Review prior authorization requests and make evidence-based decisions using clinical guidelines.
Ensure compliance with federal, state, and internal regulations while accurately documenting clinical decisions.
Provide clear, empathetic support to members, prescribers, and pharmacies, staying current with prescribing guidelines and regulatory changes.
SmithRx is a rapidly growing, venture-backed Health-Tech company that disrupts the expensive Pharmacy Benefit Management (PBM) sector with a next-generation drug acquisition platform. Since 2016, they have onboarded hundreds of thousands of members and pride themselves on a mission-driven, collaborative culture guided by values of Integrity, Courage, and Together.
Coordinates utilization review and prior authorization requests, ensuring accurate entry into the UM platform.
Provides customer service to providers and members, confirming benefits and answering authorization questions.
Facilitates communication between reviewers, hospitals, and physicians to ensure timely decisions.
University of Utah Health Plans is a patient-focused organization that enhances health through patient care, research, and education. It is part of a nationally ranked academic medical center with five hospitals and eleven clinics, fostering a culture of collaboration and excellence.
Perform prospective, concurrent, and retrospective reviews of healthcare services to ensure medical necessity and appropriate level of care.
Contact medical and support personnel to recommend alternative treatment plans and coordinate care across the healthcare continuum.
Research and resolve issues related to benefits, eligibility, and appeals while delivering targeted education to providers.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, covering claims administration, payment integrity, and care management. The company is experiencing significant momentum and investing in employees who directly shape the future of healthcare technology.
Perform patient-specific medication reviews and develop recommendations for medical drug utilization management and Medication Therapy Management.
Resolve medication and pharmacy issues for members triaged from Member Services or other departments.
Act as subject matter expert for audits, quality improvement, and LEAN projects.
IEHP is a not-for-profit health plan dedicated to healing and inspiring the human spirit by providing quality healthcare services to members. They emphasize a supportive culture with career growth and wellness programs for their team.
Review and process prior authorization requests for various medications.
Communicate prior authorization criteria to providers and act as a help desk.
Process requests via phone, fax, and web submission while maintaining HIPAA compliance.
Lumicera Health Services is a specialty pharmacy focused on optimizing patient well-being through transparency and stewardship. It fosters a diverse and creative work environment as part of the Navitus organization.
Manage end-to-end drug prior authorization and claims cases, assessing requests against clinical guidelines and plan provisions.
Communicate authorization outcomes clearly to members, providers, and internal stakeholders while resolving escalated and complex scenarios.
Serve as a subject matter expert to support teams, training, and continuous improvement initiatives.
The hiring company operates in the insurance and benefits sector, managing complex drug prior authorization and claims cases. It is a global organization with a collaborative culture that values flexibility, continuous improvement, and employee well-being.
Review, process, and troubleshoot incoming Prior Authorization requests for various medications.
Accurately process requests according to regulatory and client-specific guidelines while meeting departmental performance metrics.
Work with clinical teams and handle requests via phone, fax, and web submission.
Navitus is a pharmacy benefit manager (PBM) alternative focused on reducing drug costs to make medications more affordable. The company offers a diverse and creative work environment with numerous employee benefits and growth opportunities.
Perform medical necessity and level of care reviews using clinical judgment and guidelines.
Obtain member information via telephone and fax to assess condition and apply evidence-based criteria.
Meet decision-making SLAs and refer members for further care engagement when needed.
Oscar Health is a technology-driven health insurance company focused on simplifying healthcare for its members. We are a mission-driven organization with a diverse team, committed to innovation and equity in healthcare.
Verify insurance, obtain benefits, calculate estimates, and secure prior authorizations for outpatient services.
Act as liaison between payers and clinic staff; follow up on denied or delayed authorizations.
Maintain detailed documentation and resolve issues with physicians, nurses, and financial advocates.
University of Utah Health is a patient-focused organization enhancing health through care, research, and education. It operates five hospitals and eleven clinics with a culture of collaboration, excellence, leadership, and respect.
Manage formularies, coverage determinations, and benefit design for PBM services.
Resolve clinical inquiries from members, clients, providers, and pharmacies.
Support P&T Committees with drug monographs, summaries, and medication policies.
OHSU is Oregon's only public academic health center with hospitals, clinics, and research schools. It is Portland's largest employer and a national research hub, welcoming diverse backgrounds.
Verify prescriptions and conduct drug utilization reviews to ensure regulatory compliance.
Review Prior Authorization requests and transfer prescriptions for timely medication delivery.
Collaborate across departments to improve patient health outcomes and adherence.
PHIL is a San Francisco-based health-tech startup building a platform that connects doctors, pharmacies, and patients to streamline prescription management and delivery. The team consists of mission-driven individuals from diverse backgrounds focused on creating an innovative healthcare platform.
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established coverage guidelines.
Educate teams on medical review processes and support quality control activities.
Broadway Ventures is a veteran-owned small business delivering mission-critical support to federal health and defense customers. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it is built on integrity, collaboration, and excellence.
Provide integrated support to patients and physicians to improve medication adherence and quality of care.
Review patient assessments and EMRs to develop care plans and optimize drug therapies.
Monitor adherence, oversee technicians, and ensure compliance with pharmacy regulations.
Shields Health Solutions provides integrated specialty pharmacy support to patients and physicians. The company emphasizes high-integrity, quality-focused teamwork and confidentiality in a remote work environment.
Investigate and process complex grievances and appeals requests from members and providers.
Perform medical necessity reviews for inpatient, outpatient, ambulatory, and ancillary services.
Prepare recommendations and generate written correspondence to providers, members, and regulatory entities.
This company specializes in processing healthcare appeals and grievances for US members and providers. The organization operates with globally distributed teams, emphasizing clinical knowledge and regulatory compliance.
Verify prescriptions for therapeutic appropriateness, interactions, and dosing accuracy.
Provide proactive phone-based patient counseling and handle inbound clinical calls.
Collaborate with prescribers and supervise pharmacy technicians to maintain workflow quality.
Blink Health is a healthcare technology company that builds products to make prescriptions accessible and affordable, with a focus on removing roadblocks in the prescription supply chain. They are a collaborative team of builders and operators who value innovation and diversity.