Title: QC Analytical Data Reviewer, Pharma - Remote Location: Remote Ireland Full time Remote   Discover Impactful Work: The role of Data Reviewer is to support our Laboratory teams in ensuring the integrity and quality of laboratory and chromatographic data and reports. Ensures analyses are following validated or experimental analytical procedures, and compare results to methodology, protocol and product specifications, Standard Operating Procedures (SOPs) acceptance criteria, and Good Manufacturing Practices (GMP). Reviews data entered into databases and reports and monitors the quality of the laboratory data. This is the perfect job for someone who has strong review experience and is looking to move away from hands on lab duties.   A day in the Life  - Ensures the quality of laboratory data and reports. - Reviews chromatographic data, related notebooks and sample results for scientific soundness, completeness, accuraterepresentation of the data, and final reported results. - Evaluates data to ensure compliance with analytical methods, client criteria, Good Laboratory Practices (GLP) and Good Manufacturing Practices (GMP). - Delivers review findings noting deficiencies within the analytical data orreports in a clear and concise manner - Communicates with laboratory staff to proactively address the quality of laboratory documentation. - Prepares QC statements noting deficiencies with the analytical data set or notebooks. - Reports deficiencies to the project leader for correction. - Facilitates in conversations with lab staff on best documentation practicesand addressing quality findings. - Advocates for quality and review process changes. - Identifies and supports process improvement initiatives.     Education and Experience - BSc in Science or related field required - 2+ years of QA/QC analytical experience is essential (gaining thorough knowledge of chromatography and including experience in reviewing analytical data/results) - Thorough knowledge of SOPs and Federal Regulations to include GLP and GMP - Strong verbal and written communication skills - Strong technical knowledge including an understanding of laboratory procedures, methodology and standards - Ability to independently review laboratory reports and analytical methods - Strong attention to detail - Ability to provide clear and concise feedback and/or documentation of results

Title: Licensed Physician Reviewer Location: United States Job Description: We're unique. You should be, too. We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We're different than most primary care providers. We're rapidly expanding and we need great people to join our team. The Physician Reviewer is the primary physician reviewer for Clinical Appropriateness Reviews cases in our organization. Other duties include advising other physician reviewers and attending daily calls with health plan teams and our local teams assisting with this function and coordinating care for our patients. The position will also participate in Process and Quality improvement in our developing area of Delegated Utilization Management. ESSENTIAL JOB DUTIES/RESPONSIBILITIES: - Provides Clinical Appropriateness Reviews by covering the specified territories as assigned: - Establish 2-3 cases a day for each market covered (up to 6 markets); ensures attendance on all health plan and local calls; calls in for the weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings covering the assigned territories. - Advises other physician reviewers. - Other duties as assigned and modified by manager. KNOWLEDGE, SKILLS AND ABILITIES: - Excellent analytical and deductive reasoning skills - Good judgement and problem-solving skills - Professional and effective communication skills - Strong organizational skills - Written and verbal fluency in English - Proficient in the use of Microsoft Office products such as Outlook, Excel, Word and PowerPoint EDUCATION AND EXPERIENCE CRITERIA: - Graduate from accredited Medical School with a valid, unrestricted license is required - Completion of Internal Medicine or Family Practice residency - Completion of Fellowship in Gastroenterology - Board Certification in residency area - Board Certification in Gastroenterology - Two (2) years' experience in Hospital medicine preferred - At least one (1) year of utilization review experience preferred PAY RANGE: $204,761 - $292,515 Salary The posted pay range represents the base hourly rate or base annual full-time salary for this position. Final compensation will depend on a variety of factors including but not limited to experience, education, geographic location, and other relevant factors. This position may also be eligible for a bonuses or commissions. EMPLOYEE BENEFITS We're ChenMed and we're transforming healthcare for seniors and changing America's healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We're growing rapidly as we seek to rescue more and more seniors from inadequate health care. ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people's lives every single day. Current employees, if you want to apply to our internal career site, please click HERE Current Contingent Worker please see job aid HERE to apply #LI-Remote

