Claims reviewer jobs in New York, New YorkCreate job alerts

Job Description Dane Street is expanding our physician panel! This is a telework opportunity for supplemental income for physicians providing a caseload customized to your schedule. Our physician panel is comprised of independent contract reviewers (1099) compensated on a per-case basis. The ideal candidates will hold a NY license and be Board Certified in Neurology with experience in completing Independent Medical Exams. The ideal candidate will be New York State Workers' Comp certified. Independent Medical Exams are available to be completed across the state of New York. Requirements As Physician Reviewer/Advisor, you will utilize clinical expertise and reviews insurance appeals, and prospective and retrospective claims. The Physician Reviewer will provide an interpretation of the medical necessity of services provided by other healthcare professionals in compliance with client specific policies, nationally recognized evidence-based guidelines, and standards of care. MAJOR DUTIES AND RESPONSIBILITIES: • Reviews all medical records and addresses each question posed by the client utilizing client specific criteria or other nationally recognized evidence-based criteria, • Ensures that the rationale for the determination is clear, concise, and contains adequate supporting documentation to substantiate the decision, • Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews; refrains from using case studies, cohorts, and the like to make decisions due to their limited sample sizes, • Provides copies of any criteria utilized in a review with the report in a timely manner, • Returns cases on or before the due date and time, • Makes telephone calls as mandated by the state and/or client specifics, • Maintains proper credentialing and state licenses and any special certifications or requirements necessary to perform the job, • Attends all required orientation and training, • Performs other duties as assigned including identifying and responding to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits, • Board certification required, active practice required PLEASE BE AWARE: In the interest of the security of all parties, Dane Street will never conduct interviews via text or request checks from candidates for any reason including the purchase of equipment. Benefits Robust opportunity for supplemental income • Schedule flexibility and predictable work hours - You choose services and case types, dictate volume, and conduct exams and reviews based on your schedule availability, • No doctor/patient relationship is established and no treatment is provided. These are advisory-only opinions., • Enhanced industry expertise strengthening your medical practice with medical necessity and utilization review/management expertise, • Expanded credentials as an expert in Independent Medical Exams and physician advisor services, • Fully prepped cases, streamlined case flow, transcription services at no cost, and user-friendly work portal Dane Street supports all referral processes, scheduling, preps cases extensively, prepares all medical records, provides transcription services as applicable, facilitates all client communications, and ensures the quality and timeliness of all reports and report delivery. Apply for this job

Job Description Dane Street is expanding our physician panel! This is a telework opportunity for supplemental income for physicians providing a caseload customized to your schedule. Our physician panel is comprised of independent contract reviewers (1099) compensated on a per-case basis. The ideal candidates will hold a NY license and be Board Certified in Orthopedic Surgery, with experience in completing Independent Medical Exams. The ideal candidate will be New York State Workers' Comp certified. Independent Medical Exams are available to be completed across the state of New York. Requirements As Physician Reviewer/Advisor, you will utilize clinical expertise and reviews insurance appeals, and prospective and retrospective claims. The Physician Reviewer will provide an interpretation of the medical necessity of services provided by other healthcare professionals in compliance with client specific policies, nationally recognized evidence-based guidelines, and standards of care. MAJOR DUTIES AND RESPONSIBILITIES: • Reviews all medical records and addresses each question posed by the client utilizing client specific criteria or other nationally recognized evidence-based criteria, • Ensures that the rationale for the determination is clear, concise, and contains adequate supporting documentation to substantiate the decision, • Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews; refrains from using case studies, cohorts, and the like to make decisions due to their limited sample sizes, • Provides copies of any criteria utilized in a review with the report in a timely manner, • Returns cases on or before the due date and time, • Makes telephone calls as mandated by the state and/or client specifics, • Maintains proper credentialing and state licenses and any special certifications or requirements necessary to perform the job, • Attends all required orientation and training, • Performs other duties as assigned including identifying and responding to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits, • Board certification required, active practice required PLEASE BE AWARE: In the interest of the security of all parties, Dane Street will never conduct interviews via text or request checks from candidates for any reason including the purchase of equipment. Benefits Robust opportunity for supplemental income • Schedule flexibility and predictable work hours - You choose services and case types, dictate volume, and conduct exams and reviews based on your schedule availability, • No doctor/patient relationship is established and no treatment is provided. These are advisory-only opinions., • Enhanced industry expertise strengthening your medical practice with medical necessity and utilization review/management expertise, • Expanded credentials as an expert in Independent Medical Exams and physician advisor services, • Fully prepped cases, streamlined case flow, transcription services at no cost, and user-friendly work portal Dane Street supports all referral processes, scheduling, preps cases extensively, prepares all medical records, provides transcription services as applicable, facilitates all client communications, and ensures the quality and timeliness of all reports and report delivery. Apply for this job

