training new reviewers to include daily monitoring, mentoring, feedback, and education. - Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. - Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. - Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs. Qualifications - Active, Unrestricted RN license from the United States and in the primary home residency. - Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). - 5+ years clinical experience or 5+ years medical record coding experience required. - 3+ years utilization review experience or claims auditing required. - Working knowledge of the appeals and hearings process. - Experience using MCG or InterQual criteria preferred. - Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. - Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. - Ability to multi-task in a fast-paced production environment. Requirements - Work Location: Remote within the United States. - Travel Requirement: Up to 25% Travel for onsite hearing testimony. - Applications will be accepted through May 5, 2026. - The pay range for this position is $84,000.00 - $95,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Benefits - Generous, flexible vacation policy. - 401(k) employer match. - Comprehensive health benefits. - Educational assistance. - A variety of leadership and technical development academies to help build your skills and capabilities.

Role Description This position is responsible for processing all release of information requests in a timely and efficient manner ensuring accuracy and providing customers with the highest quality product and customer service. The associate must at all times safeguard and protect the patient's right to privacy by ensuring that only authorized individuals have access to the patient's medical information and that all releases of information are in compliance with the request, authorization, company policy, and HIPAA regulations. - Completes release of information requests including retrieving patient's medical chart and returning chart, scanning medical record accurately and correctly and transmitting daily, according to requests, established procedures, and established standards of quality and productivity. - Date stamps all requests and highlights pertinent data to facilitate processing. - Validates requests and authorizations for release of medical information according to established procedures. - Performs quality checks on all work to assure accuracy of the release, confidentiality, and proper invoicing. - Maintains equipment in excellent operating condition (inside and out). - Provides excellent customer service by being attentive and respectful; ensures understanding of customer request and follows-through as promised; and being proactive in identifying client concerns, or problems. - May receive incoming requests including opening mail, telephone inquiries, and retrieving facsimile inquiries, depending on the needs of the client. - Maintains a neat, clean, and professional personal appearance and observes the dress code established. - Maintains a clean and orderly work area, ensures that records and files are properly stored before leaving area. - Maintains working knowledge of the existing state laws and fee structure. - Works within scope of position and direction; willingly accepts assignments and is available to take on additional facilities or help out during backlogs. - Carries out responsibilities in accordance with client/site policies and procedures, including HIPAA, state/federal regulations related to operations, and labor regulations. - Maintains confidentiality, security, and standards of ethics with all information. - Works with privileged information in a conscientious manner while releasing medical records in an efficient, effective, and accurate manner. Qualifications - High School Diploma (GED) required. - A minimum of 2 years prior experience in a medical records department or like setting preferred. - Must have strong computer software experience -- general working knowledge of Microsoft Word and Excel required. - Excellent organizational skills are a must. - Must be able to type 50 wpm. - Must be able to use fax, copier, scanning machine. - Must be willing to learn new equipment and processes quickly. - Must be self-motivated, a team player. - Must have proven customer satisfaction skills. - Must be able to multi-task. Company Description Sharecare is a digital healthcare company that delivers software and tech-enabled services to stakeholders across the healthcare ecosystem to help improve care quality, drive better outcomes, and lower costs. Through its data-driven AI insights, evidence-based resources, and comprehensive platform – including benefits navigation, care management, home care resources, health information management, and more – Sharecare helps people easily and efficiently manage their healthcare and improve their well-being.

Castle Biosciences Earns "Top Workplaces USA Award" for Phoenix, Pittsburgh, and Friendswood! Learn more at www.CastleBiosciences.com Castle Biosciences Inc. is growing, and we are looking to hire a Reimbursement Specialist (Medical Records Focus) working remotely from your home office based in the USA, with a start date of May 18, 2026. Why Castle Biosciences? Exceptional Benefits Package: - Salary Range: $46,000.00 - $47,277.00. Final salary is based on Experience and Education levels. - Excellent Annual Salary + 20% Bonus Potential - 20 Accrued PTO Days Annually + 10 Paid Holidays - 401K with 100% Company Match up to 6% - 3 Health Care Plan Options + Company HSA Contribution - Company Stock Grant Upon Hire A DAY IN THE LIFE OF A Reimbursement Specialist (Medical Records Focus) This individual is responsible for resolving insurance claims for laboratory test services that require medical record documentation by requesting records from clinician offices, following up on those requests, and submitting complete medical records to payers based on their requirements, medical policy, or state laws, while providing the highest level of customer service to internal and external customers. This role spends most of its time communicating with ordering clinicians and their staff via phone, fax, and email to obtain the necessary patient medical records, analyzing received records to ensure all required documentation is included, and securing any missing information. Additional responsibilities include preparing medical record cover letters and submitting documentation to demonstrate medical necessity or compliance with medical policy criteria. When needed, this individual creates custom submission letters with arguments that support claim processing according to payer policy, state laws, or Medicare regulations, and contacts patients, physician offices, or sales to gather any remaining required information. REQUIREMENTS - High School Diploma or equivalent GED or equivalent work experience. - Two years of health insurance billing with experience in identifying and resolving claim issues for laboratory tests - Must have a working knowledge of various payers' designations of authorized representative forms - Experience handling a high volume of claims work on a daily basis (35 plus claims per day) - Must demonstrate the ability to type 35 WPM with 90% or higher accuracy. *Please see the full job description at the end of the job ad. SCHEDULE - Monday - Friday, 8:00 AM to 5:00 PM, non-exempt position, working remotely from your home office based in the USA. READY TO JOIN OUR BIOTECH TEAM? We truly appreciate your time. If this feels like the right opportunity for you, we'd love for you to complete our mobile-friendly application. We're excited to learn more about you and look forward to connecting soon! Castle Biosciences Awards and Research Developments! WORK AUTHORIZATION All candidates must be legally authorized to work in the United States. Currently, Castle Biosciences does not sponsor H-1B visas, OPT, or employment-related visas. ABOUT CASTLE BIOSCIENCES INC. At Castle, it all comes down to people. After all, disease doesn't just happen - it happens to people. We believe that disease management and treatment decisions can be better informed through a person's unique biology, which is revealed through the scientific rigor of our innovative, laboratory-developed tests. We are committed to empowering healthcare providers and patients with the goal of improved outcomes. Every employee at Castle has an impact on patient care, and we work to ensure that everyone finds their work to be both challenging and rewarding. We behave with integrity and treat our colleagues with respect and kindness. Our culture fosters an environment of trust, transparency, and collaboration. We prioritize and encourage internal growth and professional development. Castle Biosciences is an equal opportunity employer as to all protected groups, including protected veterans and individuals with disabilities. If you have a disability and you believe you need a reasonable accommodation in order to search for a job opening or to submit an online application, please e-mail ReasonableAccommodationsRequest@castlebiosciences.com. This email was created exclusively to assist disabled job seekers whose disability prevents them from being able to apply online. Only messages left for this purpose will be returned. Messages left for other purposes, such as following up on an application or technical issues not related to a disability, will not receive a response. ** No third-party recruiters, please