• Perform accurate and timely medical review of claims suspended for medical necessity • Initiate and/or respond to correspondence from providers or members concerning medical determinations

Role Description This isn't just a job; it's a chance to build something that matters. As Medical Reviewer, you'll be shaping the future of at-home care. You'll be a key part of the team, working to ensure each surgical dressing order is fully compliant with every CMS regulation, including regulation/policies as they are applied by MACs & UPICs. You’ll translate LCDs/Articles and MAC playbooks into checklists, fix packet defects pre-bill, and run our ADRs/appeals processes. Your Contributions - Policy → Practice - Interpret and operationalize LCD L33831 + Policy Article for surgical dressings; publish practical rules (when covered, limits, documentation phrases). - Stand up “go/no-go” criteria for collagen, alginate/fiber-gelling, foam, film, hydrocolloid; codify A-modifier (wound count) usage, KX/GA/GZ/EY, sizing, quantity/frequency math. - Pre-Bill Controls - Build a 2-gate QA (1: clinical completeness; 2: billing correctness) and pilot it on all surgical-dressing claims. - Create/upgrade templates for various outreach. - Audit & Appeals - Lead UPIC/MAC ADR responses (pre- and post-pay). - Coach internal billing team; establish a reusable appeals library with policy citations and exemplars. - Enablement & Analytics - Train customer-facing team members (30-min modules) and billers on the specific documentation that satisfies the LCD. - Define and track metrics: initial denial %, appeal win %, ADR turnaround, % packets with signed POD, top-defect Pareto. Qualifications - 3-5+ years medical-review experience at a UPIC or MAC (e.g., Safeguard Services, Qlarant, CoventBridge; Noridian, CGS, NGS, WPS, Novitas, Palmetto). - Hands-on adjudication of surgical dressings (A6021 collagen; A6196–A6199 alginate/fiber-gelling; A6209–A6215 foam; A6212–A6214 bordered foam; A6216–A6221 gauze; A6257–A6259 film). - Expert with proof-of-delivery standards, SWO requirements, frequency/sizing rules, and common denial rationales (e.g., two-cover stacking, over-frequency without rationale, DOS/POD mismatch). - Crisp, policy-anchored writing; calm under deadline; disciplined with PHI. Our Pledge for an Equitable Future At Verse Medical, our mission is to deliver equitable, hospital-quality care to everyone, regardless of their background or where they live. We can only achieve this if our own team reflects the diversity of the patients we serve. We are committed to building a workplace where everyone feels a sense of belonging, where their contributions are valued, and where they can do their best work. We embrace diversity of all kinds: race, gender, age, religion, identity, experience. We are actively working to build a more inclusive and equitable world, starting from within our own walls. We are an equal opportunity employer. We are also committed to providing a positive and accessible interview experience. If you require any accommodations to participate in our process, please contact us at recruiting@versemedical.com.

Role Description The Department of Healthcare and Family Services, Bureau of Professional and Ancillary Services is seeking to hire a motivated candidate to serve as a Prior Approval Reviewer. Under the direction of the Prior Approval and Customer Relations section manager, this position will serve as a specialized physician reviewer for the Medical Review Unit. The duties for this position may include but are not limited to: - Providing expert medical/clinical, consultative, program and policy advisory services related to specialized medical equipment and services to staff. - Convening regular meetings with staff to participate in developing, implementing and maintaining system changes or policy decisions that may impact medical services to individuals eligible for Medical Assistance. - Participating in developing medical criteria options for program coverage of durable medical equipment, supplies and other covered services. The ideal candidate will have strong communication skills, excellent team leadership skills, ability to thrive in a high volume and fast paced environment and demonstrate the ability to collaborate with team members to ensure operations are running effectively. Qualifications - Requires an Illinois license to practice medicine. Requirements - A minimum of two (2) years of experience making clinical prior approval decisions including, working with complex medical data, and familiarity with medical coding such as ICD-10CM, CPT or HCPCSs. - A minimum of two (2) years of professional experience communicating with medical providers on behalf of a payer regarding billing codes and rejection codes as well as medical terminology. - Requires two (2) years of experience working with Medical Management Information Systems (MMIS) or similar medical processing system. Benefits - Monday-Friday work schedule. - Flexible work schedules are available in many program areas. (Remote work may be an option for certain positions.) - Health, Life, Vision, and Dental Insurance. - Pension Plan. - Paid Parental Leave. - Deferred Compensation Program and other pre-tax benefit programs (Medical/Daycare). - Employees earn (12) paid Sick Days annually. - New Employees earn (10) paid Vacation Days their first year of service and can earn up to (25) paid Vacation Days annually. - Employees earn (3) paid Personal Days annually. - (13-14) paid holidays annually (based on start date). Company Description At the Illinois Department of Healthcare and Family Services (HFS), we value staff as our greatest asset. We work in a spirit of teamwork to help millions of Illinoisans access high quality healthcare and fulfill child support obligations to advance their physical, mental, and financial well-being. We provide healthcare coverage for children and adults through Medicaid and other medical programs, and we help ensure that children receive financial resources from both their parents through Child Support Services. The HFS Office of the Inspector General investigates, audits and reviews program activity to ensure the integrity of our programs is maintained. HFS is committed to promoting and preserving a workplace culture that embraces diversity, equity, and inclusion. We welcome and value employees with different backgrounds, life experiences, and talents. It is the collective sum of our individual differences that provides a broad perspective, leading to greater innovation and achievement. In recruiting for our team, we recognize the unique contributions of each applicant regardless of culture, ethnicity, race, national origin, sex, gender identity and expression, age, religion, disability, and sexual orientation. HFS is an equal opportunity employer.

