• Evaluating requests for authorization of clinical services from physician offices and/or imaging centers • Comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review • Reviewing clinical information submitted by providers and making decisions to issue a review determination • Maintaining current departmental standards related to productivity • Providing outstanding customer service ensuring callers receive the highest possible service • Assisting team members with questions and participating in team meetings

Role Description The Clinical Reviewer will be responsible for: - All clinical certification activities, which include but are not limited to evaluating telephone, fax or WEB requests for authorization of clinical services from physician offices and/or imaging centers. - Comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review as appropriate. - Understanding complex case specialties and case reviews. - Reviewing clinical information submitted by providers to appropriate criteria and standards and making decisions to issue a review determination or to refer to physician review if criteria are not met. - Maintaining current departmental standards related to productivity. - Training in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures. - Preparing program correspondence as needed. - Serving as a resource for members calling for assistance. - Making outbound calls as required. - Referring provider and member complaints, and appeals to appropriate departments. - Maintaining patient confidentiality in accordance with EviCore standards established in compliance with HIPAA and State regulations. - Providing outstanding customer service ensuring callers receive the highest possible service. - Running and analyzing reports to ensure all tasks are completed in a timely fashion and meet regulatory requirements. - Assisting team members in departmental chats, by phone and in person. - Acting as training assistant when assigned. - Assisting team members with questions and participating in team meetings. - Performing related duties as required. Essential Functions: - Must be able to sit through shift, demonstrate advanced proficiency in MS Office applications. - Excellent communication skills both verbal and written. - Excellent problem solving and customer service skills are required. - Must be self-directed and highly motivated with an ability to multi-task. - Excellent computer skills. - Must be able to hear and speak on the phone for an entire shift. Qualifications - Associates Degree in Nursing required. - Current, unrestricted license as an RN in state of primary residence. - Must have at least 1 year of acute care, managed care, ER, ICU experience or 2 years of clinical utilization management experience. - If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. Requirements - For this position, we anticipate offering an hourly rate of 31 - 52 USD / hourly, depending on relevant factors, including experience and geographic location. - This role is also anticipated to be eligible to participate in an annual bonus plan. Benefits - Comprehensive range of benefits, with a focus on supporting your whole health. - Health-related benefits including medical, vision, dental, and well-being and behavioral health programs starting on day one of employment. - 401(k), company paid life insurance, tuition reimbursement. - A minimum of 18 days of paid time off per year, paid holidays, and leaves of absence.

