Role Description Under the general supervision of the Director of Quality Management, the Clinical Specialist Performance Improvement is responsible for ensuring compliance of assigned providers to federal, state, local, contractual, regulatory and best practices standards and guidelines. Principal Duties and Responsibilities: - Conducts reviews of Critical/Sentinel Events to determine if the incident meets the criteria and definitions for a critical event, critical incidents, risk events, sentinel event, or media events and is related to a practice or standard of care. - Classifies a critical event or incident as either a) sentinel event, or b) non-sentinel event. - Develops and updates the "MH-WIN Procedural Guidance Manual for Reporting Critical Incidents/Events, Sentinel Events and Death Reporting Process". - Documents and reports high profile, media-reported and urgent incidents that meet the critical incident criteria. - Develops Critical/Sentinel event face-to-face trainings for the provider network for accessing the Critical/Sentinel Event Module. - Reports ALL deaths (expected and unexpected) along with the appropriate information to MDHSS within 24 hours of knowledge. - Processes the closure of assigned deaths in the MH-WIN Module. - Provides oversight and management of Performance Improvement Projects. - Reviews investigations of records and information concerning the member including, but not limited to, the review of Individual Plans of Service (IPOS), progress notes, psychiatric evaluations, Behavior Management Plans, records of dispute resolutions, grievances and appeals, and recipient rights complaints. - Provides follow-up with providers for completion of root cause analysis or investigation; a) the findings shall include actions that will minimize the further occurrence of the sentinel event (per CMS approval and MDHHS current contractual requirement); or b) a written explanation providing the rational for not pursuing an intervention. A corrective action plan or intervention must identify: objective, measurable actions; who will implement the plan of action; a timeframe for the implementation; and how the implementation of the plan will be monitored or evaluated and submitted to DWIHN. - Maintains all materials as confidential and distributes only as necessary to perform the peer review function. - Ensures that all information related to the Critical Event is uploaded in MH-WIN using the Critical Event/Sentinel Event Module and placed into the "All Scanned Documents" tab. - Reviews Critical and Sentinel Events to include analysis and reporting of member experience and satisfaction with services provided allowing for integration with the Customer Experience process. - Works with the QI Administrator and Director to develop performance improvement targets for quality, service, and efficiency of the organization. - Implements changes targeted as systems improvement. - Measures and evaluates attainment of results. - Collaborates with other DWIHN units to ensure communication, teamwork and integration to support achievement of desired improvements. - Performs related duties as assigned. Qualifications - Knowledge of DWIHN policies, procedures and practices. - Knowledge of the principles of quality improvement. - Knowledge of Utilization Management. - Knowledge of Critical/Sentinel Event policies and procedures. - Knowledge of Quality Assurance. - Knowledge of accreditation and certification standards related to the provision of mental health, developmental disability and substance use disorder services. - Knowledge of the DWIHN provider network. - Knowledge of medical and behavioral health practices and terminology. - Knowledge of compliance standards. - Knowledge of the Medicaid screening process. - Knowledge of MDHHS policies, rules, regulations and procedures. - Computer skills. - Time management skills. - Organizational skills. - Critical thinking skills. - Teamwork skills. - Conflict Resolution skills. - Decision Making skills. - Project Management skills. - Assessment skills. - Report writing skills. - Communication skills. - Multitasking skills. - Analytical skills. - Ability to communicate orally. - Ability to communicate in writing. - Ability to work effectively with others. - Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population. - Judgement/Reasoning ability. Requirements - A Master’s Degree in Social Work, Psychology, Counseling, the Human Services, the Social Services or a related field. - Three (3) years of professional experience in behavioral healthcare including at least (2) two years of experience in a community mental health setting and two years of experience in clinical practice. - A Valid State of Michigan clinical licensure: LMSW, LPC, LLP. - Must meet credentialing qualification in at least one of the following: Qualified Mental Health Professional (QMHP), Qualified Intellectual Disabilities Professional (QIDP), Qualified Children Mental Health Professional (QCMHP). - A valid State of Michigan Driver’s License with a safe and acceptable driving record. Working Conditions - Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. - This position can work remotely with supervisory approval. - Currently this position is primarily a remote position. Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process. The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer.

Role Description The Clinical Claim Review Nurse performs claim reviews to verify correct coding and correct charges. The clinical reviewer is responsible for documenting, researching state and federal guidelines and following internal procedures to determine the viability of the claim for further review in a production environment. Employees in this position receive limited supervision within a broad framework of policies and procedures and possess a comprehensive understanding of the claim review process including clinical claim review, medical record review, and a broad knowledge of applicable processes, procedures and billing guidelines. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Perform clinical review of professional or facility claims vs. medical records to determine if the claim is supported or unsupported. - Maintain standards for productivity and accuracy, as defined by the department. - Complete analysis of billing and departmental guidelines. - Provide clear and concise clinical logic to the clients and providers when necessary. - Participate as needed in the achievement and completion of department goals. - Complete focused review of medical records to evaluate clinical course of care as applicable. - Assist with resolution of claims as needed to support negotiations and appeals process. - Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance. - Maintain appropriate documentation on all claims according to departmental guidelines and procedures. - Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work. Qualifications - Associates degree. - Active and unrestricted RN license in the state of residence. - 2+ years of clinical experience within an acute care setting. - 1+ years of experience in one of the following areas: Utilization Management, pre-authorization, claim review, appeals review, or medical record review. - Intermediate level of computer skills including proficiency in Microsoft Office, Word, Excel, Outlook, and SharePoint. Requirements - Auditing and coding certifications (CPC, COC, CIC, CPB, CPMA) or ability to obtain within 1 year of employment. - CPT & HCPCS Coding experience. - Experience working with medical terminology and coding. - Proven ability to work independently. - Experience working with plan benefit language and CMS (Medicaid and Medicare). - Strong written and verbal communication skills. - Strong organizational and critical thinking skills. Benefits - Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays. - Medical Plan options along with participation in a Health Spending Account or a Health Saving account. - Dental, Vision, Life & AD&D Insurance along with Short-term disability and Long-Term Disability coverage. - 401(k) Savings Plan, Employee Stock Purchase Plan. - Education Reimbursement. - Employee Discounts. - Employee Assistance Program. - Employee Referral Bonus Program. - Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.).

