Oversee the Complex Clinical Bill Review team, managing production expectations, SLAs, client communication, and team performance.
Analyze and track internal business requirements, continuously evaluate functionality across programs, and perform requirements gathering to solve process issues.
Monitor team performance metrics, identify growth opportunities, and coordinate system enhancements including JIRA and UAT testing.
Supervise a team of 10-15 ECM staff to ensure high-quality care management services.
Oversee client outreach, enrollments, and Individual Care Plans, serving as escalation point.
Drive team to meet KPIs, collaborate on process improvements, and provide clinical oversight 30% of the time.
Vynca provides comprehensive care for individuals with complex needs, focusing on more quality days at home. The company fosters a close-knit community culture guided by core values of Excellence, Compassion, Curiosity, and Integrity.
Lead daily workflow of a remote team of up to 20 RNs, ensuring productivity and operational metrics are met.
Audit RN performance and clinical documentation to ensure compliance with APCM protocols.
Coach RNs through structured feedback and manage performance improvement plans.
Cadence is a clinical AI company that automates chronic disease treatment. It partners with over 20 health systems, serves 100,000+ patients, and was named a Top HealthTech Company by TIME and a Top Startup by LinkedIn.
Lead and support a remote clinical support team to ensure exceptional patient service and operational excellence.
Coach and mentor team members while overseeing performance, quality audits, and provider workflows.
Drive continuous improvement initiatives and maintain adherence to clinical and quality standards.
Ways2Well is redefining healthcare through regenerative and preventive medicine, offering data-driven personalized care. They operate as a remote clinical support team with a focus on high-impact healthcare and patient empowerment.
Set daily direction for your UM team, establishing priorities and reinforcing expectations.
Coach reviewers on criteria application, guiding consistent use of medical-necessity criteria.
Monitor workflow health daily, tracking intake volume and turnaround risk.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. The team is on a mission to empower people to lead healthier lives.
Review medical records to develop concise clinical reviews supporting authorization and reimbursement.
Facilitate communication with payors to ensure appropriate utilization management decisions.
Collaborate with interdisciplinary team to prevent denials and optimize patient care.
West Virginia University Health System is West Virginia’s largest health system, providing comprehensive healthcare services. With over 35,000 employees and 25 hospitals, it is the state's largest employer and offers a collaborative, patient-centered culture.
Manage a defined patient caseload while overseeing the clinical performance and compliance of an assigned team of Care Managers.
Conduct proactive outreach, device data review, care plan updates, and care coordination consistent with team standards.
Lead client-facing engagements, performance reviews, and escalation calls, representing Welby Health with clinical authority.
Welby Health is a San Diego-based healthcare organization that transforms complex condition management through technology-enabled care coordination and data-driven insights. The company partners with physicians and health systems to deliver scalable solutions improving quality of care.
Conduct Skilled Nursing Facility medical claims audit reviews applying medical review guidelines.
Document findings and generate articulation letters for audit results.
Collaborate with audit team and clients to improve medical policies and workflows.
Machinify is a leading healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. Deployed by over 85 health plans representing more than 270 million lives, the company uses an AI-powered platform and best-in-class expertise to reimagine healthcare.
Analyze health plan reports and clinical data to identify members eligible for case management.
Conduct comprehensive telephonic and virtual assessments to evaluate medical, behavioral, and social needs.
Develop, implement, and monitor individualized care plans with measurable goals and interventions.
Duly Health and Care is a physician-led medical group offering a connected network of primary and specialty care, surgery centers, imaging, lab, and therapy services. They foster a collaborative culture centered on putting patients first and supporting team growth.
Manage care for high-risk members by identifying needs and coordinating clinical, community, and in-network resources.
Perform utilization management reviews, ensure quality oversight, and support accreditation readiness.
Collaborate with multidisciplinary teams to analyze member outcomes and drive continuous improvement.
They are a health plan focused on improving outcomes for high-risk members through care coordination and quality initiatives. Their team values collaboration, clinical excellence, and mission-driven work to enhance community health.
Oversee all nursing activities for clinical research studies in the Southeast region, ensuring compliance with regulations and protocols.
Manage per diem mobile research nurses, including training, documentation, and quality control of data collection.
