ChenMedLicensed Physician Reviewer-GI (remote) ChenMedLicensed Physician Reviewer-GI (remote)Miami, FLRemote$204,761–$292,515Other duties include advising other physician reviewers and attending daily calls with health plan teams and our local teams assisting with this function and coordinating care for our patients. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow.
Aspire Health PartnersNewUTILIZATION REV SPEC I Aspire Health PartnersUTILIZATION REV SPEC IORLANDO, FLWe are currently seeking a Utilization Review Specialist to join our team and play a key role in ensuring our clients receive the care they need while supporting effective coordination with insurance providers. You’ll work closely with clinical teams, insurance representatives, and internal departments to ensure timely authorizations, support treatment planning, and contribute to high-quality patient outcomes.
CVS Health CorpPrior Authorization Clinical Reviewer CVS Health CorpPrior Authorization Clinical ReviewerFL$26.01–$74.78 / yearApplication of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
TriWest Healthcare AllianceUtilization Clinical Reviewer TriWest Healthcare AllianceUtilization Clinical ReviewerTampa, FLRemoteFull timeApplies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources.
Florida Cancer AffiliatesInsurance Reviewer Clinical Florida Cancer AffiliatesInsurance Reviewer ClinicalOcala, FloridaWhile performing the duties of this job, the employee is required to be present at the employee site during regularly scheduled business hours and regularly required to sit or stand and talk or hear. COMPETENCIES: -Uses Technical and Functional Experience: Possesses up to date knowledge of the profession and industry; is regarded as an expert in the technical/functional area; accesses and uses other expert resources when appropriate.
TriWest Healthcare AllianceClinical Quality Reviewer TriWest Healthcare AllianceClinical Quality ReviewerTampa, FLRemoteFull timeo Bachelor's in Nursing or Certified Professional in Healthcare Quality (CPHQ) o 1 or more years team lead or supervisory experience o 1 year experience in Quality Management o 1 year experience with data analysis and reporting o Experience with InterQual or similar criteria sets o General knowledge of Medicare, Veterans Administration, or other government health care programs. Technical Skills: General knowledge of Medicare, Veterans Administration, or other government health care programs; knowledge in the application of clinical criteria: InterQual, Milliman, PAS-LOS, ICD-9-CM, DSM, CPT-4, and HCPCs; Proficient with Microsoft Word and Excel.
Gainwell Technologies LLCDRG Nurse Reviewer Appeals and Hearings- Remote Gainwell Technologies LLCDRG Nurse Reviewer Appeals and Hearings- RemoteFLRemote$90,000–$99,000 / yearWe are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings. We are looking for: Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required.
ICBDMedical Records Reviewer ICBDMedical Records ReviewerLauderdale Lakes, FL$55,000–$70,000Exact Billing Solutions contributes heavily to the success of the broader ICBD family office ecosystem and benefits from the recognition awarded to other portfolio companies, including: Inc. 5000, 2024 – Top 5 Fastest-Growing Private Companies in America (ABA Centers of America) . With firsthand knowledge of how inefficiencies in revenue cycle management drain resources from patient care, our founder built a company dedicated to removing obstacles, accelerating cash flow, and delivering peace of mind to clients across specialties.
AdventHealthSecond Level Reviewer I AdventHealthSecond Level Reviewer IAltamonte Springs, FL$66,170.74–$123,073.07 / yearThe expertise and experiences you'll need to succeed: Qualification Requirements: • Bachelors of Nursing (Required) • Masters • Adult Acute Care Nurse Practitioner (ACNPC - EV Accredited Issuing Body) • Certified Clinical Documentation Specialist (CCDS - EV Accredited Issuing Body) • Certified Coding Specialist (CCS - EV Accredited Issuing Body) • Certified Documentation Improvement Practitioner (CDIP - EV Accredited Issuing Body) • Physician Assistant (PA - EV Accredited Issuing Body) • Registered Nurse (RN - EV Accredited Issuing Body). All the benefits and perks you need for you and your family: Benefits from Day One: • Medical, Dental, Vision Insurance • Life Insurance • Disability Insurance • Paid Time Off from Day One • 403-B Retirement Plan • 4 Weeks 100% Paid Parental Leave • Career Development • Whole Person Well-being Resources • Mental Health Resources and Support • Pet Benefits.
