Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes.
Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process.
Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
Virtua Health strives to connect individuals to the care they need, building a healthier community in South Jersey. They are a Magnet-recognized health system with over 14,000 colleagues, including over 2,850 doctors, physician assistants, and nurse practitioners.
Create a welcoming experience by authentically engaging every caller, every time.
Thoroughly and accurately answer questions about customers’ healthcare accounts.
Thoughtfully listen to callers’ needs and provide appropriate solutions.
Point C is a National third-party administrator (TPA) with local market presence that delivers customized self-funded benefit programs. They research the most effective cost containment strategies and are driving down the cost of plans with innovative solutions.
Support clinical staff by gathering data to complete the medical necessity review process.
Create and send letters to providers and/or members to communicate information.
Collaborate with care management teams and stakeholders to provide optimal service.
Wellmark is a mutual insurance company owned by policy holders across Iowa and South Dakota, and they’ve built their reputation on over 80 years’ worth of trust. They are motivated by the well-being of their members, putting them first and committing to sustainability and innovation.
Assists in coordinating patient care with medical staff by reviewing and maintaining provider schedules.
Ensures patient-specific needs are met by arranging interpretation services as needed.
Prepares patients for virtual appointments by ensuring the patient has what is needed for their appointment.
Ascend Healthcare provides fully integrated, quality psychiatric and behavioral health services. They foster a professional, collaborative, and rewarding workplace culture, dedicated to making a profound impact on diverse communities through exceptional patient care.
Authorizes and reviews utilization of mental health and substance abuse services.
Collects and analyzes utilization data and assists with discharge planning and care coordination.
Provides member assistance with mental health and substance abuse issues, and participates in quality improvement projects.
Magellan Health, Inc. is committed to making a difference in the healthcare industry and communities. They value professional growth and development, total health and wellness, rewards and recognition, as well as employee unity, offering a place where you can thrive.
Processes acute and post-acute inpatient medical or behavioral health and select intensive outpatient higher level of care requests through review of the submitted request and applicable clinical records
Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination, and with Care Management staff on discharge planning and transition of care activities.
Identifies and refers members with complex needs to the appropriate population health and/or care management program.
Capital Blue Cross promises to go the extra mile for our team and our community. Our employees consistently vote us one of the “Best Places to Work in PA, and we foster a flexible environment where your health and wellbeing are prioritized.
Manages client denials and concerns through analytic review of clinical documentation.
Delivers final determination based on skillsets and partnerships with Humana parties.
Investigates and resolves member and practitioner issues via phone or face to face to support quality goals.
Humana Inc. is committed to putting health first for teammates, customers, and the company. Through Humana insurance services and CenterWell healthcare services, they strive to make it easier for millions to achieve their best health, delivering needed care and service.
Act as the primary point of contact for new patients calling and emailing in.
Efficiently register and onboard a high volume of new patients.
Precisely verify patient insurance information to confirm active coverage and eligibility.
Form Health is a virtual obesity medicine clinic delivering multi-disciplinary evidence-based obesity treatment through telemedicine. Founded in 2019, Form Health is a venture-backed innovative startup with an experienced clinical and leadership team that values its employees.
Answer incoming inquiries from patients, answer questions, and schedule appointments
Make outbound phone calls to patients, pharmacies, and insurance companies
Create and triage tickets in ServiceNow
Talkiatry transforms psychiatry with accessible, human, and responsible care. They’re a national mental health practice co-founded by a patient and a triple-board-certified psychiatrist to solve the problems both groups face in accessing and providing the highest quality treatment.
Handle a high volume of calls requesting assistance with accessing behavioral health services.
Prioritize cases based on shifting needs and resources.
Work with on-call providers to triage requests, organize their workload, and secure documentation.
Array Behavioral Care is a virtual psychiatry and teletherapy practice. They aim to transform access to timely behavioral health care via telepsychiatry solutions and services.
Making outbound calls to patients, members, and customers.
Helping patients make decisions that will enhance their healthcare experience.
Assisting members and patients with benefits and insurance information.
Carenet Health pioneers advancements for experiences across the healthcare consumer journey, interacting with 1 in 3 Americans daily. They integrate human touch with data-driven technology to improve healthcare, offering best-in-class clinical expertise and personalized solutions.
Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
Guide timely care determinations using CMS regulations and evidence-based practices.
Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
HJ Staffing is seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. The company has not provided any information about its size/employees and culture but is likely a medium to large medical or staffing company.
Performing physician-level utilization management reviews for behavioral health services across all applicable levels of care.
Conducting peer-to-peer consultations with treating psychiatrists and other behavioral health providers.
Serving as a consultative clinical resource to behavioral health utilization management nurses, care managers, and operational leaders.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and AI, they leverage remotely-embedded Healthguides™ and a centralized Managed Service Organization.
Supporting an estimated 7 hours daily on telephonic support to our members and providers.
De-escalate situations by actively listening to members’ and providers' concerns and adopting a solution-focused approach.
Manage all things care coordination, including but not limited to: maintaining patient charts, rescheduling appointments, executing prescription authorization forms.
Spring Health is on a mission to revolutionize mental healthcare by removing every barrier that prevents people from getting the help they need. They partner with over 450 companies and provide care for 10 million people.
Own and manage the member-facing phone line, delivering compassionate, timely, and solutions-oriented support.
Manage expedient and accurate Verifications of Benefits (VOBs) to ensure members can access care without delay.
Collaborate and strategize cross-functionally with our member growth team to streamline onboarding and ensure a seamless member experience.
Amae Health provides outpatient psychiatric and primary care health services through value-based care arrangements. They are a Series B venture-backed Public Benefit Corporation dedicated to becoming the nation's center of excellence for individuals living with severe mental illness.
Accountable for making decisions supported by policy based on confidential financial information both from the facility and from patients to determine qualification for CICP, Charity programs, or payment arrangements.
Verify coverage and authorization for all scheduled procedures through scheduling and registration information.
Act as a liaison between the patients, physicians, patient clinics, case management, centralized billing office, third party Medicaid eligibility vendor and community agencies.
CommonSpirit is accessible to nearly one out of every four U.S. residents. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.
Be a first point of contact and deliver exemplary service to our members and providers through multiple channels including phone, email and live chat
Support members in account set up, enrollment, pharmacy coordination, and booking appointments with providers
Provide first-line technical support and escalate technical and member experience issues following standardized operating procedures
Maven Clinic is the world's largest virtual clinic for women and families, aiming to make healthcare accessible for everyone. They provide clinical, emotional, and financial support via their digital platform, serving over 2,000 employers and health plans; they have a flexible and inclusive work environment and have received over 30 workplace and innovation awards.
Conduct outbound and inbound calls to potential patients to explain services and assist with enrollment or scheduling.
Complete short intake forms to accurately collect demographic, eligibility, and clinical information.
Schedule patient appointments based on availability, location, and provider match.
Zócalo Health is a tech-driven healthcare provider built for Latinos, by Latinos, developing a new approach to care designed around shared experiences. Founded in 2021, they are backed by leading healthcare and social impact investors and are committed to expanding their reach to serve more members and communities.
Prioritizing tasks and managing a schedule of meeting a high volume of members to conduct introductory video appointments
Upholding our value of moving fast by answering and assisting with questions about our product and providing personalized recommendations for supporting member needs
Demonstrating our value of “walking through walls” to deliver an exceptional customer service experience to our members and escalating concerns or questions appropriately
Maven is the world's largest virtual clinic for women and families, aiming to make healthcare work for everyone. With over 2,000 employers and health plans trusting their platform, Maven offers clinical, emotional, and financial support across various stages of life.