Job Title : RN Clinical Reviewer Location : New York, NY 10004 Duration : 3+ Months / 13 Weeks Education : Bachelor’s in Nursing (BA/BSN) required Shift Details : 9:00 AM – 5:00 PM / Hybrid — Onsite & Remote Specific Skills : • Review medical charts for accuracy, completeness, and proper diagnosis sequencing., • Validate clinical and coding assessments in alignment with regulations., • Conduct audits of high-risk claims and billing patterns to identify discrepancies and potential FWA., • Prepare detailed clinical review reports, including rationale, research, and corrective action recommendations., • Assist with documentation for audits, compliance reviews, recoupments, and regulatory inquiries., • Active New York State RN License (Primary Source Verified), • Minimum 2 years of clinical experience We are seeking an experienced Registered Nurse (RN) to perform detailed medical chart reviews to ensure accuracy, correct sequencing of diagnoses, and compliance with regulatory guidelines. The RN will review documentation from Consultation Reports, H&P, Operative Reports, Progress Notes, and Discharge Summaries, including complex cases.

At IBSA we are driven by our 4 pillars: People, Innovation, Quality and Responsibility. Understanding People are our most valued asset we strive to have a strong result driven collaborative culture with a great work/life balance. The Director, Compliance, IBSA USA, will be responsible for establishing and updating compliance strategy and guidance for IBSA’s US commercial and medical operations in collaboration with the IBSA USA and Global compliance teams. The ideal candidate will have deep US compliance experience and prior experience building US compliance programs at a global pharmaceutical company. This individual will also exhibit exceptional dynamic range, capable of quickly pivoting between global strategy and local operational execution, with a relentless focus on ensuring that the team can meet the needs of IBSA as we continue to scale. The Director, Compliance, IBSA USA, will report to the Head of Legal Affairs, IBSA USA, and will be part of the Legal Affairs & Compliance group. With our growing footprint in the US we all share the responsibility to drive success! Responsibilities: • Develop and/or update Company compliance program, policies and SOPs in alignment with federal, state, and local regulations, including but not limited to the OIG and DOJ Guidance for Effective Compliance Programs. Ensure compliance with FDA, DOJ, OIG, and other relevant regulatory agencies’ guidelines and requirements, including but not limited to the PhRMA Code., • Develop and oversee company-wide compliance training programs. This includes reviewing and updating training content, coordinating delivery through our learning management system, and creating specialized live sessions to ensure understanding of compliance laws and policies., • Monitor commercial and non-commercial programs and contracts for adherence to IBSA’s policies including its Code of Conduct., • Provide compliance guidance on promotional and non-promotional materials to minimize risk and participate on promotional review committee. In addition, serve as Legal reviewer on promotional review committee and non-promotional review committee., • Review and approve annual engagement plans and business needs reviews for HCP engagement in connection with Commercial, Sales and Marketing and other departments, including review of HCP agreements., • As a member of the Legal Affairs and Compliance group, provide Legal and Compliance review of agreements as needs arise. IBSA Group - Public • Pivot fearlessly: Be prepared to adjust US compliance strategies and operations in response to new data, regulatory changes, or internal audit findings, ensuring that the organization remains agile and compliant., • Accept risk: Develop and implement US compliance strategies that recognize the inherent risks in the pharmaceutical industry, embracing these risks as necessary for impactful innovation and progress., • Provide guidance on complex compliance matters like anti-bribery, anti-corruption, conflicts of interest, and interactions with healthcare providers, ensuring consistent and practical advice., • Collaborate with internal Legal and Regulatory compliance team to implement tailored compliance initiatives and training programs., • Assist in drafting and updating compliance-related agreements and provide support to Legal and commercial teams on compliance provisions., • Develop and maintain a deep comprehension of Company processes, systems, technologies, data, customers, end users, vendors, and the compliance., • Stay informed about industry regulations, best practices, and emerging trends in healthcare compliance and regulatory environments., • Conduct regular risk assessments to identify compliance issues and develop strategies to mitigate risks. Monitor and audit the effectiveness of the compliance program, and when necessary, conduct internal investigations into potential violations of our Code of Conduct and company policies, working with the Legal Department. Qualifications: • Juris Doctor (JD) with at least 8 years of experience in legal/compliance roles within the healthcare industry or law firms, including at least 5 years specifically in pharmaceutical company compliance., • Strong knowledge of federal and state laws (e.g., False Claims Act, Anti-Kickback Statute, Privacy)., • Working knowledge of relevant US compliance guidelines, regulations (AKS, FCA, FDCA, HIPAA, FCPA) and PhRMA Code principles, • Knowledge of compliance risks and considerations related to healthcare sales and marketing activities, including interactions with healthcare professionals and customers and promotional activities is highly desirable., • Demonstrated knowledge and hands-on experience with the foundational elements of effective compliance programs, such as developing policies/procedures, creating and delivering training, conducting risk assessments, and conducting monitoring activities., • Professionalism, discretion, and judgment through sound decision-making to obtain solutions through collaborative efforts across the Company.

Standard Assignment Window: September to February with possible extension.Fully Remote Training: Training is fully virtual with cameras expected to be on.Start time is 8 AM Eastern Time.Training period consists of 3 weeks in virtual classroom and at least 3 additional weeks of training audits with r

As a Physician Reviewer/Advisor, you will provide expert reviews for insurance appeals and claims.