Performs pre-admission, admission, and continued stay reviews using approved medical necessity criteria.
Coordinates patient care and communicates with physicians, patients, caregivers, and third-party payers.
Manages patient progression through the healthcare system and proactively works with payers to secure certification and minimize denials.
Ochsner Health is a leading not-for-profit healthcare provider in the Gulf South, with 46 hospitals and 370+ care centers. It employs more than 38,000 team members and has been recognized as a top workplace and the No. 1 hospital in Louisiana.
Perform medical necessity and level of care reviews using clinical judgment and guidelines.
Obtain member information via telephone and fax to assess condition and apply evidence-based criteria.
Meet decision-making SLAs and refer members for further care engagement when needed.
Oscar Health is a technology-driven health insurance company focused on simplifying healthcare for its members. We are a mission-driven organization with a diverse team, committed to innovation and equity in healthcare.
Conduct clinical and billing reviews of claims, itemized bills, and UB-04 forms to ensure accuracy.
Perform utilization reviews to assess medical necessity and validate charges against policies.
Mentor reviewers, meet productivity targets, and maintain active RN licensure with CEUs.
Our partner is a healthcare services company that conducts medical claims and utilization reviews to ensure accurate billing and appropriate care. They offer a collaborative, quality-focused remote environment with opportunities for professional development.
Analyze and summarize medical records, highlighting relevant clinical findings for attorneys.
Prepare medical chronologies and long-term care assessments to support case evaluations.
Provide objective, evidence-based medical insights and coordinate with expert witnesses.
The partner company provides specialized legal nurse consulting services to attorneys, analyzing medical records and supporting injury-related cases. This role offers flexible, part-time contract work in a fully remote environment.
Perform concurrent medical record reviews on nursing units to clarify patient documentation.
Prompt physicians to resolve missing, unclear, or conflicting documentation for appropriate reimbursement.
Provide education to patient care providers on clinical documentation standards and coding requirements.
Virginia Mason Franciscan Health provides a full spectrum of health care services across the Puget Sound region, with a legacy of compassionate care and innovation. With 10 hospitals and nearly 300 care sites, the organization is dedicated to healing the whole person through rigorous research, education, and collaboration.
Review a variety of claim types including Radiology, Ambulance, Physical Therapy, and Surgical for medical necessity and coverage.
Document medical rationale for payment or denial decisions using Medicare guidelines and established criteria.
Educate internal and external staff on medical review, terminology, coverage determinations, and coding.
We transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, we are built on integrity, collaboration, and excellence.
Perform clinical reviews to evaluate medical necessity, level of care, and benefit coverage for members.
Apply internal policies, MCG, and NCCN guidelines to deliver timely and compliant utilization management decisions.
Escalate complex cases and build audit-ready documentation for Medical Director review.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. Their mission-driven culture empowers diverse perspectives to drive real impact on people's health.
Conduct medical necessity reviews and continued stay reviews using approved clinical criteria to support quality and financial outcomes.
Collaborate with liaisons, physicians, and revenue cycle teams to manage denials, appeals, and appropriate levels of care.
Maintain documentation, monitor utilization trends, and facilitate patient care planning across the care team.
Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They empower associates to challenge the status quo and put people first, fostering a collaborative and innovative culture.
Conduct comprehensive reviews of home health pre-claim review packages for Medicare compliance.
Document review outcomes with clinical rationale and meet a 7-business-day turnaround.
Maintain 98% accuracy and complete required training and quality assurance sessions.
Broadway Ventures is a consulting firm providing program management, technology, and innovative solutions to government and private sector clients. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it emphasizes integrity, collaboration, and excellence in its culture.
Provide clinical and administrative support to a remote healthcare team during weekends, holidays, and peak patient volume.
Review laboratory results, coordinate referrals and pharmacy communications, and document actions in the EMR.
Work independently while collaborating with physicians, PAs, and care coordinators to ensure continuity of care.
The partner company is a growing virtual care organization delivering remote healthcare services across Canada. Their team focuses on inclusive, accessible patient care and multidisciplinary collaboration.
Manage and triage patient vital signs remotely, using motivational interviewing to drive positive health behavior changes.