Oscar HealthPhysician Reviewer - Utilization Management Oscar HealthPhysician Reviewer - Utilization ManagementTampa, FLRemote$211,200–$277,200 / yearConduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research. Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level).
MMSNewCardiology Medical Reviewer (Project-Based) - Remote MMSCardiology Medical Reviewer (Project-Based) - RemoteMiami, FLRemotePart timeWith a global footprint across four continents, MMS not only maintains an industry-leading customer satisfaction rating but also fosters a collaborative and inclusive work environment where employees can thrive. Responsible for strategies in pre and post marketing risk management, as well as keeping abreast of pharmacovigilance methods and trends in published literature and global regulations.
Bayfront HealthHospital Coding Reviewer/ Educator- Inpatient Bayfront HealthHospital Coding Reviewer/ Educator- InpatientOrlando, FloridaRemoteThrough our award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities, our 27,000+ team members serve communities that span Florida’s east to west coasts and beyond. Multifacility responsibility for ensuring all aspects of coding is carried out accurately and efficiently through chart reviews, problem account resolution, and coding education according to established rules and regulatory guidelines across Orlando Health System.
Florida Medical ClinicHospital Coding Reviewer/ Educator- Inpatient Florida Medical ClinicHospital Coding Reviewer/ Educator- InpatientOrlando, FloridaRemoteThrough our award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities, our 27,000+ team members serve communities that span Florida’s east to west coasts and beyond. Multifacility responsibility for ensuring all aspects of coding is carried out accurately and efficiently through chart reviews, problem account resolution, and coding education according to established rules and regulatory guidelines across Orlando Health System.
Orlando HealthHospital Coding Reviewer/ Educator- Inpatient Orlando HealthHospital Coding Reviewer/ Educator- InpatientOrlando, FloridaRemoteThrough our award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities, our 27,000+ team members serve communities that span Florida’s east to west coasts and beyond. Multifacility responsibility for ensuring all aspects of coding is carried out accurately and efficiently through chart reviews, problem account resolution, and coding education according to established rules and regulatory guidelines across Orlando Health System.
TriWest Healthcare AllianceClaims Reviewer TriWest Healthcare AllianceClaims ReviewerTampa, FLRemoteFull timeProficient with claim and coding tools and resources, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management, and/or the Claims Subcontractor as needed.
University of MiamiConcurrent Medical Code Reviewer - CCS/Remote University of MiamiConcurrent Medical Code Reviewer - CCS/RemoteHialeah, FLRemoteRequest clarification from the provider when there is conflicting, incomplete, or incorrect information in the health record regarding a significant reportable condition or procedure or other reportable data element collaborating with the Clinical Documentation Specialists for concurrent queries to the providers, ensuring physician responses to queries are reflected in the code assignment. Validates the accuracy of codes assigned by the computer assisted coding software, recognizing inappropriate application of clinical coding regulations/guidelines, and revising the codes assigned based on expert subject matter knowledge and provider documentation.
Baptist HealthHospital Coding Reviewer/ Educator- Inpatient Baptist HealthHospital Coding Reviewer/ Educator- InpatientOrlando, FloridaRemoteThrough our award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities, our 27,000+ team members serve communities that span Florida’s east to west coasts and beyond. Multifacility responsibility for ensuring all aspects of coding is carried out accurately and efficiently through chart reviews, problem account resolution, and coding education according to established rules and regulatory guidelines across Orlando Health System.
