Manage UM nurse team performance, SLAs, and quality improvement.
Handle escalated UM cases and provider disputes 25% of time.
Partner with clients, medical directors, and IDTs to ensure consistent decision-making.
IntusCare builds an end-to-end ecosystem for Programs of All-Inclusive Care for the Elderly (PACE) to improve care, financial performance, and compliance. As a healthcare technology company, we empower teams to improve outcomes for dual-eligible seniors.
Set daily direction for your UM team, establishing priorities and reinforcing expectations.
Coach reviewers on criteria application, guiding consistent use of medical-necessity criteria.
Monitor workflow health daily, tracking intake volume and turnaround risk.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. The team is on a mission to empower people to lead healthier lives.
Applies approved utilization criteria to monitor appropriateness of admissions and continued stay reviews.
Communicates with third-party payers for initial and concurrent clinical review to ensure medical necessity.
Tracks length of stay and resource utilization to identify at-risk patients and supports appeals on denied cases.
University of Utah Health is a patient-focused healthcare organization dedicated to enhancing health and well-being through patient care, research, and education. It is a nationally ranked Level 1 Trauma Center with five hospitals and eleven clinics, fostering a culture of collaboration, excellence, and respect.
Conduct utilization review to determine medical necessity of admission and continued stay using established criteria.
Collaborate with payers to secure authorization and work with multidisciplinary teams to reduce length of stay and readmissions.
Provide clinical data for denial management, appeal letter writing, and trend identification to improve processes.
OHSU is Oregon's only public academic health center, providing patient care, groundbreaking research, and training health professionals. As Portland's largest employer, we offer diverse opportunities in a system of hospitals and clinics, committed to building an anti-racist, multicultural institution.
Accurately abstracts and cleans clinical data for CMS and national registries.
Provides feedback on measures and comparative data to physicians and management.
Participates in multidisciplinary teams to identify improvement opportunities in documentation and practice patterns.
UnityPoint Health is a healthcare system focused on providing quality care and fostering a culture of belonging. Recognized as a Top 150 Place to Work in Healthcare, they offer competitive benefits and support for team members.
Lead technology-enabled quality assurance for contact center and claims operations, including transcript quality and conversation insights.
Drive governance, standards, and continuous improvement for hybrid human-AI quality monitoring workflows.
Translate quality data into actionable insights for Operations, Claims, Training, and Marketing teams.
Travel Insured International is a leading travel insurance provider with more than 30 years in business. As a key component of Crum & Forster's Specialty Business Unit, the company offers travel protection plans to consumers and agency partners, committed to dependable coverage and end-to-end satisfaction.
Support analytical operations of Provider Services by performing data analyses and creating reports.
Evaluate provider network adequacy and performance via data modeling, analysis, and reporting.
Complete reports and projects for teams like Provider Services, Client Services, Implementation, and Sales.
Navitus is a pharmacy benefit manager (PBM) alternative committed to reducing drug costs and making medications more affordable. They value diversity, creativity, and growth, and focus on excellent service.
Review medical records to develop concise clinical reviews supporting authorization and reimbursement.
Facilitate communication with payors to ensure appropriate utilization management decisions.
Collaborate with interdisciplinary team to prevent denials and optimize patient care.
West Virginia University Health System is West Virginia’s largest health system, providing comprehensive healthcare services. With over 35,000 employees and 25 hospitals, it is the state's largest employer and offers a collaborative, patient-centered culture.
Lead portions of regulatory assessments, external audits, and accreditation processes for Commercial, Medicare, Medicaid, and Marketplace departments.
Act as primary point of contact for internal and external partners on regulatory activity, quality efforts, SOP development, and client delegation agreements.
Maintain regulatory gap status reporting, track work streams, and lead change management related to regulatory requirements.
Prime Therapeutics is a pharmacy benefit manager (PBM) with a purpose beyond profits, reimagining pharmacy solutions to connect care for those they serve. The company is a large, purpose-driven organization focused on simplifying healthcare and fostering a collaborative culture.
Ensures prior authorization requests meet contractual requirements and are reviewed using evidence-based standards.
Performs concurrent or retrospective review of acute in-patient care services using established criteria.
Participates in Utilization Management Care Programs.
Central California Alliance for Health is a regional non-profit health plan providing accessible, quality health care guided by local innovation to members in five California counties. The organization employs over 500 dedicated employees in a respectful, diverse, professional, and fun culture.