Perform monthly wellness calls with patients, collaborating with care teams to set patient-centric goals.
Escalate urgent care needs appropriately and meet program engagement metrics in a remote MST-based role.
Vivo Care is building a future where care is continuous, personal, and connected, challenging the status quo in healthcare. We are a fast-growing startup where everyone has a voice, fostering a culture of inclusion, collaboration, and innovation.
Perform medical reviews and utilization management to determine medical necessity for services and appeals.
Evaluate medical records and document decisions using clinical guidelines and protocol sets.
Educate members, providers, and staff on coverage determinations, medical terminology, and coding procedures.
Palmetto GBA is a healthcare administrator and one of the nation's largest medical claims processors. As part of BlueCross BlueShield of South Carolina, we've served clients for 70+ years and offer training and tuition assistance.
Perform prospective, concurrent, and retrospective reviews of healthcare services to ensure medical necessity and appropriate level of care.
Contact medical and support personnel to recommend alternative treatment plans and coordinate care across the healthcare continuum.
Research and resolve issues related to benefits, eligibility, and appeals while delivering targeted education to providers.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, covering claims administration, payment integrity, and care management. The company is experiencing significant momentum and investing in employees who directly shape the future of healthcare technology.
Oversee medical necessity reviews for home health, acute, post-acute, and outpatient services for Medicare Advantage populations.
Collaborate with treating physicians, nursing teams, and external agencies to promote evidence-based care and appropriate resource utilization.
Apply CMS regulations, coverage determinations, MCG criteria, and medical policies in a fully remote, part-time physician leadership role.
Jobgether is an AI-powered job matching platform that connects candidates with employers. It uses objective screening to share top-fitting applicants with hiring companies, emphasizing data privacy and human oversight throughout the recruitment process.
Support medication-focused clinical programs to improve patient health outcomes and medication adherence through education, outreach, and medication reviews.
Conduct outbound calls to confirm medication use, provide education, and counsel patients on complex regimens.
Use electronic health record systems to document interactions accurately and support efficient clinical workflows.
This company provides medication-focused clinical programs to improve patient health outcomes and medication adherence. It operates as a fully remote team with multidisciplinary collaboration, though specific size and culture are not detailed.
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established coverage guidelines.
Educate teams on medical review processes and support quality control activities.
Broadway Ventures is a veteran-owned small business delivering mission-critical support to federal health and defense customers. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it is built on integrity, collaboration, and excellence.
Guide patients through complex health concerns and help them achieve wellness goals while addressing social determinants of health.
Build trusting relationships through empathetic listening and create comprehensive care plans for consistent action.
Work 100% remotely as a 1099 contractor, setting your own hours and interacting with patients via video or phone.
Solace pairs patients with expert healthcare advocates to navigate the complex U.S. healthcare system and improve health outcomes. A lean, mission-driven Series C startup founded in 2022, its U.S.-based team is intense, urgent, and passionate about redefining healthcare.
Oversee system-level utilization management activities across the organization.
Ensure compliance with medical necessity criteria such as InterQual and Milliman.
Manage professional staff and review processes to optimize patient care.
Piedmont Healthcare is a healthcare system providing comprehensive medical services. It is a large organization focused on utilization management and quality care.
Coordinates utilization review and prior authorization requests, ensuring accurate entry into the UM platform.
Provides customer service to providers and members, confirming benefits and answering authorization questions.
Facilitates communication between reviewers, hospitals, and physicians to ensure timely decisions.
University of Utah Health Plans is a patient-focused organization that enhances health through patient care, research, and education. It is part of a nationally ranked academic medical center with five hospitals and eleven clinics, fostering a culture of collaboration and excellence.
Conduct clinical audits for suspected fraud, waste, and abuse with high autonomy.
Document findings in formal reports, graphs, and audit logs, aligning with unit goals.
Develop and present FWA-related education to Oscar teams, ensuring compliance with regulations.
Oscar is a health insurance company built on a full stack technology platform, focused on serving members like a doctor in the family. Founded in 2012, it is a forward-thinking company that values diversity and innovation, with a culture of fostering belonging and support.