• Perform medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. • Document decisions using indicated protocol sets or clinical guidelines. • Provide support and review of medical claims and utilization practices. • Monitor process's timeliness in accordance with contractor standards. • Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. • Utilize allocated resources to back up review determination. • Review interdepartmental requests and medical information in a timely/effective manner to complete utilization process. • Conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. • Perform screenings/assessments and determine risk via telephone. • Review/determine eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services. • Provide education to members and their families/caregivers. • Review first level appeal and ensure utilization or claim review provides thorough documentation of each determination and basis for each. • Conduct research necessary to make thorough/accurate basis for each determination made. • Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. • Respond accurately and timely with appropriate documentation to members and providers on all rendered determinations. • Participate in quality control activities in support of the corporate and team-based objectives.

Role Description The Cardiologist, Virtual Care specializes in diseases of the heart and blood vessels. It is part of a clinical care team that focuses on outpatient medicine, continuity of care, health maintenance, and disease prevention for elderly patients. The Cardiologist, Virtual Care manages complex cardiac conditions such as: - Heart attacks - Abnormal heartbeat rhythms - Congestive heart failure The Cardiologist provides preventative techniques for dealing with potential heart-related illnesses and spends 100% of their time clinically focused on direct patient virtual care, inclusive of patient-facing time and general administrative time (charting, etc.) as it relates to direct patient care. Your direct supervisor will be the Director of Cardiology. Use your skills to make an impact: - Conduct virtual consultations with patients to diagnose and treat cardiovascular conditions - Develop and implement personalized treatment plans for patients with cardiovascular diseases - Collaborate with other healthcare professionals to provide comprehensive care to patients - Order and interpret diagnostic tests, such as ECGs and echocardiograms - Prescribe medications and therapies for cardiovascular conditions Qualifications - Current medical license in good standing - Board certification in Cardiology - 5+ years of experience in Cardiology - Proficiency in electronic medical records (EMRs) and telemedicine platforms - Familiarity with clinical guidelines for cardiovascular care - Licensure requirements of the state of jurisdiction Requirements - This role is considered patient facing and is part of Humana/Senior Bridge's Tuberculosis (TB) screening program. - If selected for this role, you will be required to be screened for TB. - Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Benefits - Competitive benefits that support whole-person well-being - Medical, dental, and vision benefits - 401(k) retirement savings plan - Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave) - Short-term and long-term disability - Life insurance - Many other opportunities Company Description CenterWell Senior Primary Care provides proactive, preventive care to seniors, including: - Wellness visits - Physical exams - Chronic condition management - Screenings - Minor injury treatment Our unique care model focuses on personalized experiences, taking time to listen, learn, and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists, and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive, and, most of all, personalized.

Role Description - Bewertung der Technischer Dokumentationen (TD-Review) von Medizinprodukten unter MDR. - Durchführung von Audits nach MDR, ISO 13485, und ggf. MDSAP. - Beurteilung von Änderungen an Produkten und QM-Systemen, SSCPs, PSURs, und Vigilanz, im Rahmen der kontinuierlichen Überwachung. - Erstellung von Auditprogrammen und Stichprobenpläne, Zuweisung von Ressourcen, Verifizierung von Anträgen, Klassifizierung, Codierung, etc. - Mitwirkung an Konformitätsbewertungsverfahren, insbesondere bei komplexen oder neuartigen Medizinprodukten. - Fachlicher Austausch mit internen und externen Experten (z. B. Klinische Experten, Risikobewerter). - Unterstützung bei Behördenanfragen, ggf. Teilnahme an Inspektionen durch ZLG, DAkkS, und SCC. - Unterstützung von internen Verbesserungsmaßnahmen. - Finale Zulassung von Medizinprodukten. Qualifications - Abgeschlossenes Studium in einem relevanten Fachbereich (z. B. Medizintechnik, Biomedizin, Ingenieurwissenschaften, Naturwissenschaften). - Mehrjährige Berufserfahrung (> 4 Jahre) in der Entwicklung, Herstellung, Prüfung oder Qualitätssicherung von aktiven oder nichtaktiven Medizinprodukten. - Idealerweise mehrjährige (>10 Jahre) Berufserfahrung als Auditor und/oder Produktbewerter bei einer Benannten Stelle für die MDR-Verordnung (EU) 2017/745. - Tiefgehende Kenntnisse der MDR, ISO 13485, ISO 14971, ISO 10993, IEC 62304, IEC 62366-1, IEC 60601, ISO 14155, MDSAP Dokumente, sowie weiterer regulatorischer Anforderungen, MDCG-Leitlinien und Produktnormen. - Anerkannte und nachweisliche Qualifikationen als Lead Auditor für MDR, ISO 13485 und idealerweise MDSAP. - Ausgeprägte Fähigkeit zur Bewertung komplexer technischer und klinischer Sachverhalte. - Fließende Deutsch- und Englischkenntnisse in Wort und Schrift. - Hohes Maß an Eigenverantwortung, Objektivität und professioneller Kommunikation. - Bereitschaft zu internationaler Reisetätigkeit (nach Bedarf).

Role Description As a Clinical Review Nurse, you won’t just review charts—you’ll write compelling clinical arguments that help hospitals recover millions in lost revenue due to denied insurance claims. You’ll use your nursing knowledge, attention to detail, and love of documentation to make a real difference—without ever setting foot in a courtroom or hospital shift. - Analyze denied insurance claims and complete medical records. - Apply clinical reasoning, national criteria (InterQual/Milliman), and best practices to determine if appeals are justified. - Draft persuasive, medically sound appeal letters that clearly support the need for treatment or services. - Collaborate with our legal team to ensure appeals are compelling and complete. - Stay informed on healthcare regulations, payer trends, and clinical updates. Qualifications - RN License (required) - 5+ years of acute hospital experience (required) - Certification in Case Management, Legal Nurse Consulting, or Coding is a plus. - Possess knowledge and experience with national clinical criteria applied in case management including InterQual and Milliman standards. - Experience and knowledge of managed care contracts, account receivables and revenue cycle functions (preferred). - Experience and success in medical record chart review and appealing managed care denials (preferred). Benefits - 100% Remote: Work from anywhere in the U.S. while making a tangible difference. - Competitive Salary: $65,000–$85,000 per year (commensurate with experience). - Robust Benefits Package: 401(k) with corporate match, comprehensive health, dental, and vision insurance. - Work-Life Balance: Flexible schedule and paid time off. - Career Growth: Access to professional development, mentorship, and upward mobility within a thriving company. - Additional Perks: Life insurance and performance-based bonuses.