Utilization Clinical Reviewer TriWest Healthcare AllianceUtilization Clinical ReviewerMilwaukee, WIRemoteFull 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.
Clinical Quality Reviewer TriWest Healthcare AllianceClinical Quality ReviewerMilwaukee, WIRemoteFull 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.
Reviewer - Therapy Services Elevance Health IncReviewer - Therapy ServicesWaukesha, WIMinimum Requirements: Requires graduate of a college level program in physical therapy, occupational therapy, or speech language pathology or an accredited two-year program for a Physical Therapist Assistant, Occupational Therapist Assistant, or Speech Language Pathologist Assistant and minimum of 1 year of clinical experience; or any combination of education and experience, which would provide an equivalent background. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Data Reviewer, Quality Control Arrowhead Pharmaceuticals IncData Reviewer, Quality ControlVerona, WI$80,000–$90,000 / yearArrowhead is leading the field in bringing the promise of RNAi to address diseases outside of the liver, and our clinical pipeline includes disease targets in the liver and lung with a promising pipeline of preclinical candidates. Using a broad portfolio of RNA chemistries and efficient modes of delivery, Arrowhead therapies trigger the RNA interference mechanism to induce rapid, deep, and durable knockdown of target genes.
Data Reviewer, Analytical Development Arrowhead Pharmaceuticals IncData Reviewer, Analytical DevelopmentVerona, WI$80,000–$90,000 / yearArrowhead is leading the field in bringing the promise of RNAi to address diseases outside of the liver, and our clinical pipeline includes disease targets in the liver and lung with a promising pipeline of preclinical candidates. Using a broad portfolio of RNA chemistries and efficient modes of delivery, Arrowhead therapies trigger the RNA interference mechanism to induce rapid, deep, and durable knockdown of target genes.
Data Reviewer, Analytical Development Arrowhead PharmaceuticalsData Reviewer, Analytical DevelopmentMadison, WI$80,000–$90,000 / yearArrowhead is leading the field in bringing the promise of RNAi to address diseases outside of the liver, and our clinical pipeline includes disease targets in the liver and lung with a promising pipeline of preclinical candidates. Using a broad portfolio of RNA chemistries and efficient modes of delivery, Arrowhead therapies trigger the RNA interference mechanism to induce rapid, deep, and durable knockdown of target genes.
Data Reviewer, Quality Control Arrowhead PharmaceuticalsData Reviewer, Quality ControlMadison, WI$80,000–$90,000 / yearArrowhead is leading the field in bringing the promise of RNAi to address diseases outside of the liver, and our clinical pipeline includes disease targets in the liver and lung with a promising pipeline of preclinical candidates. Using a broad portfolio of RNA chemistries and efficient modes of delivery, Arrowhead therapies trigger the RNA interference mechanism to induce rapid, deep, and durable knockdown of target genes.
Claims Reviewer TriWest Healthcare AllianceClaims ReviewerMilwaukee, WIRemoteFull 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.
Sr Claims Reviewer TriWest Healthcare AllianceSr Claims ReviewerMilwaukee, WIRemoteFull 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.
Supervisor, Clinical Quality Review Medica Health Plans IncSupervisor, Clinical Quality ReviewWI$78,700–$118,020 / yearTranslates regulatory and coding requirements into practical guidance for internal teams and external partners Serves as a clinical subject matter resource during internal, vendor, or provider discussions Assists Director and Manager as needed to develop, introduce and support overall goals Develops linkages with specific departments on behalf of the Clinical Review area such as Data Management, Legal, Network Management, Compliance, Pharmacy and Complementary Networks. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the positions scope and responsibility, internal pay equity and external market salary data.
Principal Clinical Content- Physician - UpToDate®, Physician Editor, Adult Neurology Wolters Kluwer N.V.Principal Clinical Content- Physician - UpToDate®, Physician Editor, Adult NeurologyWI$173,500–$310,000 / yearUpToDate editors work closely with outside authors, section editors, editors-in-chief, and peer reviewers to ensure the material is accurate and free of bias. In the remaining 10 to 20% time, Physician Editors should continue patient care activities, using their clinical experience to help ensure the content of the program is maximally useful at the point of care.
RN CLIN DOCUMENT SPEC QUALITY- ENTERPRISE QUALITY CDI/UR/DM Froedtert & The Medical College of WisconsinRN CLIN DOCUMENT SPEC QUALITY- ENTERPRISE QUALITY CDI/UR/DMMILWAUKEE, WI$38.92–$60.33 / hourJob Summary: The RN Second-Level CDI & Quality Reviewer is a senior-level clinical documentation professional responsible for performing in-depth, concurrent and retrospective reviews of medical records to ensure accurate documentation that supports correct Diagnosis-Related Group (DRG) assignment and other quality-based outcomes. In addition to validating query appropriateness and documentation practices, this role analyzes Patient Safety Indicators (PSIs), Hospital-Acquired Conditions (HACs), and other publicly reported hospital quality metrics.