Conduct clinical reviews of inpatient admissions and continued stays using approved medical necessity criteria.
Collaborate with physicians, care managers, and payer teams to resolve utilization concerns and prevent denials.
Support quality improvement initiatives, maintain accurate documentation, and communicate review outcomes effectively.
This role is with a partner company focused on healthcare utilization management, helping hospitals improve patient outcomes and ensure appropriate resource use. The team operates as a distributed remote group supporting care coordination, revenue integrity, and clinical compliance.
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.
Audit medical summaries, timelines and record classifications against source records.
Write clinical review guidelines and gold-standard examples for research and engineering teams.
Flag clinically significant omissions, causation issues and prior-history findings.
Brighterway builds AI-native claims software and administration for casualty claims, starting with workers' compensation medical-legal review. The team is small, technical, and close to customers, with everyone shipping and talking directly to users.
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.
Review inpatient medical records to validate DRG coding accuracy.
Apply clinical judgment to identify discrepancies, coding errors, and overpayments.
Document evidence-based audit findings and meet quality standards.
The company specializes in healthcare claims auditing and analytics, improving accuracy and consistency in payments. It is a collaborative, fully remote environment that values precision, teamwork, and continuous improvement.
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.
Audit skilled nursing facility (SNF) medical claims for medically appropriate services using applicable guidelines and policies.
Document findings, generate audit letters, and support audit findings during the appeals process.
Work collaboratively with the audit team, clients, and contractors to improve medical policies and audit workflows.
Machinify is a healthcare intelligence company with expertise across the payment continuum, delivering value, transparency, and efficiency to health plan clients. Deployed by over 85 health plans representing more than 270 million lives, the company combines an AI-powered platform with best-in-class expertise to drive down healthcare costs.
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.
Audit medical claims for government payers, applying medical review guidelines and documenting findings.
Generate letters articulating audit findings and support them during the appeals process.
Collaborate with the audit team and clients to improve medical policies and minimize appeals.
Machinify is a healthcare intelligence company providing AI-powered payment solutions for health plans. It serves over 85 health plans and more than 270 million lives, with a culture focused on innovation and reducing healthcare costs.
Review and validate assigned assessments (SOC, ROC, Recert, Transfer, Discharge) for accuracy and completeness.
Identify and correct errors impacting reimbursement, quality measures, or compliance before submission.
Provide actionable feedback and education to field clinicians to improve documentation and process outcomes.
Adaptive Home Health is a Texas-based home health agency building a higher-acuity, patient-centered care model. They use technology to streamline documentation and QA workflows, supporting clinical operations and compliance teams in a remote-first environment.
Conduct clinical reviews of medical records during fraud investigations and program integrity initiatives.
Apply Medicare and Medicaid guidelines to determine appropriateness of payment coverage.
Compile investigative summary reports and provide training on medical terminology and policy interpretation.
CoventBridge Integrity Systems delivers investigative services, technology, and expertise that help healthcare and government organizations protect critical programs, strengthen oversight, and address fraud, waste, abuse, and operational risk. They are an equal opportunity employer committed to diversity and inclusion, maintaining a drug-free workplace.
Perform prospective, concurrent, and retrospective utilization review to ensure medical necessity and appropriate level of care.
Research and respond to appeals, coordinate discharge planning, and analyze care patterns.
Collaborate with providers and internal teams to resolve benefit and eligibility issues.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, helping them modernize operations and compete effectively. The company is expanding and investing in its people, offering opportunities to shape the future of healthcare technology.
Review, investigate, and appeal denied hospital insurance claims using clinical documentation and payer policies.
Develop evidence-based appeal letters addressing medical necessity, level-of-care, and charge discrepancies.
Collaborate with nursing, revenue integrity, and financial teams to resolve denials and prevent future rejections.
This partner company is a healthcare system that provides hospital services and focuses on revenue integrity. It supports fully remote work and values clinical expertise, collaboration, and financial sustainability.
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 high-volume outbound telephone outreach to patients to introduce pharmacy services and guide them through enrollment.
Document patient consent and update electronic health records, including preferred pharmacy and electronic prescriptions.
Manage outreach queues, meet call center performance expectations, and uphold HIPAA privacy standards.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered approach. The company fosters an innovative, evolving environment focused on improving patient outcomes and quality of life.
Conduct telephonic nursing assessments and triage using clinical protocols.
Provide health education and care recommendations to patients.
Collaborate with remote RNs to meet quality and performance metrics.
Carenet Health delivers telephonic clinical assessments, health education, and utilization management services. They are a growing, collaborative company with a nationwide remote team of registered nurses.
Review lab results issued through Maple and assign appropriate follow-up recommendations for patients.
Contact patients directly when critical results require immediate emergency care and escalate complex cases to physicians.
Support specialist referrals, prepare documentation, and review consult reports to ensure timely follow-up.
Maple is Canada's leading on-demand healthcare platform, connecting patients with Canadian-licensed doctors, nurse practitioners and specialists. With over 8 million patients and 7,000 business and government partners, Maple empowers bold thinking and an inspiring team culture focused on making an impact.
Evaluate AI-generated clinical interactions for accuracy, safety, and appropriateness.
Annotate and score AI responses against evidence-based protocols and structured rubrics.
Provide detailed written feedback and participate in calibration sessions to enhance AI reliability.
The company focuses on improving AI-powered clinical solutions by leveraging clinical expertise. It is an early-stage partner organization offering flexible, remote contract opportunities for healthcare professionals.
Oversee delegated audits related to UM, Credentialing, Claims, Enrollment, and Appeals processes to ensure compliance with payer contracts.
Educate staff, update policies and workflows, and act as a liaison between payers and local market leadership during audits.
Operationalize regulatory communications from governing bodies and document process changes for upstream and downstream teams.
Dignity Health Management Services offers integrated management and business services to healthcare providers, focusing on managed care administrative and clinical services to contain costs and improve quality. It is part of CommonSpirit Health, a large health system with a mission-driven culture centered on community and patient care.