Title: RN Oasis Reviewer - Home Health Care - Part Time (4 days per week!) Location: Location: Marlton, New Jersey Job Description: At Virtua Health, we exist for one reason to better serve you. That means being here for you in all the moments that matter, striving each day to connect you to the care you need. Whether that's wellness and prevention, experienced specialists, life-changing care, or something in-between we are your partner in health devoted to building a healthier community. If you live or work in South Jersey, exceptional care is all around. Our medical and surgical experts are among the best in the country. We assembled more than 14,000 colleagues, including over 2,850 skilled and compassionate doctors, physician assistants, and nurse practitioners equipped with the latest technologies, treatments, and techniques to provide exceptional care close to home. A Magnet-recognized health system ranked by U.S. News and World Report, we've received multiple awards for quality, safety, and outstanding work environment. In addition to five hospitals, seven emergency departments, seven urgent care centers, and more than 280 other locations, we're committed to the well-being of the community. That means bringing life-changing resources and health services directly into our communities through our Eat Well food access program, telehealth, home health, rehabilitation, mobile screenings, paramedic programs, and convenient online scheduling. We're also affiliated with Penn Medicine for cancer and neurosciences, and the Children's Hospital of Philadelphia for pediatrics. Location: Lippincott - 301 Lippincott Drive Remote Type: On-Site Employment Type: Employee Employment Classification: Regular Time Type: Part-time Work Shift: 1st Shift (United States of America) Total Weekly Hours: 32 Additional Locations: Job Information: - Location: In-Person, Marlton NJ - Hours: Part Time, 32 hours per week (4 days per week, 8:00a - 4:30p.) - Schedule: Mon, Tues, Thurs, Fri - Weekends/Holidays: Every 6th weekend, 1 holiday per year. - Required Experience: Home Health Care experience. - Preferred Experience: Coding experience; Oasis experience. - JNESO union Summary: Responsible for assessing, diagnosing, planning, implementing, and evaluating patient care through outcome identification and evidence based - practice for the patient in their homes. Coordinates patient care and communicates and collaborates extensively with other members of the healthcare team, patients, patient families and significant others to develop the plan of care. Supervises the Home Health Aide in the home. Promotes delivery of quality care and efficient utilization of agency resources. Position Responsibilities: Conducts comprehensive patient assessments incorporating psychosocial and physiological status as well as health behaviors, compliance with therapeutic regime and technical procedures. Coordinates plan of treatment with the physician through timely and appropriate communication with the physician. Administers, monitors, and documents therapeutic interventions and regimes. Demonstrates complete knowledge of established standards for documentation, use of point of service devise, and time frames for completion. Educates patient and family / significant other regarding disease process, individual care needs, wellness, medications, safety issues, etc. Collaborates with other members of the healthcare team to establish the plan of care. Maintains standard precautions and patient safety principles. Identifies and participates in performance improvement activities. Maintains professional and departmental level competencies. Position Qualifications Required / Experience Required: Must have a valid NJ RN License. Approved licenses must be presented and maintained in accordance with the State of New Jersey Licensing Board. 1 - 2 years recent work experience in a hospital i.e. Med/Surg, E.R., OB/GYN, Peds, MICU, CCU or other specialty units and/or one-year recent community health experience. Broad knowledge of nursing practice and ability to apply specific skills in the home health setting. Required Education: Baccalaureate Degree preferred. Hourly Rate: $44.57 - $60.44 The actual salary/rate will vary based on applicants experience as well as internal equity and alignment with market data. Virtua offers a comprehensive package of benefits for full-time and part-time colleagues, including, but not limited to: medical/prescription, dental and vision insurance; health and dependent care flexible spending accounts; 403(b) (401(k) subject to collective bargaining agreement); paid time off, paid sick leave as provided under state and local paid sick leave laws, short-term disability and optional long-term disability, colleague and dependent life insurance and supplemental life and AD&D insurance; tuition assistance, and an employee assistance program that includes free counseling sessions. Eligibility for benefits is governed by the applicable plan documents and policies.

• 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.