Serve as the nursing subject matter expert for assigned studies, collaborating cross-functionally to support study execution.
Science 37 accelerates clinical research by enabling universal trial access for patients through Direct-to-Patient Site and Patient Recruitment solutions, powered by a proprietary technology stack. The company employs in-house medical and operational experts to enhance quality and streamline study orchestration, fostering a culture of innovation and teamwork.
Review Home Health prior authorization requests using CMS guidelines and clinical judgment.
Lead and mentor the Home Health UM nursing team, ensuring quality and compliance.
Collaborate with cross-functional partners to optimize care and improve utilization.
Clover Health provides high-quality, affordable healthcare for America's seniors by combining data, technology, and preventive care. They are a mission-driven team with diverse expertise, focused on improving members' lives through innovation and empathy.
Define and maintain clinical standards for home visits, including medication administration, infusion practices, and patient assessment.
Investigate adverse events and near misses, conduct root cause analyses, and implement corrective actions.
Collaborate cross-functionally to integrate clinical quality into product development, analytics, and compliance.
They provide home-based specialty pharmacy and infusion care services. They are a rapidly scaling healthcare technology company focused on quality, patient safety, and cross-functional collaboration.
Conduct telephonic clinical assessments and health education using nursing process and protocols.
Utilize critical thinking to triage, make care recommendations, and document patient interactions.
Work a schedule including evenings and weekends, with full-time flexibility and remote setup.
Carenet Health provides clinical services and health education to patients through innovative telephonic channels. They are a growing organization with a collaborative team of registered nurses across the United States.
Review medically complex claims, pre-authorization requests, appeals, and fraud and abuse referrals.
Assess payment determinations using clinical information and established guidelines.
Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
Broadway Ventures transforms 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 empower clients with tailored solutions, operating with integrity and collaboration.
Support clinical process improvement initiatives and monitor performance to client SLAs.
Conduct root cause analyses and develop remediation plans for process variations.
Collaborate with product and analytics teams to optimize letters and template tracking.
Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans and providers to optimize care quality and reduce costs. The company has been named to the Inc. 5000 list and ranked a Top 5 LinkedIn Startup, backed by leading investors, with a culture that values empathy and collaboration.
Review and evaluate electronic medical records of emergency department admissions to screen for medical necessity using InterQual or MCG criteria.
Apply evidence-based clinical guidelines to assess and ensure proper utilization of healthcare resources.
Enter clinical review information into the system for transmission to insurance companies for authorization.
Netsmart provides advanced healthcare technology solutions for post-acute and human services clients, enabling better care through a comprehensive platform. We are a vision-driven team passionate about innovation, and we have been recognized as one of the best companies to work for.
Coordinate and provide care that is timely, effective, and member-centric while following HMO processes.
Manage case assignments including outreach, documentation, monitoring for case progression, and case closure.
Assist members in reaching wellness by addressing barriers, social determinants, and psychosocial issues.
Guidehealth is a data-powered healthcare company dedicated to making great healthcare affordable and improving patient outcomes. It is a physician-led, performance-driven organization with a culture of empathy, accountability, and continuous learning.
Directly supervise, coach, and develop the non-clinician care team, setting performance expectations and productivity targets.
Own clinician scheduling and coverage planning across a 24x7x365 operation, managing PTO, shift swaps, and real-time staffing decisions.
Drive patient queue management and throughput to meet SLAs, identifying bottlenecks and implementing AI-driven improvements.
Curai Health is an AI-powered virtual multispecialty primary care clinic that uses machine learning to deliver affordable and accessible healthcare. It is a remote-first company with a mission-driven team committed to improving health outcomes at scale.
Provides comprehensive remote patient support and care coordination to optimize health outcomes in a virtual environment.
Collaborates with physicians and healthcare team members to assess patient status and develop personalized care plans.
Monitors patient progress, educates on disease processes, and advocates for patient needs to ensure high-quality care.
St. Joseph's Hospital and Medical Center is a 571-bed not-for-profit hospital in Phoenix, Arizona, offering quaternary care, medical education, and research. It is a nationally recognized center with over 125 years of history, consistently named an outstanding place to work.