Performs clinical quality assurance review of daily clinical validation reviews and communicates differing audit decisions to ensure accuracy.
Integrates healthcare auditing principles and uses industry knowledge to substantiate decisions, reviewing medical records and applying clinical criteria.
Serves as a mentor to other QA auditors and may flex into initial audit or appeals roles as needed.
Cotiviti provides healthcare auditing and recovery solutions to ensure high quality recoverable claims. As a company, it employs a sizable workforce and fosters a culture of compliance, accuracy, and continuous improvement through professional skepticism and mentorship.
Review and evaluate electronic medical records of emergency department admissions to screen for medical necessity using InterQual or MCG criteria.
Apply evidence-based clinical guidelines to assess and ensure proper utilization of healthcare resources.
Enter clinical review information into the system for transmission to insurance companies for authorization.
Netsmart provides advanced healthcare technology solutions for post-acute and human services clients, enabling better care through a comprehensive platform. We are a vision-driven team passionate about innovation, and we have been recognized as one of the best companies to work for.
Drive cross-functional collaboration and track progress using project management tools to ensure on-time delivery of objectives.
Conduct audits of call and email communications to assess quality and accuracy, compiling feedback summaries for management.
Support patient-focused teams with quality improvement initiatives and maintain documentation such as SOPs and protocols.
Natera is a global leader in cell-free DNA testing for oncology, women's health, and organ health. The team consists of highly dedicated statisticians, geneticists, doctors, and other professionals from world-class institutions, fostering a culture of hard work and growth.
Manage insurance authorizations for clients in PHP and IOP programs, including pre-certifications and concurrent reviews.
Verify benefits, obtain Single Case Agreements, and build medical necessity cases using ASAM, LOCUS, and CALOCUS criteria.
Maintain accurate authorization, denial, and SCA records and prepare appeals on denied authorizations.
AWA and PRC are dual behavioral health organizations operating PHP and IOP programs across South Florida. They exist to serve clients and families at their most critical moments.
Provide Delegated Utilization Management by covering specified territories with 2-3 cases daily per market.
Advise other physician reviewers and attend daily calls with health plan teams and local teams.
Participate in Process and Quality improvement in Delegated Utilization Management.
ChenMed is a family-owned, physician-led organization transforming healthcare for seniors by providing a patient-centered environment. The company is rapidly expanding and offers comprehensive benefits, career development, and work-life balance for its employees.
Analyse centre performance, identify risks, and provide guidance for improvement.
Collaborate with internal teams and stakeholders to maintain high-quality learning outcomes.
NCFE is an educational awarding organization with over 170 years of experience, dedicated to promoting and advancing learning to create a fairer society. They have a flexible workforce of quality assurance professionals who work to ensure high standards in education and training.
Mentor and support the quality assurance team to enhance skills and drive motivation.
Evaluate calls to ensure adherence to scripts, SOPs, and compliance regulations.
Generate reports on call quality scores and provide data-driven insights to management.
Natera is a global leader in cell-free DNA testing, dedicated to oncology, women's health, and organ health. The team consists of highly dedicated professionals from world-class institutions who care deeply about their work and each other.
Manage quality initiatives and operational processes for value-based care programs. - Analyze data and support reporting functions across ACO programs. - Serve as liaison between providers, vendors, and internal stakeholders.
Curana Health is a national leader in value-based care for senior living communities and skilled nursing facilities, offering on-site primary care and Medicare Advantage plans. Founded in 2021, the company serves over 200,000 seniors across 32 states with a team of more than 1,000 clinicians and support staff, and was ranked #147 on the Inc. 5000 list.
Analyze Medicaid claims, encounter, and program data to identify trends and risks.
Support fraud, waste, and abuse and payment integrity initiatives through analysis and research.
Translate complex findings into clear recommendations for decision-makers.
BerryDunn is a professional services firm providing tax, advisory, and consulting services to businesses, nonprofits, and government agencies. They have been recognized for their inclusive culture and focus on employee well-being.
Lead clinical quality, quality improvement, and risk adjustment programs in a managed care environment.
Analyze performance data to identify trends, gaps, and opportunities for improved care and cost reduction.
Provide people leadership, coaching, and development to clinical and quality team members.
Our partner is a healthcare organization focused on improving access, quality, and outcomes. They operate in a managed care environment with a collaborative, purpose-driven culture.