Overview Medicare Medical Review RN (Medical Reviewer III) - REMOTE The Medicare Medical Review RN (Medical Reviewer III) will primarily be responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. In addition, this position applies Medicare and Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage. In assuming this position, you will be a critical contributor to meeting CoventBridge Group's objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse. This position will report directly to the Medical Review Supervisor and will work in our Grove City, OH office. If not local, remotely from a home office. At this time, CoventBridge is not considering candidates who require visa sponsorship, currently or in the future, including but not limited to H-1B, H-2B, E-3, TN, O-1, F-1 (OPT/CPT, or J-1 Visa Statuses.) Responsibilities/ Requirements Responsibilities: - Reviews information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare or Medicaid payment policies - Utilizes extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare/Medicaid and Contractor guidelines for coverage determinations - Coordinates and compiles the written Investigative Summary Report to the PI Investigator upon completion of the records review - Incorporates leadership and communication skills to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel - Provides training to UPIC staff on medical terminology, reading medical records, and policy interpretation - Provides expert witness testimony as required - Completes assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy - Maintains chain of custody on all documents and follows all confidentiality and security guidelines - Performs other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations Requirements: - 2 years minimum experience at a government contractor (ZPIC, UPIC, RAC, MAC, etc.) - 2 years minimum working knowledge of ICS 10-CM/CPT coding experience - 4 years minimum experience of working knowledge of Diagnosis Related Groups (DRG's), Prospective Payment Systems or Part B claims and Medicare coverage guidelines - Knowledge of, and the ability to correctly identify, Medicare and Medicaid coverage guidelines - Advance knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/ quality assurance procedures, ICD 10-CM and CPT coding, Medicare coverage guidelines and payment methodologies (i.e., Correct Coding Initiative, DRG's, Prospective Payment Systems and Ambulatory Surgical center), NCPCP and other types of prescription drug claims - Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required - Should possess excellent oral and written communication skills with an ability to write professional summary reports - Knowledge of and ability to use Microsoft Word, Excel, and Internet applications - Able to efficiently organize and manage workload and assignments - Must have and maintain a valid driver' license for the associate's state of residence as onsite audits are part of the role as a nurse reviewer Educational/Experience Qualifications: - Graduate from an accredited school of nursing and have an active license as a Registered Nurse (RN) required - Preference given to BSN or higher prepared nurses with recent medical review claims experience in Medicare or Medicaid reviews Benefits - Medical, Dental, Vision plans - Life, LTD and STD paid by the employer - 401(k) with company match up to 4% - Paid Time Off and company paid holidays - Tuition assistance after 1 year of service The salary range for this role is $65,000 to $75,000 annually. This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs. Pursuant to the respective Fair Chance Ordinances of both Los Angeles and San Francisco, we will consider for employment qualified applicants with arrest and conviction records. About Us: CoventBridge Group is the global leader in full-service investigations providing Surveillance, SIU and Compliance, Claims Investigation, Counter-Fraud Programs, Desktop Investigations, Social Media, Record Retrieval, Canvasses and Vendor Management programs. The company provides top tier data privacy and security practices, deploys robust case management technology customized to clients’ needs and delivers worldwide coverage via its 1000 employees and affiliates worldwide. CoventBridge is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintains a drug-free workplace. CoventBridge is committed to the full inclusion of all qualified individuals. As part of this commitment, CoventBridge will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact: Human Resources; 888-932-7364; humanresources@coventbridge.com. https://coventbridge.com/licensing/

Anticipated End Date: 2026-03-30 Position Title: Clinical Pharmacist (Prior Authorization) Job Description: Clinical Pharmacist (Prior Authorization) Location(s): - Indianapolis, IN - Mason, OH - Louisville, KY - Atlanta, GA Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. CarelonRx is a proud member of the Elevance Health family of companies providing unparalleled level of service in pharmacy benefits. By leveraging the power of new technologies, our strong, clinical-first lens and deep pharmacy expertise, we are actively defining our innovative role in the industry. The Clinical Pharmacist (Prior Authorization) is responsible for managing the selection and utilization of pharmaceuticals and supports core clinical programs such as DUR, DIS and formulary management. How you will make an impact: - Researches and synthesizes detailed clinical data related to pharmaceuticals. - Prepares and presents therapeutic class reviews and drug monograph information to the Pharmacy and Therapeutics Committee. - May review and approve or deny coverage for pharmaceuticals (as permitted by state/federal law or state/federal program contracts) based on medical necessity criteria, and coordinates with internal stakeholders or health plan medical directors as needed. - Serves as a clinical resource to other pharmacists on areas such as prospective, inpatient and retrospective DURs and provides dosage conversion and clinical support for therapeutic interventions. - Prepares information for network physicians. Minimum Requirements: - Requires BA/BS in Pharmacy. - Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience; or any combination of education and experience, which would provide an equivalent background. - Requires a registered pharmacist. - Must possess an active unrestricted state license to practice pharmacy as a Registered Pharmacist (RPh). - For associates working within Puerto Rico who are member or patient facing either in a clinical setting or in the Best Transportation unit, a current PR health certificate and a current PR Law 300 certificate are required for this position. Preferred Qualifications, Skills, and Experiences: - Possess an active unrestricted state license to practice pharmacy as a Registered Pharmacist (RPh) in the following states: Indiana. - PharmD strongly preferred. Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US, unless they are command-sanctioned activities. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Job Level: Non-Management Exempt Workshift: Job Family: MED > Licensed/Registered Pharmacist/Pharmacy Technician Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

