• 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 • Performs 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, and correct coding for claims/operations • Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement • Documents medical rationale to justify payment or denial of services and/or supplies • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines • Participates in quality control activities in support of the corporate and team-based objectives • Provides guidance, direction, and input as needed to LPN team members • Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback • Assists with special projects and specialty duties/responsibilities as assigned by Management

Role Description The Care Plan Reviewer (Clinical Case Manager BH) utilizes advanced clinical judgment and critical thinking skills to support appropriate member behavioral healthcare through review of assessment and care planning documentation and consultation with care coordinators to support psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. Responsibilities include: - Be clinically and culturally competent/responsive with training and experience necessary to provide clinical consultation for members' complex needs across child-serving systems. - Assessment of Member’s Child and Family-Centered Care Plans and Crisis and Safety Plan: - Review assessments of member's needs and determine approach to meeting needs by evaluating comprehensiveness of member's Child and Family-Centered Care Plans. - Apply clinical judgment to incorporate strategies designed to reduce risk factors and address complex clinical indicators impacting care planning and resolution of member issues. - Review crisis and safety plans for members experiencing a behavioral health need to support appropriate individualized trauma-informed interventions and de-escalation strategies. - Enhancement of Medical Appropriateness and Quality of Care: - Application and/or interpretation of applicable criteria and clinical guidelines, policies, procedures, and regulatory standards while completing reviews and prior approvals to assess member's needs to ensure timely administration of benefits. - Consult with supervisors, Medical Directors, and/or other programs to overcome barriers to meeting goals and objectives; present cases at case conferences to obtain multidisciplinary views to achieve optimal outcomes. - Identify and escalate quality of care issues through established channels. - Ability to speak to medical and behavioral health professionals to influence appropriate member care. - Utilize motivational interviewing skills to provide coaching to care coordination staff and supervisors to support the child and family-centered care planning process consistent with System of Care Principles and High-Fidelity Wraparound practice. - Provide coaching, information, and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. - Analyze all utilization, self-report, and clinical data available to consolidate information and begin to identify comprehensive member needs. Qualifications - Unencumbered Behavioral Health clinical license in Ohio is required (LMFT, LSW, LPC). - 2+ years of experience in children's mental health, child welfare, developmental disabilities, juvenile justice, or a human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers. - Experience in one or more of the following areas of expertise: family systems, community systems and resources, case management, child and family counseling/therapy, child protection, or child development. - 1+ year(s) of experience with personal computers, keyboard, multi-systems navigation, and MS Office Suite applications. - Willing and able to travel in-state up to 10% of the time with a personal vehicle. Preferred Qualifications - LPCC, IMFT, LISW licenses are preferred. - 3+ years of direct clinical practice experience post-Master's degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility. - Managed care/utilization review experience. - Case management and discharge planning experience. Education - Minimum of a Master's degree in Counseling, Social Work, or Marriage and Family Therapy is required. Anticipated Weekly Hours - 40 Time Type - Full time Pay Range The typical pay range for this role is: $60,522.00 - $129,615.00. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography, and other relevant factors. This position is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range listed above. Benefits This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include: - Medical, dental, and vision coverage - Paid time off - Retirement savings options - Wellness programs - Other resources, based on eligibility Additional details about available benefits are provided during the application process and on Benefits Moments.

Role Description SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse. We are looking to add a Nurse Reviewer to our SGS team of talented professionals. What you'll do: - Conduct medical record reviews and apply sound clinical judgment to claim payment decisions. - Perform additional research on medical claims data and other sources of information to identify problems. - Review sophisticated data model output and utilize a variety of tools to detect potential fraud. - Support ongoing fraud investigations and requests for information. - Identify and develop cases for future administrative action, including referral to law enforcement, education, and overpayment recovery. - Work with external agencies to develop cases and corrective actions. - Respond to requests for data and support. - Present issues of concern, citing regulatory violations and alleging schemes to defraud the Government. - Research regulations and cite violations. - Conduct self-directed research to uncover problems in Medicaid payments made to institutional and non-institutional providers. - Make claim payment decisions based on clinical knowledge. - Telework available in the contiguous United States. Qualifications - 7 years with AS/AA; 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD. - Proven experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity. - Current nursing license. - Strong investigative skills. - Strong communication and organization skills. - Ability to apply Federal, State and Managed Care Organization (MCO) regulations to claims under review. - Strong PC knowledge and skills. - US citizenship required. Requirements - Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases. - Experience involving review of services performed for Medicaid. - Have a CPC (Certified Professional Coder) certificate. Essential Functions - This position may require the incumbent to appear in court to testify to work findings. - Ability to compose correspondence, reports, and referral summary letters. - Ability to communicate effectively, internally and externally. - Ability to handle confidential material. - Ability to report work activity on a timely basis. - Ability to work independently and as a member of a team to deliver high quality work. - Ability to attend meetings, training, and conferences; overnight travel required. Benefits - Target Salary Range: $66,000 - $106,000. - Salary determined by various factors, including but not limited to, the scope and responsibilities of the position, the individual’s experience, education, knowledge, skills, and competencies, as well as geographic location and business and contract considerations. - Employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay. EEO EEO: Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.