Role Description The Clinical Navigator is responsible for utilizing professional clinical skills, including the ability to foster patient relationships through empathy and clinical experience, to provide personalized, high-touch support to patients throughout their musculoskeletal care journey. The role will engage with patients and providers to provide expert, clinically relevant, evidence-based care navigation. The Clinical Navigator will manage the intake process, including telephonic outreach to engage patients with the TailorCare program and manage a series of touch points throughout the care journey as the trusted clinical advocate. Each Clinical Navigator will be assigned to a specified patient caseload in which they are responsible for managing. The touch points will uncover patient barriers and internal motivators, guiding patients from onboarding and therapy initiation to milestone celebrations, motivation, maintenance, and eventual “graduation” from the program. You’ll work collaboratively to enhance the patient experience and support patient compliance and persistence initiatives by building individual relationships with patients. As a patient educator, you will provide ongoing education and therapy support to the patient, their caregiver, clinical staff, and/or support network. Primary Responsibilities - Conduct outreach to patients eligible for TailorCare and educate them on the value of the program. - Conduct intake assessments to identify patient clinical issues and needs. - Provide health coaching throughout the journey to support adherence and compliance to their treatment plan. - Provide condition education and shared decision making with patients to identify the correct treatment plan to meet their goals. - Demonstrates empathy and effectively engages patients, creating a personalized relationship-based connection built on trust and rapport. - Utilize motivational patient interviewing tools to quickly and accurately anticipate and address patient barriers; personalize patient messaging concisely, within established time parameters, and in a way that resonates with the patient. - Communicate effectively; understand and influence patient initiation and support processes, encourage patient confidence and accountability to help patients start and stay on therapy. - Provide information to the care team and proactively reach out after the clinical decision has been made to start patients on new care pathways. - Provide continuous updates, guidance, and triaging when needed and most importantly ensuring that the patient is driving towards the right health outcomes. - Collaborate with provider teams, ancillary services and other community support programs. - Perform other duties as assigned. Qualifications - Preferred time zone(s): Mountain Standard Time or Pacific Standard Time. - Doctor of Physical Therapy, Doctor of Physiotherapy (DPTs), or Master of Physical Therapy (MPTs) required. - PT with current, unrestricted license in Georgia, Texas, and/or Colorado (Compact License preferred - You may be asked to apply for and maintain additional licenses over time). - Previous telephonic patient support environment experience, including use of an inbound/outbound call system, with seamless warm transfers. - Strong communication and written skills to a variety of audiences, and experience working with a treatment team. - Proven adaptability to changing business demands and problem solving in a fast-paced environment. - Experience in motivational patient interviewing and coaching behavior change. - Ability to work within established guardrails while maintaining personal rapport with the patient. - Self-starter with proven adaptability to changing business demands and product relevance in a fast-paced environment. - High level of comfort with technology, including Microsoft Office products, working on dual monitors, CRM, and strong typing skills are required. - 3+ years orthopedic experience. Skills - Previous telephonic patient support environment experience, including use of an inbound/outbound call system, with seamless warm transfers. - Previous experience with remote/telemedicine care delivery. Location This role is 100% remote, but preferred home location in Mountain Standard Time or Pacific Standard Time. Benefits - Meaningful Work: We are dedicated to our mission and deeply value our patients and each other. Each day offers the opportunity to make a positive impact. - Work Environment: We operate as a remote-first company with options for a hybrid work model in Nashville. - Time Off: Our generous paid time off (PTO) and holiday plans ensure you have ample time to rest and recharge. - Family First: We offer paid parental leave and support a healthy work-life balance, encouraging flexibility and autonomy. We love talking about our family and pets! - Comprehensive Benefits: From Day 1, employees enjoy medical, dental, vision, life, and disability insurance, wellness resources and an employer HSA contribution. - Fair Compensation: We are committed to equitable pay for all team members and support your future goals with a 401k plan that includes employer matching. - Community: We foster an inclusive environment where you can rely on your teammates, share honest feedback, and feel comfortable being your authentic self at work each day. TailorCare seeks to recruit and retain staff from diverse backgrounds and encourages qualified candidates to apply. TailorCare is an equal opportunity employer and does not discriminate on the basis of age, sex, gender identity/expression, sexual orientation, color, race, creed, national origin, ancestry, religion, marital status, political belief, physical or mental disability, pregnancy, military, or veteran status.

• Oversee day‑to‑day clinical operations to ensure delivery according to protocol, SOPs, ICH/GCP, and regulatory requirements • Serve as the primary operational contact for Sponsors, providing updates, managing expectations, and ensuring high‑quality study execution • Lead and support CRAs, including training, supervision, performance oversight, co‑monitoring, and review/approval of monitoring visit reports • Ensure site and country performance through proactive review of monitoring activities, protocol deviations, data listings, recruitment progress, and issue escalation • Maintain oversight of study documentation, including TMF quality, CTMS accuracy, monitoring plans, training plans, and study‑specific materials • Collaborate with the Project Manager on study planning, investigator payments, resource allocation, study communications, and revenue forecasting • Contribute to study meetings, Investigator Meetings, feasibility assessments, and, when required, local project management, CRA support, and bid defense activities