• Apply specialized, clinical knowledge of hospital partners: categorize, code, summarize, interpret and calculate registry/case information from nuanced, patient medical records. • Ensure quality submission of all data in specified registries or measure data repositories, maintaining a high accuracy threshold. • Prioritize, organize, and meet tight deadlines for multiple concurrent tasks and team requests; uses tact and judgment to manage expectations, flag obstacles, and propose solutions in a timely manner. • Navigate new technical systems: electronic medical records (EMR) and registry/case entry tools; use team resources to troubleshoot technical issues with systems and applications with a focus on solutions. • Contribute to team best practices, data dictionaries, abstraction guidelines, and other business rule documents; identifies process improvement opportunities to help streamline tasks and processes. • Keeps up to date on mandated regulatory/publicly reported data requirements as specified by federal, state, payer, and other agencies. • Any or other additional responsibilities as assigned

Role Description Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Location: This position is full-time (40 hours/week) Monday through Friday in a typical office environment. This role is remote position for South Carolina, Georgia, North Carolina or Alabama. What You'll Do: - Perform medical claim reviews for one or more of the following: - Claims for medically complex services - Services that require preauthorization/predetermination - Requests for appeal or reconsideration - Referrals for potential fraud and/or abuse - Correct coding for claims/operations - Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. - Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. - Monitor process’s timeliness in accordance with contractor standards. - Document medical rationale to justify payment or denial of services and/or supplies. - Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. - Participate in quality control activities in support of the corporate and team-based objectives. - Provide guidance, direction, and input as needed to LPN team members. - Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback. - Assist with special projects and specialty duties/responsibilities as assigned by management. Qualifications - Associate's in a job related field - Graduate of Accredited School of Nursing. - Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). - 2 years clinical experience. - Working knowledge of word processing software. - Ability to work independently, prioritize effectively, and make sound decisions. - Good judgment skills. - Demonstrated customer service and organizational skills. - Demonstrated oral and written communication skills. - Analytical or critical thinking skills. - Ability to handle confidential or sensitive information with discretion. - Microsoft Office. Benefits - 401(k) retirement savings plan with company match - Subsidized health plans, dental and vision coverage - Life insurance - Paid Time Off (PTO) - Nine paid holidays - On-site cafeterias and fitness centers in significant locations - Wellness programs and a healthy lifestyle premium discount - Tuition assistance - Service Recognition Company Description We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

