AxelonNewInpatient UM Clinician AxelonInpatient UM ClinicianCharlestown, MARemote$50–$55 / hour2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines) Managed care experience Experience performing discharge planning All employees working remotely will be required to adhere to Wellenses Telecommuter Policy Licensure, Certification or Conditions of Employment: Active, unrestricted RN license in state of residence Pre-employment **** Ability to take after hours call, including evening/nights/weekends Competencies, Skills, and Attributes: Strong oral and. The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes.
US Tech Solutions, Inc.Clinical Reviewer Outpatient Registered Nurse # 26-10731 US Tech Solutions, Inc.Clinical Reviewer Outpatient Registered Nurse # 26-10731Canton, MA$50–$50 / hourKey Responsibilities/Duties – what you will be doing:Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames. Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.
US Tech Solutions, Inc.Clinical Reviewer Utilization Management Registered Nurse # 26-07418 US Tech Solutions, Inc.Clinical Reviewer Utilization Management Registered Nurse # 26-07418Canton, MA$60–$61 / hourKey Responsibilities/Duties – what you will be doingProvides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames. Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.
University of Massachusetts Medical SchoolClinical Reviewer - PASRR University of Massachusetts Medical SchoolClinical Reviewer - PASRRWestborough, MassachusettsRemoteUnder the general supervision of the Associate Director, or designee, the Clinical Reviewer - PASRR is responsible for reviewing submitted referrals and any accompanying clinical documentation to the Pre-Admission Screening and Resident Review (PASRR) unit for completeness. Ability to understand and utilize resources for problem solving, in order to deal with problems involving multiple variables, effectively prioritizing and executing tasks in a high pressure, fast paced environment.
Point32Health, Inc.Clinical Reviewer, BH outpatient services Point32Health, Inc.Clinical Reviewer, BH outpatient servicesCanton, MA$81,217.85–$121,826.77 / yearThe BH UM Clinician works collaboratively with the Behavioral Health leadership within the Behavioral Health department and other appropriate Point32Health staff to identify and address opportunities to improve service, reduce administrative cost, ensure clinically appropriate delivery of benefit covered services, and support department and organizational business goals. Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes: Medical, dental and vision coverage Retirement plans Paid time off Employer-paid life and disability insurance with additional buy-up coverage options Tuition program Well-being benefits Full suite of benefits to support career development, individual & family health, and financial health.
CVS Health CorpPrior Authorization Clinical Reviewer CVS Health CorpPrior Authorization Clinical ReviewerMA$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.
University of Massachusetts Medical SchoolNurse Reviewer II-LOC University of Massachusetts Medical SchoolNurse Reviewer II-LOCWestborough, MassachusettsUnder the general supervision of the Associate Director, or designee, the Nurse Reviewer II is responsible for completing in-person assessments and reviewing supporting documentation to determine clinical eligibility for individuals who are residing in the community receiving services through the Family Assistance Pathway. • Maintain positive working relationships with members, and relevant formal/informal supports, provider organizations, program consultants and state agencies.
Phenom PeopleNewPrior Authorization Trainer/QA Reviewer - Inpatient Accounts - Hybrid schedule Phenom PeoplePrior Authorization Trainer/QA Reviewer - Inpatient Accounts - Hybrid scheduleBoston, MAThe QA Reviewer/Analyst, under the direction of the Director, is responsible for identifying and mitigating risk of denials to the Department and ensuring highest quality of work by the Admissions Counselors via daily management of Patient Access EPIC WQs (Patient/Account/Claims); weekly review of the in-house high dollar Ontrac accounts; monitoring of DFCI patients in BWH beds; oversight of denials in conjunction with Department Team Leads and Manager, among other responsibilities aimed at improving the financial healthof the Department overall. Will assist Team Leads and Manager in reviewing Ontrac exceptions and tracking KPI and meeting Department expectations, e.g., elective teams days out, urgent team completed post discharge metrics.
Dane StreetBoard Certified-(M.D, D.O) Boston Family Practice Record Reviewer Dane StreetBoard Certified-(M.D, D.O) Boston Family Practice Record ReviewerBoston, MAAs Physician Reviewer/Advisor you will utilize clinical expertise and reviews insurance appeals, and prospective and retrospective claims.
MMSNewCardiology Medical Reviewer (Project-Based) - Remote MMSCardiology Medical Reviewer (Project-Based) - RemoteBoston, MARemotePart 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.
LanceSoft IncMedical Reviewer LanceSoft IncMedical ReviewerCambridge, MA$110–$120 / hourFull timeSummary of Key Responsibilities: Perform daily medical review and causality assessment of ICSRs in accurate, consistent, and timely manner to contribute to continuous signal detection and management process Collaborate with other pharmacovigilance colleagues to align on a harmonized approach to identifying, evaluating and communicating safety issues Identify topics for escalation and collaborate with safety product leads to investigate potential safety signals Collaborate with GPSRM Quality and Case Management teams to identify case review issues and inconsistency and work on addressing these issues under the leadership of Head of Medical Review Participate in process improvements for the Medical Review team Maintain close communication with the case processing and medical case review vendors Qualifications: There is a strong pipeline, significant resources, and every intention of continuing the phenomenal rate of success and growth. The ideal candidate will have the following mix of personal and professional characteristics: Medical Degree with a minimum of 1 year of medical practice is required Must have a minimum of 2 years of pharmaceutical industry experience within pharmacovigilance or clinical research Experience in medical case review is a strong plus Sound clinical acumen and a wide range of therapeutic area knowledge.