Title: Administrative Reviewer Location: Denver United States Salary: $6,022.00 - $9,636.00 Monthly Job Type: Full Time Job Description: About this Position: Provides independent third party review and quality improvement processes for the Division of Child Welfare (CW) and the Division of Youth Services (DYS) service delivery. These reviews and quality assurance processes include: - Administrative Reviews, - Court-ordered Substituting Administrative Reviews, - Quality Assurance Reviews (including reviews of child protection assessments and in-home service cases), - Child and Family Services Reviews - Ad-hoc reviews, and - IV-E eligibility reviews to maximize Title IV-E revenue and ensure that court orders contain federally required language. Quality Case Reviews: - Responsible for conducting periodic Administrative Reviews for children every six months they are in care, and Administrative Permanency Reviews every 12 months children are in out-of-home (foster) care per CRS 19-2906.5 and 19-3-702. This process involves collecting, analyzing, interpreting and summarizing data gathered through the file read and personal interview. Based on the data collected, a determination will be made as to the compliance or non-compliance with Federal and State regulations that govern all children and youth in the custody of the county department of human/social services or Division of Youth Services. Recommends administrative response and/or sanctions for non-compliance. - This position will also conduct reviews of child welfare assessments as well as cases involving the provision of in-home services. This position will also participate in the Child and Family Services reviews. Reviews occur in the county departments. Each Cl-II staff is assigned to a number of counties and will travel daily to these different counties in order to conduct reviews. Approximately 6-8 over-night stays may be required per month. Training and Technical Assistance: - Communicates with and influences a variety of county, region, court, State Program and other state staff in order to address case specific and systemic issues. This involves providing case specific technical assistance as well as larger trainings on systemic issues. Contact Reviewer and other duties as assigned: - Specific to assigned counties, this position is in charge of scheduling review staff to cover the assigned counties in their geographic area. This includes determining the necessary number of reviews days required by each county in order to remain in compliance with Federal requirements of timely periodic reviews, securing appropriate resources (county space, computers, etc.), communicating and altering schedules with other review staff, etc. - Training and Technical Assistance: • Communicates with and influences a variety of county, region, court, State Program and other state staff in order to address case specific and systemic issues. This involves providing case specific technical assistance as well as larger trainings on systemic issues. Contact Reviewer and other duties as assigned: • Specific to assigned counties, this position is in charge of scheduling review staff to cover the assigned counties in their geographic area. This includes determining the necessary number of reviews days required by each county in order to remain in compliance with Federal requirements of timely periodic reviews, securing appropriate resources (county space, computers, etc.), communicating and altering schedules with other review staff, etc. Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights MINIMUM QUALIFICATIONS: Experience Only: - Six (6) years of relevant experience in an occupation related to the work assigned to this position. Must have two (2) years of professional human services investigative experience conducting child and/or youth abuse and neglect investigations, provision of ongoing child protection and/or youth services, or supervision of professional social caseworkers in child protection and/or youth services. Experience must demonstrate working knowledge and experience utilizing Volume VII Regulations and the Colorado Children's Code, and Colorado child welfare processes. - AND Two (2) years of relevant experience including ongoing permanency casework and/or intake and assessment casework. OR Education and Experience: - A combination of related education and/or relevant experience in an occupation related to the work assigned equal to six (6) years. Experience must include a minimum of two (2) years of professional human services investigative experience conducting child and/or youth abuse and neglect investigations, provision of ongoing child protection and/or youth services, or supervision of professional social caseworkers in child protection and/or youth services. Experience must demonstrate working knowledge and experience utilizing Volume VII Regulations and the Colorado Children's Code, and Colorado child welfare processes - AND Two (2) years of relevant experience including ongoing permanency casework and/or intake and assessment casework. Preferred Qualifications: - Minimum of 1 year experience with Colorado Trails or other relevant SACWIS systems - Ability to read and evaluate multiple volumes of typed and/or hand-written case materials on a daily basis; and - Possess intermediate computer skills to enter information into various databases, produce reports, and email information to colleagues and others. - Strong preference will be given to candidates with 3-5 years of experience conducting child and/or youth abuse and neglect investigations, provision of ongoing child protection and/or youth services, or supervision of professional social caseworkers in child protection and/or youth services. - Strong preference will be given to candidates who possess a bachelor’s degree in any of the fields listed in the Minimum Qualifications section of this announcement. - Certified through the Child Welfare Training Academy Experience supervising child welfare caseworkers conducting assessments or on-going service delivery. - Exceptional communication skills, including demonstrated success in developing curriculum and providing training utilizing adult learning theory. Highly Desirable Knowledge, Skills, and Abilities: - Demonstrated working knowledge and understanding of federal and state law and how it applies to the administrative review process; - Knowledge and ability to provide technical expertise and training regarding the Adoption and Safety Families Act (ASFA) and federal mandates to insure that all orders issued by the courts within the district contain the federally required findings in order to maximize Title IV-E funding for children and families served by county departments and regions; - Ability to conduct reviews which may substitute for court reviews, and work directly with the county to develop and operate a combined Administrative Review 6-month periodic review process; - Ability to act as a liaison between the judicial district, county department, region, and state; - Ability to manage scheduling needs of multiple counties and multiple reviewers to ensure reviews are completed timely; - Ability to manage and resolve conflicts, confrontations, and disagreements in a positive and constructive manner to minimize negative personal impact; - Ability to derive logical conclusions from available information, utilizing a combination of judgment and formal guidance, in order to determine if departmental objectives have been met; - Ability to effectively communicate in both written and oral format to prepare and present review findings and provide technical assistance; - Ability to set and prioritize workload, identify short- and long-term goals and develop strategies to achieve them; and - Ability to negotiate to find mutually acceptable solutions, and builds consensus through give and take. Conditions of Employment: - Full background check and reference check required - This position requires State of Colorado residency at the time of application (unless otherwise identified in the posting), and residency within the state throughout the duration of employment in this position - Must possess a valid, non-restricted Colorado Driver’s License or an non-restricted U.S. Driver's License for positions within 30 miles of the CO state border - This position has hybrid work arrangements. This position has a home office with expectation of frequent travel throughout their assigned counties. - Home as Sole and Permanent Work Place - The employee's home address shall serve as their official and regular work location for employment purposes. While a portion of work will be performed from the home office, the majority of duties are expected to occur within County Departments of Human Services or other assigned county facilities, as determined by business needs. - This Compliance Investigator II position will primarily conduct reviews throughout the greater Denver Metro area, with occasional travel to rural counties and regions as needed. - A home office located within 20 miles of the Colorado Department of Human Services (CDHS) offices at 1575 Sherman Street; Denver, CO. Relocation to a home office within these parameters may be required. - Employees must maintain a home office, including reliable internet access and, if required, a phone, to perform assigned duties effectively. - Former State employees who were disciplinarily terminated or resigned in lieu of termination must: - Disclose the information on the application - Explain why the prior termination or resignation should not disqualify the applicant from the current position. - Provide you employee number from your prior State employment. Absent extraordinary circumstances, prior disciplinary termination or resignation in lieu of termination and failure to provide this information will disqualify the applicant from future State employment with CDHS.

Role Description The Medical Records Clerk Appeals Specialist oversees the managing of patient health files in a facility. Their duties include: - Filing records - Assisting in audits - Collecting information - Supplying the nursing department with appropriate documents and forms This role serves as the primary point of contact for all record requests and ensures the accurate, timely, and confidential handling of clinical documentation for clients, families, referents, legal entities, payers, and regulatory agencies. Additionally, the position supports the Utilization Review team by preparing and tracking written insurance appeals. Qualifications - Strong knowledge of HIPAA and confidentiality regulations - Familiarity with AHCA, DCF, and CARF standards - Ability to manage high volumes of requests while maintaining accuracy and timeliness - Excellent attention to detail and organizational skills - Proficiency in EHR platforms (e.g., BestNotes) and Microsoft Office Suite - Strong written and verbal communication skills - Professional discretion and ability to maintain confidentiality in all matters - Understands and maintains professional boundaries - Demonstrates an understanding of rules/limits of patient confidentiality and maintains appropriate levels of client confidentiality/privacy - Demonstrates consideration of and respect for values and cultural beliefs Requirements - High School Diploma or GED required - Associate’s or bachelor’s degree in health information management, Healthcare Administration, or related field preferred - Minimum of 2 years in medical records, health information management within a behavioral health or healthcare setting - Experience with payer appeals and electronic health record systems preferred - Valid Florida Driver’s License - Current CPR and First Aid Certification, or willingness to complete within the first 30 days of employment - Clearance of TB test Benefits - Pay rate: $20.00 to $22.00 an hour based on experience - Remote work opportunity - Monday through Friday hours: 8:30 AM to 5:00 PM