Conducts utilization review to determine medical necessity of admission and continued stay using established criteria.
Communicates with payers to secure authorization and negotiate medical necessity decisions.
Educates providers on documentation requirements and participates in strategies to reduce length of stay and readmissions.
OHSU is Oregon’s only public academic health center, providing patient care and conducting groundbreaking research while training health care professionals. As Portland’s largest employer, it offers a diverse and inclusive culture with opportunities for growth across Oregon and Southwest Washington.
Perform concurrent inpatient utilization review using InterQual criteria to determine medical necessity.
Engage in clinical collaboration with physicians and care teams to support appropriate level-of-care decisions.
Maintain documentation, comply with regulations, and ensure quality customer service.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations serving over 700 clients across 10 industries. With over 66,000 employees across 13 countries and 65 delivery centers, the company combines scale and expertise to create meaningful impact.
Perform case reviews and process requests for elective services and durable medical equipment.
Collaborate with physicians, vendors, and providers to ensure regulatory compliance and timely service.
Provide high-quality customer service to members and healthcare professionals.
Elderplan provides Medicare and Medicaid managed care health plans designed to help people stay independent. They are part of MJHS, a supportive community committed to excellence, respect, and collaboration.
Perform concurrent and retrospective reviews on all facility and appropriate home health services.
Monitor level and quality of care and proactively manage acutely and chronically ill patients.
Act as liaison to Plan Medical Director and coordinate interdisciplinary approach.
Curana Health is a national leader in value-based care for senior living communities and skilled nursing facilities. Founded in 2021, they serve 200,000+ seniors in 1,500+ communities across 32 states with a team of over 1,000 clinicians.
Conduct clinical reviews of medical records to determine medical necessity and payer compliance.
Evaluate denial cases including appeals, audits, and no-authorization determinations.
Develop evidence-based clinical rationales aligned with payer and regulatory guidelines.
This partner company provides clinical review and healthcare reimbursement support services. The team is remote and operates in a fast-paced, performance-driven environment.
Performs activities related to insurance company notifications and obtaining certifications/authorizations related to Utilization Review.
Communicates clinical information and updates to insurance companies as requested or required to justify medical necessity.
Liaises with third-party payers regarding UR requirements and assists with complex authorization needs impacting patient transition planning.
Phoebe Putney Health System is southwest Georgia’s preferred career choice for professionals who want to improve the community’s health by joining a respected, cutting-edge team. They are one of the area’s premier employers, offering a close-knit culture, outstanding benefits and many ways to develop your career.
Provide clinical review and correspondence for utilization management, including medical necessity reviews and member communications.
Collaborate with Medical Directors to ensure evidence-based decisions that meet NCQA and CMS standards.
Maintain productivity and quality while working 100% remotely in a fast-paced environment.
Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With over 250 employees, the company fosters a supportive, growth-oriented environment and has been named to the Inc. 5000 list and a Top 5 LinkedIn Startup.
Support payer audits and medical record reviews, ensuring timely submission of documentation.
Manage medical review requests and appeals associated with CMS contractors and regulatory agencies.
Review clinical documentation using audit checklists and partner with teams to gather required records.
VitalCaring is a provider of home health and hospice services founded in 2021. They are a growing company focused on quality and compliance, with a mission to deliver exceptional patient care.
Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
Apply payer-specific guidelines and internal policies to support clear, defensible clinical narratives.
Meet assigned turnaround times and document findings accurately in designated systems.
CorroHealth helps clients exceed their financial health goals through scalable reimbursement solutions and clinical expertise, leveraging technology and analytics. The company builds long-term careers by investing in professional development and personal growth, fostering a culture of accountability and success.
Must have at least 5 years' RN experience with current licensure, a bachelor's degree or equivalent, and at least 1 year of leadership with direct reports.
Responsible for overseeing RN denials management specialists, pre-bill utilization reviews, payer calls, workflow optimization, and collaboration with internal RCM teams.
Blends clinical expertise with revenue cycle management to protect the organization's bottom line, decrease A/R, and ensure compliance.
Banner Health is one of the largest nonprofit health care systems in the country, providing hospital services, primary care, research, and physician practices across multiple states. With 31 facilities and a focus on innovation, they recently earned Great Place To Work certification, reflecting their investment in employee happiness and fulfillment.
Act as a liaison for a patient panel of medically stable patients, coordinating care between internal and external providers.
Monitor and triage lab orders and results, providing education and medical management support to patients and families.
Triage emergent issues in a time-sensitive manner and coordinate care with hospitals for medical stabilization admissions.
Equip is the leading virtual, evidence-based eating disorder treatment program on a mission to ensure everyone with an eating disorder can access treatment that works. Founded in 2019, the company is fully virtual and has been recognized as one of the most influential companies of 2023, with a diverse and passionate team.
Supports and facilitates the design, development and implementation of Utilization Management data collection methodologies.
Displays and analyzes data to identify trends and works collaboratively to develop a plan of action.
Northside Hospital is an award-winning, state-of-the-art healthcare provider that is continually growing in Atlanta and beyond. As a large healthcare organization, they offer opportunities for healthcare professionals to join a team focused on expanding quality and reach of care.