Role Description This position is responsible for processing all release of information (ROI) requests in a timely, efficient, and accurate manner while delivering exceptional customer service. The Associate must safeguard patient privacy at all times by ensuring that only authorized individuals access medical records, and that all information is released in accordance with the request, applicable authorization, company policies, and HIPAA regulations. This role also provides support to team members and management by serving as a subject matter expert, trainer, and escalation point. The Lead plays a key role in ensuring high-quality output and operational consistency by mentoring colleagues, assisting with work assignments, and monitoring quality and productivity metrics. Essential Functions - Processes ROI requests from facilities timely, accurately, and in accordance with established procedures and quality standards. - Validates requests and authorizations for medical record releases based on company policy and legal guidelines. - Performs quality checks to ensure accuracy, confidentiality, and correct billing of all released records. - Maintains equipment in excellent working condition. - Delivers outstanding customer service by being attentive, respectful, and responsive to client needs proactively identifying and resolving concerns. - Maintains a clean, professional appearance and complies with the company dress code. - Maintains up-to-date knowledge of applicable state laws and fee structures. - Works within assigned scope and is flexible in accepting additional assignments or account coverage during backlogs. - Complies with client site policies and procedures, including HIPAA, state/federal regulations, and labor laws. - Handles confidential information with integrity and professionalism while ensuring efficient, accurate record release. - Provides onboarding and training services for new employees. - Supports customer service by managing escalations and resolving issues. - Communicates regularly with supervisors and managers regarding quality, client concerns, or system issues. - Assists with administrative tasks such as queue management and work assignments. - Produces reports and metrics as requested. Qualifications - High School Diploma (GED) required; degree preferred. - Minimum 3 years' ROI fulfillment experience with Sharecare HDS or 4 years of external ROI experience required. - Advanced knowledge of multiple EMR platforms and ROI request types. - Strong organizational and multitasking skills essential. - Proficiency in Microsoft Office applications. - Strong documentation, communication, and customer service skills. - Demonstrated ability to manage time effectively and meet task deadlines. - Willingness to learn programs and processes quickly. - Self-motivated, dependable, and able to work independently or as part of a team. - Proven ability to maintain productivity, utilization, and quality performance standards. - Strong interpersonal and problem-solving skills. - Serve as the Subject Matter Expert (SME) for assigned customer accounts, demonstrating strong skills in documentation, communication, and organization. - Demonstrates strong leadership abilities. - Ability to assist with onboarding and training of new employees. - Ability to monitor production, utilization, and quality of employees. - Ability to assist with adhering to customer SLAs, including turnaround time (TAT). Physical Requirements - Ability to sit or stand for extended periods. - Physical ability to lift and carry up to 25 lbs. - Manual dexterity is sufficient for long periods typing, writing, and handling documents. - Visual acuity to read documents and use a computer monitor. - Clear speaking and hearing ability for communication. - Adequate hand-eye coordination and sensory abilities for job-related tasks. Information Governance Accountabilities - Understand the organization's information governance program and the role's responsibilities. - Participate in required education and compliance training. HIPAA/Compliance - Maintain the confidentiality of patient and client information. - Comply with HIPAA standards and all relevant corporate integrity and security obligations. - Report any unethical, fraudulent, or illegal behavior. - Maintain current HIPAA certification annually.

Physician Clinical Reviewer - Rheumatology- REMOTE locations Home time type Part time job requisition id R-16265 Job Posting Title Physician Clinical Reviewer - Rheumatology- REMOTE Job Description Key member of the utilization management team, and provides timely medical review of service requests that do not initially meet the applicable medical necessity guidelines. Routinely interacts with physicians, leadership and management staff, other Physician Clinical Reviewers (PCR), and health plan membersand staff whenever a physician`s input is needed or required.   Responsibilities Physician Clinical Reviewer – Job Description Responsibilities - Reviews cases in which clinical determinations cannot be made by the Initial Clinical Reviewer. - Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory time frame of the request by phone or fax. - Provides clinical rationale for standard and expedited appeals. - Provides assistance and acts as a resource to Initial Clinical Reviewers as needed to discuss cases and problems. - Utilizes medical/clinical review guidelines and parameters to assure consistency in the physician review process so as to reflect appropriate utilization and compliance with Prime's policies/procedures, as well as URAC and NCQA guidelines. - Ensures documentation of all communications with medical office staff and/or physician/provider is recorded in a timely and accurate manner. - Participates in on-going inter-rater reliability training and testing - Assists the Medical Director and/or VP, Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines, and/or system support. - On a requested basis, reviews appeal cases and/or attends hearings for discussion of utilization management decisions. - On a requested basis, may function as Medical Director for select health plans or regions, assuming overall accountability for utilization management while working in conjunction with the VP, Medical Director - Other duties as assigned.   Education & Experience - Education Level - DO - MBBS - MD - Required - Yes - Yes - Yes - Fields of Study - Experience Level - 5+ years - Required - Yes - Details - Clinical Must be eligible to work in the United States without the need for work visa or residency sponsorship. Additional Qualifications Preferred Qualifications Physical Demands - Must be able to remain in a stationary position 50% of the time. Must be able to "move or traverse" - Must be able to constantly operate a computer and/or other office productivity equipment - Must be able to hear and constantly communicate information and ideas. Must be able to exchange accurate information - Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures. Potential pay for this position ranges from $90.87 - $154.33 based on experience and skills.