Case Review Manager – Independent Reviews, IRO/UR

🕒 Outubro 30

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $85.000 - $95.000 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

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• Aberta há 12 dias.

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RediMinds, Inc

SiteLinkedInTodas as Vagas

11 - 50 funcionários

Fundada em 2016

🏥 Saúde

🤖 Inteligência Artificial

☁️ SaaS

💰 $225.000 Grant em 2020-05

Healthcare • Artificial Intelligence • SaaS

A RediMinds é uma empresa de tecnologia em saúde que desenvolve e opera plataformas baseadas em IA para apoiar a análise médica regulada, a arbitragem e outras decisões de alto impacto na área da saúde. Seus produtos automatizam o recebimento de solicitações, a indexação de documentos, a extração de evidências, a geração de linhas do tempo e resumos clínicos, o matching e a certificação de revisores, além de produzir decisões auditáveis e supervisionadas por profissionais para fluxos de trabalho como autorização prévia/ePA, resolução independente de disputas (IDR) federal e estadual, revisão externa estadual, benefícios por incapacidade da Previdência Social, compensação trabalhista, detecção de fraudes, desperdícios e abusos, e revisão de DRG. A empresa enfatiza a tomada de decisão com human-in-the-loop (a IA prepara o trabalho; profissionais clínicos qualificados assinam as decisões), a capacidade de defesa regulatória e a conformidade com padrões de segurança em saúde (URAC, HITRUST, SOC 2 e HIPAA), além de publicar pesquisas revisadas por pares.

Descrição

• Review incoming case files for completeness and accuracy, including case summaries, member and service details, clinical records, supporting documents, and key dates • Identify missing or inconsistent information • Validate system-generated summaries and case information against underlying records • Escalate discrepancies and ensure a reliable foundation for clinician review • Quality-check clinicians’ written reviews for completeness, internal consistency, clear rationale, accurate evidence references, and responsiveness to the question under review • Work directly with clinicians to clarify or correct documentation gaps while preserving independent clinical judgment and decision-making authority • Perform final quality assurance on determination letters before issuance • Coordinate with clinical and operations teams to resolve issues, maintain accurate case records, and meet standard and expedited review deadlines • Protect confidential health information and follow independence and conflict-of-interest safeguards • Identify opportunities to strengthen quality and improve workflows

🎯 Requisitos

• Hands-on experience in utilization review (UR), healthcare appeals, independent review, clinical review operations, or closely related medical-record and decision-document quality assurance • Ability to read and critically assess clinical documentation, identify omissions or inconsistencies, and raise well-founded questions for the appropriate clinical reviewer • Excellent written communication and editing skills • Exceptional attention to detail, sound judgment, and ability to manage multiple cases against firm deadlines • Comfort working in technology-enabled systems and independently verifying summaries, documents, and other system outputs against source records • Understanding of patient confidentiality and impartial, well-documented healthcare review processes • Bachelor’s degree in a healthcare-related field or an equivalent combination of education and relevant experience • Evening or weekend work may be required when needed to meet regulatory deadlines • Direct experience with an Independent Review Organization (IRO), external grievance reviews, or external healthcare appeals is especially valuable but not required • Experience with Pennsylvania Personal Assistance Services (PAS) cases, Community HealthChoices, Medicaid managed care, or long-term services and supports (LTSS) is welcome but not required • Experience auditing clinical review rationales and final determination or appeal letters is especially valuable but not required • Clinical credential such as RN or LPN/LVN or relevant clinical training is especially valuable but not required

🏖️ Benefícios

• Fully remote work arrangement • Self-directed role with close collaboration across clinical and operations teams • Equal opportunity and inclusive work environment

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