Source Job

• Conduct coverage reviews based on member plan benefits and policies.
• Document clinical review findings, actions, and outcomes.
• Communicate and collaborate with providers for benefit determinations.

Capital Blue Cross promises to go the extra mile for their team and community. They foster a flexible environment where health and wellbeing are prioritized and employees consistently vote it as one of the "Best Places to Work in PA."

• 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.

• Conduct clinical reviews for inpatient admissions and post-acute settings using evidence-based guidelines and CMS criteria.
• Serve as the primary physician reviewer for escalated or complex cases requiring high-level medical judgment.
• Partner with care management teams to identify utilization trends and develop interventions to reduce unnecessary admissions or extended stays.

It appears to be a healthcare organization. They ensure timely and appropriate care determinations for their Medicare Advantage members.

• 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.

• 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.

• Working with a team of Intake Coordinators and Utilization Review Nurses to ensure quality and timely determinations.
• Striving for continuous improvement and an excellent work-life balance to produce top-notch results.
• Coordinating and providing care management that is timely, effective, efficient, equitable, safe, and member centered.

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers.

• 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.

• Review and refine AI-generated clinical summaries and indicators related to medical necessity.
• Collaborate with Product and Data Science teams to define and validate clinical logic.
• Translate clinical knowledge into prompts and guidelines for large language models.

SmarterDx builds clinical AI that is transforming how hospitals translate care into payment. Founded by physicians in 2020, their platform connects clinical context with revenue intelligence, helping health systems recover millions in missed revenue, improve quality scores, and appeal every denial.

• Provide support to the Utilization Management Nurse and RN Appeals Writer.
• Help prevent clinical denials related to lack of clinical authorization and untimely notifications.
• Investigate root cause of clinical denials and document them in Epic and follow-up of appeal outcome.

Piedmont Healthcare provides healthcare services. They value diverse teams, a shared purpose, and schedule flexibility.

• Answers first level calls in Utilization Review.
• Evaluates certification requests by reviewing group specific requirements.
• Triage the call to determine if a Utilization Review Nurse is needed.

Cottingham & Butler sells a promise to help clients through life’s toughest moments by hiring, training, and growing the best professionals. The company culture is guided by the theme of “better every day” constantly pushing themselves to be better than yesterday.

• Create and maintain client profiles by accurately inputting information into the client's system
• Work closely with clinical staff to retrieve necessary information required for processing patient claims
• Verify the completeness and accuracy of client information, make necessary updates, and review and analyze claim documentation for compliance with established guidelines and requirements

Limitlessli specializes in recruiting, hiring, and managing high-caliber remote staff for dynamic and growing healthcare facilities. They connect clients with highly qualified professionals, offering tailored services to meet their clients' unique business needs.