Role Description The Clinical Preservice/Clinical Appeals Reviewer is responsible for performing MassHealth LTSS pre-service clinical coverage reviews and determinations and clinically appropriate appeal hearing representation. The Preservice Reviewer/ Clinical Appeals is responsible for attending appeal hearings, defending MassHealth LTSS prior authorization determinations. This position collaborates closely with managers and peers. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Assesses the appropriateness of services when adjudicating prior authorizations based on submitted documentation, benefit plan, MassHealth policies and medical necessity guidelines, program requirements, and standards of care. - Identifies solutions to non-standard requests and problems. - Participates in regular meetings with leadership and team members to support collaboration and ensure operational efficiency and team alignment. - Maintains performance in accordance with established quality standards, evidence-based guidelines, departmental benchmarks, and operational workflows. - Adjudicates prior authorizations in a timely manner, ensuring completion ahead of Cornelius due dates to ensure compliance with the Interoperability Rule. - Promotes consistency and accuracy in clinical decision-making by applying medical necessity guidelines and program standards across cases and programs. - Engages, coordinates, and provides education to LTSS providers on prior authorization requirements and medical necessity guidelines to support clinical decision making. - Provides clinical mentorship and guidance to support junior reviewer development. - Acts as an SME for specific service lines or programs, providing specialized expertise. - Supports cross-functional programs and workstream initiatives. - Adheres to their approved assigned schedule and participates in overtime coverage as required by program needs. - Responds to and assists with support of inquiries and escalations. - Effectively manages and prioritizes workload to meet quality and productivity goals. - Performs additional duties and provides coverage assigned by management. Clinical & Regulatory Responsibilities - Maintains compliance with MassHealth clinical guidelines, regulatory requirements (CMS and applicable state and federal regulations), and program policies. - Works with internal stakeholders (e.g., Medical Directors, Team Leads, Program Managers) to support the clinical coverage review process and elevates complex or high-risk cases to clinical leadership. - Identifies and reports on utilization trends, including potential overuse or underuse of services. - Supports audit, regulatory, and accreditation activities to maintain compliance and program integrity. - Prepares and presents cases for discussion during weekly clinical case rounds. Appeals Responsibilities - Ensures the appeals process is executed in compliance with regulatory and business unit standards, including scheduling appeals for designated PA appeals staff. - Acts as a liaison between the OLTSS and the BOH, fostering collaboration and effective communication. - Attends BOH proceedings for high-profile or complex appeal cases as needed. - Coordinates appeals activities with the applicable LTSS Program Manager. - Provides support for prehearing conferences through planning and collaboration. - Oversees quality assurance for the Appeals team, ensuring consistency and adherence to standards. - Analyzes trends within appeals and recommends policy enhancements in response to identified patterns impacting PA appeals. Documentation & Quality Assurance - Maintains clear, accurate, and defensible documentation in all prior authorization determinations and corresponding decision letters in accordance with MassHealth guidelines as well as state regulations and federal regulations. - Participates in internal and external quality audits as needed. - Drives improvement in individual quality performance and productivity metrics through ongoing monitoring and analysis. - Ensures prior authorizations are adjudicated ahead of the Cornelius due date to remain in compliance with the CMS Interoperability Rule. - Maintains a PA audit score of at least 90%. - Demonstrates proficiency by earning a minimum score of 75% on the IRR Assessment. - Performs all assigned duties in compliance with SLA and contractual requirements. Communication & Provider Collaboration - Communicates determinations clearly and professionally. - Engages in provider outreach as needed to support prior authorization determinations. - Educates providers on prior authorization and medical necessity criteria. - Collaborates with PAUM programs and MALTSS workstreams to support program objectives as appropriate. Operational Efficiency & Process Improvement - Identifies workflow inefficiencies and recommends process improvements. - Participates in process improvement projects, including automation or system enhancements. - Supports onboarding and training of new staff as needed. - Demonstrates proficiency in clinical systems and documentation tools. - Independently resolves moderately complex issues with minimal supervision. Professional Development - Maintains current clinical knowledge through ongoing continuing education, training, and professional development. - Keeps up to date with program requirements, regulatory changes, and evolving clinical guidelines. - Stays informed on industry best practices and internal organizational processes. - Monitors updates to MassHealth policies, clinical guidelines, and authorization requirements to ensure compliance. - Participates in competency assessments and completes all required ongoing training. Qualifications - Ability to maintain current professional licensure in accordance with contractual requirements, ensuring alignment with the qualifications necessary to effectively perform assigned job duties. - Demonstrated solid written and verbal communication skills, with the ability to build relationships and collaborate effectively. - Ability to work independently and as part of a team. Requirements - *All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase. - 401k contribution (all benefits are subject to eligibility requirements). - Hourly pay for this role will range from $35.00 to $63.00 per hour based on full-time employment.