LancesoftNewDirector, Medical Reviewer LancesoftDirector, Medical ReviewerCambridge, MA$139.86Accountabilities Oversight of global medical review of individual case safety reports for Client investigational and marketed products from all sources includes but not limited to the following: seriousness criteria confirmation and expectedness/listedness assessment review of the reporter s causality and company causality assessment event confirmation and coding as per convention, analysis of similar events as required, provide sound rationale in Company. Proven ability to work in international environment and with cross-functional teams, with good interpersonal skills / assertiveness / team spirit / coaching skills.
Athol HospitalNewRN Clinical Coordinator, Case Management, 32-Hours, Days, No Weekends or Holidays Athol HospitalRN Clinical Coordinator, Case Management, 32-Hours, Days, No Weekends or HolidaysAthol, Massachusetts$38–$57.48 / hourWorks collaboratively with a multidisciplinary team to determine each patient's needs concurrently including post-acute care when needed; addresses LOS issues, appropriate leveling of patient status; addresses potential needs, resources, referrals for other disciplines etc. Responsible for completing nursing sections of the SNF Level of Care forms for Mass Health patients in need of care, SNF placement, timely and efficiently and other forms assisting in transition of care as identified and collaborates with the social worker.
University of Massachusetts Medical SchoolClinical Coordinator University of Massachusetts Medical SchoolClinical CoordinatorWestborough, MassachusettsUnder the general direction of the Associate Director, or designee, the Clinical Coordinator is responsible to develop, prioritize, and oversee staff activities specifically designed to promote the coordination of care for those MassHealth members who have medically complex, chronic or catastrophic illnesses that require a customized approach to how, when, and where they receive medically necessary health care services. 3 years of related work experience with prior authorization and/or eligibility determinations for disabled, medically complex, home care, rehab or long term care populations strongly preferred.
VITRA HealthTelehealth Nurse (4-Day Work Week on site) VITRA HealthTelehealth Nurse (4-Day Work Week on site)Boston, MA$38–$48Through innovative home- and community-based services, Vitra supports aging adults, people with disabilities, and individuals with complex care needs— supported by a Nurse, and Case Manager, Vitra ensures clients receive compassionate, personalized, and dignified care. Requires lifting and carrying equipment and supplies weighing up to 35 pounds; requires pushing and pulling equipment and supplies weighing up to 35 pounds; requires walking and standing; requires frequent sitting more than 75% of the workday; requires the ability to navigate stairs; requires visual acuity and manual dexterity to operate equipment. .
Integrated Resources, IncNewInpatient UM Clinician Integrated Resources, IncInpatient UM ClinicianCharlestown, MA, MARemoteExperience: " 2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines) " Managed care experience " Experience performing discharge planning " All employees working remotely will be required to adhere to Wellenses Telecommuter Policy Licensure, Certification or Conditions of Employment: Active, unrestricted RN license in state of residence Pre-employment background check Ability to take after hours call, including evening/nights/weekends Competencies, Skills, and Attributes: Strong oral and. The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes.
Axelon Services CorporationNewInpatient UM Clinician Axelon Services CorporationInpatient UM ClinicianCharlestown, MA, MARemote$50–$55 / hour2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines) " Managed care experience " Experience performing discharge planning " All employees working remotely will be required to adhere to Wellenses Telecommuter Policy Licensure, Certification or Conditions of Employment: Active, unrestricted RN license in state of residence Pre-employment **** Ability to take after hours call, including evening/nights/weekends Competencies, Skills, and Attributes: Strong oral and. The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes.
Heywood HospitalRN Care Coordinator, Case Management, 8-Hours, Mornings, Weekends, 4 hour shifts on Saturdays and Sundays Heywood HospitalRN Care Coordinator, Case Management, 8-Hours, Mornings, Weekends, 4 hour shifts on Saturdays and SundaysGardner, Massachusetts$38–$57.48 / hourQuality & Statistical Data: Reviews medical record for abnormal findings,complications, delays and deviations from expected clinical outcomes reports such to Provider and/or Director to maintain an efficient, cost effective episode of care for each patient and documents intervention provided. Organizational ExpectationsBehavioral Attributes:The following behavioral attributes are required: achievement motivation, flexibility, concern for order, initiative, self-confidence, self control, customer service orientation, interpersonal effectiveness, teamwork and information seeking.
Baystate HealthNurse Excellence Programs Strategist Baystate HealthNurse Excellence Programs StrategistSpringfield, MA$118,934–$136,718 / yearThis system-wide Nurse Excellence Programs Strategist partners with nursing leadership, shared governance councils, and frontline nurses to cultivate a professional practice environment grounded in exemplary professional practice, transformational leadership, structural empowerment, new knowledge and innovations, quality, safety, well-being, and empirical nursing outcomes. Under the general direction of the System Director of Nursing Excellence, the Nurse Excellence Programs Strategist serves as a key strategic leader responsible for advancing systemwide professional nursing excellence through the successful achievement and sustainment of ANCC Magnet®, Pathway to Excellence®, and Practice Transition Accreditation Program (PTAP) designations.
Baystate Health SystemNurse Excellence Programs Strategist Baystate Health SystemNurse Excellence Programs StrategistSpringfield, MAThis system-wide Nurse Excellence Programs Strategist partners with nursing leadership, shared governance councils, and frontline nurses to cultivate a professional practice environment grounded in exemplary professional practice, transformational leadership, structural empowerment, new knowledge and innovations, quality, safety, well-being, and empirical nursing outcomes. Summary: Under the general direction of the System Director of Nursing Excellence, the Nurse Excellence Programs Strategist serves as a key strategic leader responsible for advancing systemwide professional nursing excellence through the successful achievement and sustainment of ANCC Magnet®, Pathway to Excellence®, and Practice Transition Accreditation Program (PTAP) designations.