Zelis Healthcare, Inc.Inpatient DRG Sr. Reviewer Zelis Healthcare, Inc.Inpatient DRG Sr. ReviewerSt. Petersburg, FL$95,000–$120,650 / yearWhat You'll Bring to Zelis: Registered Nurse licensure preferred Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT) 5+ years reviewing and/or auditing ICD-10 CM, MS-DRG, and APR-DRG claims preferred Solid understanding of audit techniques, identification of revenue opportunities, and financial negotiation with providers Experience and working knowledge of Health Insurance, Medicare guidelines, and various healthcare programs Strong understanding of hospital coding and billing rules Clinical and critical thinking skills to evaluate appropriate coding Strong organization skills with attention to detail Excellent communication skills both verbal and written, and skilled at developing and maintaining effective working relationships Demonstrated thought leadership and motivation skills, a self-starter with an ability to research and resolve issues. As part of the Price Optimization division, this role is responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG Quality Assurance reviews in an effort to increase the savings achieved for Zelis clients.
TriWest Healthcare AllianceSr Claims Reviewer TriWest Healthcare AllianceSr Claims ReviewerTampa, FLRemoteFull timeProficient with claim and coding tools such as Supercoder, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. This role will serve as a SME and will collaborate with Claims leadership, Training, the Claims Content Specialist, and internal business partners to ensure procedures and training materials are accurate and complete.
Health Business Solutions LLCManager, Clinical Appeals Health Business Solutions LLCManager, Clinical AppealsCooper City, FLThe ideal candidate brings a strong background in clinical review, medical necessity denials, payer appeal processes, and team leadership—ideally across both U.S. and offshore teams (e.g., Philippines). We are seeking an experienced and highly organized Manager of Clinical Appeals to lead our clinical appeals operations across commercial and government payers.
Mastermind Care IncBilingual Clinical Therapist Mastermind Care IncBilingual Clinical TherapistMargate, FLEnsure communication with Billing company/utilization reviewer to complete concurrent reviews, correct and or provide any record documentation needed for authorization of treatment days. Collaborate with Clinical Director and Lead Behavioral Health Tech to approve all clinical passes for clients in community housing level of care.
ARC GroupClinical Review Nurse - Remote ARC GroupClinical Review Nurse - RemoteJacksonville, FLORIDARemote90% of time will be spent on one or more of the following activities depending on assignments: Review and analyze pre and post pay complex health care claims from a medical perspective, inclusive of prior authorization:Perform clinical review work as assigned; may provide guidance to other team members and accurately interpret and apply broad CMS guidelines to specific and highly variable situations. The incumbent applies clinical knowledge to assess the medical necessity, level of services and appropriateness of care which may include cases requiring prior authorization, complex pre-payment medical review or post-payment medical review.
Dane Street, LLCGroup Health Clinical QA Supervisor Dane Street, LLCGroup Health Clinical QA Supervisorwest palm beach, FLWe process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.
Dane Street, LLCNewUtilization Management, Clinical QA Supervisor Dane Street, LLCUtilization Management, Clinical QA Supervisorwest palm beach, FLWe process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.
Pinnacle Home CareNewClinical Review LPN - Weekend - Part-Time Pinnacle Home CareClinical Review LPN - Weekend - Part-TimeOrlando, FLWe're seeking an experienced Clinical Review Specialist to join our growing team and ensure every patient's care plan starts with clinical excellence, regulatory compliance, and a compassionate touch. Personalized, One-on-One Care: Help patients heal and regain their independence by delivering individualized care in the comfort of their homes.
GMMI, Inc.Nurse Case Manager GMMI, Inc.Nurse Case ManagerPembroke Pines, FLThe Medical Case Managers responsibilities include but are not limited to: assessment of strengths and weaknesses, implementation of a treatment plan, coordination and availability of resources, familiarity with the insured policy and its’ limitations and the communication and documentation with the appropriate entities that require information as per the stated policies and procedures while adhering to HIPAA and/or GDPR compliance. The Medical Case Manager is a Licensed Practical Nurse or a Registered Nurse who is accountable and capable of securing and reviewing clinical data in order to approve requests for admissions, procedures and services that meet clinical review criteria.
