Key Responsibilities: Review and evaluate clinical information submitted with PA requests for medical necessity, appropriateness, and benefit coverage. Conduct clinical reviews for outpatient, inpatient, and specialty services, including J-code medications and durable medical equipment (DME) as applicable. Apply CMS Medicare Advantage guidelines, internal policies, and clinical criteria (MCG/InterQual) to decision-making. Collaborate with physicians, pharmacists, UM staff, and external providers to ensure accurate and timely case resolution. Escalate complex or borderline cases to Medical Directors for final determination. Document decisions, rationale, and communications in the clinical system of record with clarity and accuracy. Support audits, appeals, and compliance-related documentation requests. Participate in quality improvement initiatives and workflow optimization. Educate providers and internal teams on medical policy, coverage criteria, and regulatory requirements. Qualifications: Registered Nurse (RN) with active, unrestricted license in [state]. 3+years of clinical experience in Utilization Management, Prior Authorization, Case Review, or related. 2+ years of direct experience with Medicare Advantage plans and CMS requirements. Familiarity with medical management software and PA platforms (e.g., GuidingCare, TruCare, Epic, or similar). Working knowledge of MCG/InterQual guidelines, CMS NCD/LCDs. Excellent clinical decision-making, documentation, and communication skills. Ability to work independently and manage high case volumes in a fast-paced environment. Job Type: Full-time Schedule: Day shift Experience: CMS Requirements: 2 years (Required) Clinical: 3 years (Required) Work Location: In person
As a skilled and experienced Java Developer, you will be responsible for leading and driving the full lifecycle of product development. This includes tasks such as ideation, design, development, testing, and validation. Collaborating with cross-functional team members, you will play a key role in developing UI layouts/designs and UX Models using a rapid prototyping approach. Your expertise will be utilized in working with agile development methodology, driven by the latest ALM tools like Azure DevOps or JIRA. Your primary focus will be on producing high-quality software code that adheres to contemporary architectural concepts, design patterns, and best coding practices. You should have the ability to interpret written requirements, identify gaps, and seek clarifications from Product Managers. Estimating stories, producing detailed designs based on architecture discussions, and writing good quality code for complex system components are crucial aspects of this role. Additionally, you will be involved in conducting thorough code reviews of complex components, providing guidance to Developers/Junior Developers on code implementation and low-level design, and reviewing QA Lead's test strategies and plans. Your technical skills should include a strong background in Java Development, building RESTful web services using the Spring Boot Framework, as well as experience with Hibernate, Maven, Node JS, and MySQL/PostgreSQL. This is a full-time position that requires you to work in-person during day shifts. The ideal candidate should have at least 5 years of experience in Java development, with preferred experience in JSP and AJAX for 3 years. If you are a proactive and detail-oriented professional with a passion for software development, this opportunity is perfect for you.,
As a Registered Nurse (RN) with active, unrestricted license in [state], your primary responsibility will be to review and assess clinical information submitted with Prior Authorization (PA) requests to determine medical necessity, appropriateness, and benefit coverage. You will conduct clinical evaluations for outpatient, inpatient, and specialty services, including J-code medications and durable medical equipment (DME) as applicable. It will be essential for you to apply CMS Medicare Advantage guidelines, internal policies, and clinical criteria (such as MCG/InterQual) to make informed decisions. Collaboration will be a key aspect of your role as you work closely with physicians, pharmacists, Utilization Management (UM) staff, and external providers to ensure accurate and timely resolution of cases. In situations involving complex or borderline cases, you will be required to escalate them to Medical Directors for a final determination. Your ability to document decisions, rationale, and communications clearly and accurately in the clinical system of record will be crucial. You will also be expected to provide support for audits, appeals, and compliance-related documentation requests, as well as participate in quality improvement initiatives and workflow optimization. Educating providers and internal teams on medical policy, coverage criteria, and regulatory requirements will be part of your regular responsibilities. To be successful in this role, you should have a minimum of 3 years of clinical experience in Utilization Management, Prior Authorization, Case Review, or related fields, along with at least 2 years of direct experience working with Medicare Advantage plans and understanding CMS requirements. Familiarity with medical management software and PA platforms, such as GuidingCare, TruCare, Epic, or similar, will be advantageous. A working knowledge of MCG/InterQual guidelines and CMS NCD/LCDs is also required. Your excellent clinical decision-making, documentation, and communication skills will be critical in this position. The ability to work independently and efficiently manage high case volumes in a fast-paced environment is essential for success. This is a full-time position with a day shift schedule. The work location is in person, and the job type is Full-time. The required experience includes 2 years of CMS Requirements and 3 years of Clinical experience.,
Key Responsibilities: Assist in the design and drafting of building services using AutoCAD Support senior engineers in preparing technical drawings and layouts Coordinate with on-site teams and other departments for project execution Work on HVAC, plumbing, fire-fighting, and electrical systems (based on specialization) Ensure compliance with industry standards and project specifications Prepare and maintain documentation related to the project Provide timely updates and communicate project status effectively Required Skills: Diploma or Degree in Electrical or Mechanical Engineering AutoCAD proficiency is a must Basic knowledge of Revit is preferred Exposure to the building/construction industry is highly desirable Good communication skills (fluent English not mandatory, but ability to convey information clearly is essential) Willingness to learn and adapt in a fast-paced environment Job Type: Full-time Ability to commute/relocate: Bangalore, Karnataka: Reliably commute or planning to relocate before starting work (Preferred) Work Location: In person
You will be responsible for developing and maintaining advanced applications on the Flutter platform, utilizing a rich set of dependencies crucial to our primary projects. Your role will involve collaborating with cross-functional teams to define, design, and implement new features with high precision and efficiency. It is essential to ensure the creation of robust, secure, scalable, and efficient code that meets both technical and business requirements. Proficiency in using GraphQL for handling complex queries and mutations within Flutter applications is key. Additionally, you will extensively work with Hasura to maximize its capabilities beyond real-time data, ensuring optimal integration and performance. Your responsibilities will also include managing the automated distribution of Flutter applications across various platforms, including mobile and web. To excel in this role, you should have proven experience in Flutter and Dart development, supported by a strong portfolio of previous projects. A solid understanding of the full mobile development life cycle, coupled with a background in full-stack development, is necessary. Deep expertise in GraphQL is required, showcasing the ability to construct complex queries and mutations effectively. Proficiency with Hasura is essential, demonstrating a comprehensive understanding of its functionalities. Experience with Node.js and relational databases like PostgreSQL will be beneficial. Strong problem-solving skills and the capacity to offer innovative solutions are highly valued. Excellent communication and collaboration skills are vital, as you will be working in a fast-paced, remote team environment. Nice to have qualifications include contributions to open-source projects, experience with Kotlin or Swift, familiarity with native mobile distribution tools like Fastlane, Jenkins, Bitrise, and Codemagic, as well as expertise with specific dependencies such as build_runner, graphql_codegen, get, provider, and graphql flutter.,