Role Description The Clinical Reviewer (CR) is a specialized role that performs clinical review, typically ahead of significant project milestones (interim analysis, study closeout, submission etc.). The studies supported by the CR are often, but not exclusively, comparative safety and efficacy (Phase 3) trials with large, multi-faceted data sets. The review tasks performed by this role include both point-to-point clinical review checks and interpretive analysis such as reviewing data for submission, highlighting errors, raising queries etc. from a clinical perspective. The CR will work as an extension of the clinician/clinical scientist and will be responsible for the clinical review of one or more studies with the ability to move easily from project to project as necessary. - Ensure data readiness for important milestones including, but not limited to, interim analysis, final analysis, snapshots to support submissions, Data Monitoring Committee reviews and publications. - Review participant level data across a study in adherence with CRF Completion guidelines (CCGs) and the Data Review Plan (DRP). - Conduct point-to-point data checks (e.g. verifying the presence of a lab test that satisfies study inclusion criteria) and interpretive analysis (e.g. reviewing to identify inconsistencies in the participant’s data). - Generate queries on discrepant data and follow to resolution including escalation of issues that cannot be resolved through the query process. - Create and use data review best practices and associated data review tools to identify trends and any safety signals. - May identify protocol deviations during routine clinical review and escalation as appropriate. - Follow relevant SOPs and regulations, have an excellent understanding of and comply with applicable training requirements, constantly seeking further improvements in quality and efficiency of clinical procedures. - May liaise with data management, clinical and site management along with other members of the study team. - Attend Clinical Meetings and Study Meetings as necessary. Qualifications - Bachelor’s degree or nursing degree is preferred. - At least 7 years of clinical research experience in the pharmaceutical industry (Strong monitoring experience is a plus). - 3+ years experience of oncology experience. - Direct clinical review and query writing/resolution experience required. - Possess sufficient clinical knowledge to assess if participant data is scientifically and clinically valid. - Prior EDC experience preferred. - Proficient in reviewing large scale listings in Microsoft Excel format (filter, sort, data format (date)). - Basic understanding of how data points from different fields/CRFs interact and how data collection impacts analysis. - Ability to work independently in a virtual setting and as part of a remote team. - Ability to prioritize and adjust work priorities quickly as needed to meet deadlines (i.e. fluid, flexible work style). - Possess basic knowledge of data management including case report form design, workings of electronic edit checks, implementation of data handling conventions and interpretation of data status reports. - Good written and oral communication skills with strong attention to detail required. Requirements - Industry experience with Oncology is required. - Candidates must reside in US, or Canada with no sponsorship needs. Benefits - Company car or car allowance. - Health benefits to include Medical, Dental and Vision. - Company match 401k. - Eligibility to participate in Employee Stock Purchase Plan. - Eligibility to earn commissions/bonus based on company and individual performance. - Flexible paid time off (PTO) and sick time. Salary Range $80,600.00 - $145,000.00. The base salary range represents the anticipated low and high of the Syneos Health range for this position. Actual salary will vary based on various factors such as the candidate’s qualifications, skills, competencies, and proficiency for the role.