AHCCCS Arizona Health Care Cost Containment System Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility. AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry. Come join our dynamic and dedicated team. Claims Medical Review Consultant Division of Fee for Service Management (DFSM) Job Location: Address: 150 North 18th Avenue Phoenix, Arizona 85007 This position may offer the ability to work remotely within Arizona based upon the department's needs and continual meeting of expected performance measures. All AHCCCS Employees must reside within the state of Arizona. Posting Details: Salary: $71,032 FLSA Status: Exempt Grade: 22 Closing Date: Open until filled Job Summary: The position is responsible for monitoring, evaluating and approving or denying payment of medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review for the Fee for Service population. The position determines medical necessity based on standards of care, rules, regulations, policies and procedures governing the provision of covered services. The State of Arizona strives for a work culture that affords employees flexibility, autonomy, and trust. Across our many agencies, boards, and commissions, many State employees participate in the State’s Remote Work Program and are able to work remotely in their homes, in offices, and in hoteling spaces. All work, including remote work, should be performed within Arizona unless an exception is properly authorized in advance. Major duties and responsibilities include but are not limited to: • Performs medical claims review/adjudication using claims industry standards. Determines if a claim meets emergency criteria, medical necessity, and/or correct revenue code/CPT/HCPC coding. Also determines if the level of care and length of stay is appropriate for the AHCCCS recipient. • Prepares reports and analyzes savings and trends. Interacts with other departments/providers as needed. • Performs special projects including but not limited to research projects. Knowledge, Skills & Abilities (KSAs): Knowledge of: • Medical nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physical disabled, developmentally disabled, behavioral/mental health, and Tribal • Healthcare delivery system nationally and locally • Managed care processes • Acute nursing processes including assessment, planning, intervention, and evaluation • InterQual Criteria • CCI • Coding: CPT, HCPCS, ICD-9 • Medical Claims Review • Statistical analysis • Computer data retrieval and input • Interpretation of governmental agencies • AHCCCS Rules and Regulations • Code of Federal Regulations Skill in: • Organizational skills that result in prioritization of multiple tasks • Interpretation of rules, laws and agency policy pertaining to the AHCCCS program • Good written and communication skills • Computer skills • Utilization Review skills • Medical Claims Review skills • Producing work products with limited supervision • Effectively collaborating with people in positions of all levels • Research and analysis • Team player and can work independently Ability to: • Interpret and apply medical and claims policies • Read and interpret medical documentation • Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding • Determine appropriate hospital levels of care and lengths of stay • Respond to inquiries for UR/CPT coding decisions • Maintain data for monthly reports • Work independently with minimal supervision Selective Preference(s): Minimum: Must maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher) and 3 years of relevant healthcare experience. May require a valid Arizona Driver License for travel-related duties. Preferred: Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served. Pre-Employment Requirements: • Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency’s ability to reasonably accommodate any restrictions. • Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.) If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver’s License Requirements. All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify). Benefits: Among the many benefits of a career with the State of Arizona, there are: • 10 paid holidays per year • Paid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees) • Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child. Learn more about the Paid Parental Leave pilot program here. • Other Leaves - Bereavement, civic duty, and military. • A top-ranked retirement program with lifetime pension benefits • A robust and affordable insurance plan, including medical, dental, life, and disability insurance • Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications) • RideShare and Public Transit Subsidy • A variety of learning and career development opportunities By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion. Learn more about the Paid Parental Leave program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page Retirement: Lifetime Pension Benefit Program • Administered through the Arizona State Retirement System (ASRS) • Defined benefit plan that provides for life-long income upon retirement. • Required participation for Long-Term Disability (LTD) and ASRS Retirement plan. • Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period). Deferred Retirement Compensation Program • Voluntary participation. • Program administered through Nationwide. • Tax-deferred retirement investments through payroll deductions. Contact Us: Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov. Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.

• Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval process at first call while promoting a supportive team approach with call center staff. • Renders authorization approval based on established clinical criteria; escalates to a Field Medical Director (FMD) if authorization cannot be approved during initial review. • Reviews charts and analyzes clinical record documentation in order to approve services that meet clinical review criteria. • Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff. • Converses with medical office staff to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale, while providing optimum customer service through professional/accurate communication and maintaining NCQA and health plans required timeframes. • Documents all communication with medical office staff and/or treating provider. • Practices and maintains the principles of utilization management by adhering to policies and procedures. • Participates in on-going training programs to ensure quality performance in compliance with applicable standards and regulations, as well as, being audited to ensure guidelines are applied appropriately.