• Assists in development and maintenance of an efficient UM program to meet the needs of health plan members commensurate with company values. • Perform clinical reviews (i.e., part A, B, appeals, quality of care) and conduct peer to peer discussions. • Participate in inter-rater reliability activities. • Participate in analysis of utilization data and suggest improvement opportunities. • Provide appropriate mentoring and leadership to clinical teams as well as develop relationships to support growth and fiscal responsibility. • Participate in committees and workgroups to achieve department and corporate objectives. • Provide clinical support and participate in utilization management, quality management, clinical services and care management programs to identify opportunities for improvement and efficiency. • Serves as a clinical resource and subject matter expert to both clinical and non-clinical staff throughout the Devoted Health Plan. • Active participation in acute and post acute clinical rounds. • Conduct discussions with physicians in the Devoted network regarding: medical policies, utilization management, use of resources, and quality.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Join IQVIA’s Sponsor-Dedicated FSP team and help advance healthcare through real-world evidence. In this role, you’ll work closely with one sponsor, gaining deep knowledge of their therapies while leveraging IQVIA’s global expertise. - Provides scientific and strategic leadership for RWE/Epidemiology studies - Serves as the primary lead for assigned studies or scientific workstreams - Ensures scientific rigor and operational feasibility of studies - Drives high-complexity deliverables such as protocols, publications, and analyses - May represent the sponsor in scientific discussions with vendors and external stakeholders Organizational Relationships - Reports to the sponsor’s RWE/Epidemiology Lead within their Integrated Evidence Generation (IEG) organization - Collaborates with Medical Evidence Development (MED) colleagues, CMO colleagues, Clinicians, HV&E/GAV, and other cross-functional scientific partners - Interfaces with other external vendors supporting study design and execution Responsibilities Scientific Expertise - Serves as a subject matter expert in epidemiology or related field - Provides strategic guidance on scientific approach and analytical methodologies - Leads development of scientific deliverables (e.g., study concepts, study protocols, statistical analysis plan, etc.) - Ensures quality and scientific integrity across all outputs - Conducts and oversees literature reviews - Supports real world data assessment and landscape evaluation - Responds to rapid epidemiological requests, including safety questions and information requests Study Execution Oversight - Provides input on study feasibility and resource needs - Leads scientific oversight of study execution, in collaboration with MED Evidence Generation Ops teams and external vendors - Ensures quality review and contributes to inspection/audit readiness for RWE/Epi studies - Performs/oversees code lookup and data QC tasks - Performs other relevant tasks as needed to support study execution Requirements - PhD in Epidemiology or related field preferred - Master’s with significant experience in rare exceptions - Experience designing and/or leading RWE/Epidemiology studies preferred - Experience designing study protocols, research reports, and/or publications preferred - Experience working in a matrixed, cross-functional team environment preferred Skills - Deep expertise in epidemiologic methods - Strong verbal and written communication skills - Strong organizational skills and project management capability - Ability to work effectively in a cross-functional environment - Ability to collaborate with analysts/programmers to ensure execution of analysis plans Benefits - Be part of a forward-thinking team that helps shape the next generation of evidence-based healthcare - Work hand-in-hand with one leading sponsor, gaining deep expertise in their therapies - Access IQVIA’s global network who supports your growth - This is your chance to make an impact, while building a career that matters Company Description IQVIA is a leading global provider of clinical research services, commercial insights and healthcare intelligence to the life sciences and healthcare industries. We create intelligent connections to accelerate the development and commercialization of innovative medical treatments to help improve patient outcomes and population health worldwide.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Medical Director will have program management responsibilities including: - Clinical policy development - Program development/implementation - Overseeing clinical/non-clinical activities - Utilization review/management May also be responsible for: - Developing and implementing programs to improve quality, cost, and outcomes - Providing clinical consultation and serving as clinical/strategic advisor to enhance clinical operations - Identifying cost of care opportunities - Serving as a resource to staff including Medical Director Associates - Managing an entire clinical program How you will make an impact: - Supports clinicians to ensure timely and consistent responses to members and providers - Provides guidance for clinical operational aspects of a program - Conducts peer-to-peer clinical reviews with attending physicians or other providers - May conduct peer-to-peer clinical appeal case reviews - Serves as a resource and consultant to other areas of the company - May represent the company to external entities and/or serve on internal and/or external committees - May chair company committees - Interprets medical policies and clinical guidelines - May develop and propose new medical policies based on changes in healthcare - Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes - Identifies and develops opportunities for innovation to increase effectiveness and quality Qualifications - Requires MD or DO and Board certification approved by ABMS or AOA - Must possess an active unrestricted medical license to practice medicine or a health profession - Minimum of 10 years of clinical experience; or any combination of education and experience providing an equivalent background - For Health Solutions and Carelon organizations, minimum of 5 years of experience providing health care is required - Strong oral, written, and interpersonal communication skills - Problem-solving skills, facilitation skills, and analytical skills Requirements - Must be located in a state or territory of the United States when conducting utilization review or appeals consideration - Associates in this role must follow specific policies, procedures, guidelines as stated by the Government Business Division Preferred Qualifications - Experience in managed care strongly preferred - 1-2 years utilization management review experience preferred - Clinical experience working in internal medicine or family practice strongly preferred - Knowledgeable of Medicaid/Medicare policies and guidelines strongly preferred Benefits - Market-competitive total rewards including merit increases, paid holidays, Paid Time Off, and incentive bonus programs - Medical, dental, vision, short and long term disability benefits - 401(k) + match, stock purchase plan, life insurance - Wellness programs and financial education resources

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Utilization Review Nurse will provide professional assessments and review for the medical necessity of treatment requests and plans. The standard work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Standard Time, with rotating weekend coverage as required. - Provide professional assessment and review for the medical necessity of treatment requests and plans. - Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity; and post claim or post service reviews. - Cross train and provide cross coverage as needed. - Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). - Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. - Refer requests that fall outside of established guidelines to advance review or senior care consultants. - Process appeals for non-certification of services, complete non-certification letters when appropriate. - Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. - Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs. - Complete documentation for all reviews in appropriate documentation software. - Utilize guidelines in appropriate hierarchy including MCG guidelines, internal medical policies, group specific policies, and NCCN. - Meet productivity, quality, and turnaround times daily. - Pass external audits to include URAC and NCQA. - Maintain HIPPA compliance per company’s policy and procedures. - Maintain confidentiality and minimum requirement rules. - Complete all required yearly training per company’s expected time limit. - Complete and pass all annual testing including IRRA at 90% or higher. Qualifications - Current RN license in the United States or U.S. territory. - Associate’s degree or diploma (Nursing program) required. - 1+ year clinical experience required. - Ability to perform the essential job functions safely and successfully with or without reasonable accommodation. - Ability to maintain regular, punctual attendance. - Ability to sit for 6-8 hours. - Constant use of computer keyboard and mouse; repetitive use of both hands. - Occasional to frequent twisting of neck; occasional bending of neck and at waist. Requirements - Must be able to remain in a stationary position 50% of the time. - Occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities. - Constantly operate a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc. - Frequently position self to maintain files in file cabinets. - Frequently move boxes or equipment weighing up to 25 pounds. - Must communicate information and ideas so others understand. - Must be able to observe details at close range. Benefits - Competitive base salary and benefits effective day one. - Comprehensive medical and dental through our own health solutions. - Paid Time Off—rest and recharge time is non-negotiable. - Mental health support, retirement planning, and financial protection. - Professional development with clear career progression and learning budgets. - Mission-driven culture where diverse perspectives drive real impact on people's health.