CatalentNewQuality Operations Manager CatalentQuality Operations ManagerSaint Petersburg, FLRole/pulliManage complex and high-level proactive compliance initiatives and continuous improvement efforts in collaboration with internal Catalent stakeholders./liliProvide leadership support and oversight to Quality teams responsible for CAPA management and batch record review and release activities./liliProvide lead investigator, reviewer/approver, mentorship/coaching, rapid response, operational excellence analysis, technical writing, preventive action planning, and compliance monitoring systems (e.g., TrackWise) training./liliEnsure site proactive compliance initiative training programs meet regulatory and customer requirements./liliRecommend and drive process improvements based on trend data from CAPAs, complaints, investigations, audits, and quality metrics./liliPerform advanced review of supporting documentation including batch documentation, test results, specifications, training records, SOPs, calibration records, and validation documentation./liliParticipate in site quality initiatives and support Management Review and metric reporting activities./liliOther duties as assigned./li/ulpThe Candidate/pulliBachelors Degree in Science or related field required (Chemistry, Microbiology or Biology); with a minimum of five years related experience in QA pharmaceutical manufacturing./liliPrior experience working with investigation writing, including root cause analysis and report writing a must (prior experience with preparing annual product reviews preferred)./liliQuality
Orlando HealthRN Care Manager (Case Management) - Part-Time - Days - Bayfront Hospital - St. Petersburg Orlando HealthRN Care Manager (Case Management) - Part-Time - Days - Bayfront Hospital - St. PetersburgSt. Petersburg, FloridaPromotes and facilitates effective management of hospital resources from admission to discharge, collaborating with the assigned clinical team to identify patient most likely to benefit from care coordination services to include assessing patients’ risk factors and the need for care coordination, clinical utilization management and the transition to the next appropriate level of care. Orlando Health Bayfront Hospital is part of the Orlando Health system of care, which includes award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities that span Florida’s east to west coasts, Central Alabama and Puerto Rico.
Bayfront HealthRN Care Manager (Case Management) - Part-Time - Days - Bayfront Hospital - St. Petersburg Bayfront HealthRN Care Manager (Case Management) - Part-Time - Days - Bayfront Hospital - St. PetersburgSt. Petersburg, FloridaPromotes and facilitates effective management of hospital resources from admission to discharge, collaborating with the assigned clinical team to identify patient most likely to benefit from care coordination services to include assessing patients’ risk factors and the need for care coordination, clinical utilization management and the transition to the next appropriate level of care. Orlando Health Bayfront Hospital is part of the Orlando Health system of care, which includes award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities that span Florida’s east to west coasts, Central Alabama and Puerto Rico.
Orlando Health VenturesRN Care Manager Case Management - Bayfront Hospital St. Petersburg Florida Orlando Health VenturesRN Care Manager Case Management - Bayfront Hospital St. Petersburg FloridaSt. Petersburg, FLJob Overview Promotes and facilitates effective management of hospital resources from admission to discharge, collaborating with the assigned clinical team to identify patients most likely to benefit from care coordination services, including assessing patients risk factors and the need for care coordination, clinical utilization management, and the transition to the next appropriate level of care. Orlando Health Bayfront Hospital is part of the Orlando Health system of care, which includes award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices, and outpatient facilities that span Floridas east to west coasts, Central Alabama, and Puerto Rico.
Integrated Resources, IncMedical Claim Review Nurse Integrated Resources, IncMedical Claim Review NurseMiami, FLRemoteContractorRequired Years of Experience: Requires a minimum of 2 years of experience in inpatient payment integrity medical claim review including DRG Validation or Itemized Bill Review, including 2 years’ experience working with ICD-10, MS-DRG, AP-DRG and APR-DRG, CPT, HCPCS; or any combination of education and experience, which would provide an equivalent background. • Preferred: Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Inpatient Coder (CIC), Clinical Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), or other advanced HIM/coding certifications
Loyal Source Government Services LLCHybrid - Psychologist Loyal Source Government Services LLCHybrid - PsychologistFt Lauderdale, FL$140,275.20–$152,275.20 / yearWith a focus in government healthcare, technical and support services, engineering, and travel healthcare, Loyal Source provides exceptional custom solutions to both private enterprise and government agencies. Participate in peer consultations, staff meetings, and trainings; be responsible for entering determinations within the Department of Veteran Affairs guideline requirements; and perform of other duties as required by the reviewer's manager.