Perform comprehensive medical record and claims review to make payment determinations for Medicare PART A.
Conduct in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles.
Make clinical judgment decisions based on clinical experience when applicable.
Empower AI provides federal agency leaders with tools to elevate their workforce's potential through meaningful transformation. Headquartered in Reston, Va., Empower AI leverages three decades of experience solving complex challenges in Health, Defense, and Civilian missions.
Review medically complex claims, pre-authorization requests, appeals, and fraud/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 (SDVOSB), they empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth.
Review medically complex claims, pre-authorization requests, appeals, and fraud/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 (SDVOSB), they empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth.
Review clinical information for appropriateness, congruency, and accuracy.
Review and communicate OASIS edit recommendations to each clinician.
Provide customer service/education and act as a resource to Medicare Certified Offices.
BAYADA Home Health Care delivers home health care with compassion, excellence, and reliability. As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates, with 50 years of experience.
Maintain a working knowledge and understanding of DMEOPS CPT and ICD-10 codes.
Utilize the company billing and collections system to identify and resolve any claims that have been unpaid, short paid and/or denied.
Review EOB's and other correspondence from insurance companies for correct reimbursement according to rules and regulations and contract terms.
Hanger, Inc. is the world's premier provider of orthotic and prosthetic (O&P) services and products, offering the most advanced O&P solutions, clinically differentiated programs and unsurpassed customer service. They have 160 years of clinical excellence and innovation, and its vision is to lead the orthotic and prosthetic markets by providing superior patient care, outcomes, services and value.
Review patient records to ensure documentation aligns with medical, legal, regulatory, and insurance standards.\n- Abstract appropriate supporting documentation into abstraction tool.\n- Collaborate with healthcare providers or internal staff to clarify unclear or incomplete documentation.
Capital Blue Cross promises to go the extra mile for its team and community, and its employees consistently vote it one of the “Best Places to Work in PA”. The company offers a flexible environment where health and wellbeing are prioritized and invests in training and continuing education.
Coordinate and support the hospital’s Utilization Review and Case Management program.
Review patient charts and clinical documentation to verify medical necessity.
Monitor patient progress and coordinate care management strategies.
NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. With hospitals in Indiana, Michigan, Texas, and Arizona, they’re expanding access to their unique model of care across the United States.
Perform in-depth medical claim reviews using UB-04 and itemized statements.
Verify itemized charge accuracy based on policy and industry standards.
Validate system denials and suggest system enhancements for efficiency.
Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. They bring together an AI-powered platform, are deployed by over 85 health plans, and represent more than 270 million lives.
Complete timely review of healthcare services using appropriate medical criteria to support determinations.
Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make great healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages Healthguides™ and a Managed Service Organization to build stronger connections with patients and providers.
Ensuring the accuracy, integrity, and quality of coding practices within the HIM department.
Conducting thorough reviews of clinical documentation, coding, and billing processes to ensure compliance.
Educating and training coding staff on best practices and updates in coding guidelines.
Cooper University Health Care is committed to providing extraordinary health care. They focus on clinical innovations and access to facilities, equipment, technologies and research protocols, and offer competitive rates, compensation programs, benefits, and career growth.
Provide clinical insight to support attorneys in healthcare legal cases.
Organize and manage electronic medical records for efficient case review.
Conduct medical literature research and prepare summaries for case allegations.
TLC Management's mission is grounded in compassionate care, accountability, and doing what’s right—every time. As a multi‑state senior care organization, they are committed to supporting our communities with strong clinical practices, ethical leadership, and thoughtful decision‑making.
Processes acute and post-acute inpatient medical and select intensive outpatient higher level of care requests through clinical review.
Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies to requests.
Collaborates with UM department staff and Medical Directors to make a final determination, and with Care Management staff on discharge planning.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. At Capital, employees work alongside a caring team of supportive colleagues and are encouraged to volunteer in their community.
Assess referred concurrent denials and determine next steps for resolution.
Review medical record documentation to support denial management strategies.
Advocate for patients to ensure coverage and reimbursement.
They are currently looking for a Utilization Management Coordinator. By enhancing operational efficiencies and implementing educational initiatives, this role significantly impacts the financial and quality outcomes of healthcare delivery.
Responsible for answering phone calls and emails in a timely manner, professionally answering questions from clients, insurances, or patients.
Review patient documentation for accuracy and qualification, manage shipments by sending sales orders, and review sales orders for accuracy after shipment completion.
Create claims and/or invoices confirming sales orders, billing electronically or via paper, and monitor the patient billing module, updating information as needed.
Cala Health strives to free individuals from chronic diseases, starting with a non-invasive prescription therapy for hand tremor and expanding into neurology and cardiology. They empower thousands to regain confidence and ease in their lives by applying pioneering technology and offer a comprehensive benefits package aligned with their compensation philosophy.