iMPROve Health

Physician

• Perform independent external medical reviews remotely on an ad hoc basis as an independent contractor.
• Conduct objective, evidence-based peer reviews of clinical cases within the pediatric critical care specialty.
• Make final determinations regarding medical necessity and quality of care.
• Ensure decisions are fair, unbiased, and aligned with current standards of practice.
• Submit reviews in a timely and professional manner using the provided IT systems.

Peer Reviewer – Pediatric Critical Care Physician

Nurse

• Perform utilization review activities in accordance with program requirements, contractual obligations, clinical guidelines, and regulatory standards
• Conduct telephonic Nursing Facility Level of Care (LOC) reviews for Michigan Medicaid beneficiaries
• Perform verification, secondary, and quality reviews for Long-Term Services & Supports (LTSS) cases
• Conduct virtual Home Help assessments using Microsoft Teams
• Review medical records, assessments, care plans, and supporting clinical documentation to determine eligibility and medical necessity
• Apply evidence-based clinical criteria and state regulations to support review determinations
• Manage cases from assignment through completion while meeting established turnaround times
• Document review findings accurately within secure electronic systems and state portals
• Communicate with providers, beneficiaries, and internal staff regarding review findings and requests for additional information
• Participate in administrative hearings and appeals to represent review determinations when required
• Maintain current knowledge of contractual requirements, Medicaid regulations, and applicable clinical guidelines
• Comply with HIPAA, FISMA, URAC, CMS, organizational policies, and security requirements
• Participate in required training, calibration, and quality assurance activities
• Perform other duties as assigned

Contingent Registered Nurse, UR/LTSS

Reviewer

• Complete IDR/IIDR case reviews in accordance with contract requirements and deadlines
• Manage assigned deliverables, ensuring accuracy, quality, and timeliness
• Develop and monitor timelines and work plans for assigned cases
• Perform accurate and timely data entry into CMS systems and internal databases
• Process and manage incoming and outgoing Conflict of Interest (COI) case reviews
• Securely handle and transmit sensitive case information
• Maintain compliance with HIPAA, FISMA, URAC, and CMS standards
• Proactively identify and resolve issues affecting timelines or deliverables
• Communicate with internal teams and stakeholders
• Perform other duties as assigned

IDR/IIDR Reviewer – Contingent

• Perform independent clinical reviews supporting medical management, utilization review, external review, quality review, and other healthcare review programs
• Review medical records and supporting documentation to make objective, clinically sound determinations
• Complete assigned case reviews accurately and within required turnaround times
• Prioritize incoming review assignments and manage multiple cases simultaneously
• Document review findings accurately in electronic case management systems and web-based portals
• Prepare clear, concise, and well-supported written determinations
• Ensure outgoing review documentation is complete, accurate, and submitted within contractual deadlines
• Maintain compliance with HIPAA, CMS, URAC, FISMA, and other applicable regulatory requirements
• Participate in quality assurance activities, audits, and ongoing training
• Collaborate effectively with internal teams while maintaining reviewer independence and objectivity
• Assist with additional review activities and projects as business needs require
• Work 20 hours per week during normal business hours, Monday through Friday, Eastern Time, with additional hours as needed

Peer Reviewer – Pediatric Critical Care Physician

Contingent Registered Nurse, UR/LTSS

IDR/IIDR Reviewer – Contingent

Independent Review Nurse – Part Time