Role Description Seeking Registered Nurse for fully remote role to perform complex medical record and claim reviews (Standard or Program Integrity) to make coverage determinations based on applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization/practice guidelines, clinical review judgment and when appropriate, monitor for potential indicators of fraud, waste, and abuse. Provides professional assessment, planning, coordination, implementation, and reporting of complex data to support the Medical Review Accuracy Contract (MRAC). Essential Functions - Perform complex medical record and claims review in accordance with all State and Federal mandated regulations/guidelines. - Accurately enter medical review data into the medical review system. - Apply clinical review judgment, based on clinical experience when applicable and review completeness of documentation to determine if documentation supports claim as billed. - Reasonably determines appropriateness to consult a Subject Matter Expert (SME) for clarification. - When performing Program Integrity (PI) reviews, assess investigative allegations and medical review findings, and/or other claims data to determine patterns and detect potential indicators of fraud, waste and abuse (FWA). - Accurately identify additional findings in the review of evidence of potential FWA not detected by the Medical Review Contractor. - Consistently meet or exceed productivity and accuracy standards of 98% minimum IRR established by the customer and/or the Company. Qualifications - Registered Nurse, with a current unobstructed license to practice nursing in the United States. - Graduate of a Board approved Registered Nursing program. - Desired experience performing medical review for fraud, waste, and abuse (FWA) investigations. - Knowledgeable of ICD-9-CM, ICD-10, CPT-4 and HCPCS coding. - One year or more of utilizing InterQual and/or Milliman guidelines against inpatient services experience is preferred. Requirements - A Bachelor’s Degree in Nursing (BSN) or other related field is preferred. - A minimum of five (5) years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice. - A minimum of three (3) or more years’ experience in medical review for payment accuracy, particularly with Medicare Part A, Skilled Nursing Facility, and/or Home Health. - Minimum of 2 (two) years’ experience in the medical review processes of MACs, SMRC, CERT, QICs and/or BFCC-QIOs. - Experience with Medicare Part A and Medicare Part B claims. Certifications - Certification in coding highly preferred. Knowledge, Skills, Abilities, Others - Physical: Reaching at or below shoulder, Sit or Stand. - Mental: Work Review: Supervising others, Pace: Pause Control.

Role Description The Teammate is responsible for conducting thorough and accurate reviews of healthcare billing and claims documentation. - Review medical claims and billing documentation to ensure accuracy, completeness, and compliance with regulatory requirements, coding guidelines, and payer policies. - Verify the appropriateness of billed services, procedures, and diagnosis codes. - Identify potential compliance issues, including incorrect coding, unbundling, upcoding, and other billing irregularities. - Conduct audits to ensure adherence to industry regulations, such as HIPAA and CMS guidelines. - Evaluate the accuracy and adequacy of clinical documentation, ensuring it supports the billed services and complies with medical necessity guidelines. - Collaborate with healthcare providers to obtain additional information or clarification, if necessary. - Analyze claim denials and rejections, identify root causes, and recommend corrective actions to prevent future denials. - Work closely with billing and coding teams to resolve claim discrepancies and resubmit claims, if needed. - Identify potentially fraudulent activities or abuse in billing practices. - Report suspicious activities and work with internal compliance teams and external agencies to investigate and resolve fraud cases. Qualifications - High School Diploma or Equivalent required. - Experience in medical billing, claims processing, or coding within a healthcare environment, with a strong focus on third-party payer guidelines and regulations. - Related experience, 1-2 years highly preferred. - In-depth knowledge of coding systems (e.g., ICD-10-CM, CPT, HCPCS) and billing requirements across various healthcare settings. - Familiarity with billing and coding compliance regulations, such as HIPAA, CMS guidelines, and National Correct Coding Initiative (NCCI) edits. - Strong analytical skills and attention to detail, with the ability to review and interpret complex billing and coding documentation. - Proficiency in using billing software and electronic health record (EHR) systems. - Excellent communication and interpersonal skills, with the ability to collaborate effectively with internal teams, healthcare providers, and insurance companies. Requirements - Remote Work requires secure, stable, quiet, compliant work area and free of dependent care. - M-F Eastern Business Hours Required using only MGB compliant equipment. - 8:00–4:30 PM EST preferred or 8:30-5:00 EST. Benefits - Competitive base pay. - Comprehensive benefits. - Career advancement opportunities. - Differentials, premiums, and bonuses as applicable. - Recognition programs designed to celebrate your contributions and support your professional growth.