Perform utilization review including precertification and concurrent reviews using medical necessity criteria.
Collaborate with medical directors and providers on complex cases and integrate AI tools into workflow.
Initiate referrals to disease management programs and participate in quality improvement initiatives.
Guidehealth is a data-powered healthcare company that uses AI and predictive analytics to improve healthcare affordability and patient outcomes. It is a physician-led organization with a culture of accountability, learning, innovation, and empathy.
Ensure acute hospital admissions have appropriate level of care and meet medical necessity.
Monitor patient progress in plan of care for continued stay.
Provide clinical information to payer to authorize acute hospital stay and continued services.
Piedmont Healthcare is a healthcare organization focused on patient outcomes. It offers a supportive culture with diverse teams, schedule flexibility, and comprehensive benefits, fostering employee growth and well-being.
Supervise daily operations of clinical compliance auditors and specialists.
Assist in developing coordinated team processes and managing UM and PHM plan adherence.
Serve as clinical services liaison to senior management and ensure timely documentation.
Guidehealth is a data-powered healthcare company focused on operational excellence and value-based care. They emphasize empathy, AI, and collaboration, with a remote-first culture.
Provides visionary leadership and strategic direction for care coordination and service delivery teams.
Drives transformational initiatives to scale operations, enhance quality, and improve patient outcomes.
Uses data analytics and key performance indicators to monitor program effectiveness and guide evidence-based decision-making.
WellSky is a technology company that provides software, analytics, and services for intelligent, coordinated care across health and community care. The company fosters a culture of independent thinking, collaboration, and innovation, with a focus on improving outcomes and lowering costs.
Review Home Health prior authorization requests for medical necessity using CMS regulations and Clover clinical guidelines.
Perform initial and concurrent clinical reviews, ensuring appropriate care in the least restrictive setting.
Collaborate with providers and internal teams to support timely decision-making and positive member outcomes.
Clover Health is a healthcare company that uses data and technology to provide affordable, high-quality insurance plans for seniors. The company fosters a remote-first culture with a diverse and mission-driven team focused on improving member outcomes.
Implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center.
Functions within the multidisciplinary team to secure complex pre-authorizations and prevent/appeal clinical denials.
Utilizes clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided.
The Ohio State University is a top-20 public university with one of America’s leading academic health centers. They are a team of dedicated colleagues with access to boundless resources.
Provide telephonic case management and utilization review for assigned consumers.
Develop, implement, and monitor individualized care plans to ensure quality and cost-effective outcomes.
Collaborate with healthcare providers, payors, and internal teams to coordinate care.
Cottingham & Butler helps clients through life's toughest moments by providing insurance and benefits solutions. The company fosters a culture of continuous improvement, seeking to hire, train, and grow the best professionals in the industry.
Perform prospective, concurrent, and retrospective utilization reviews for behavioral health services across multiple care settings.
Assess medical necessity and coordinate care with providers, members, and internal teams to ensure appropriate access and treatment.
Support discharge planning, benefit utilization, and regulatory compliance while improving overall care quality.
This company provides high-quality behavioral health coordination and utilization management services to improve member outcomes. They foster a supportive, collaborative environment focused on professional growth and clinical excellence.
Provide telephonic case management to proactively drive return to work.
Perform utilization review and coordinate care with providers and adjusters.
Evaluate treatment plans and partner with adjusters to achieve optimal outcomes.
AmTrust Financial Services is a fast-growing commercial insurance company providing comprehensive telephonic case management. They foster a diverse and inclusive culture with a focus on attracting and retaining the best talent.
Oversee and manage the CareConnect Clinical Triage and Treat team, ensuring timely, high-quality remote patient care 7 days a week.
Analyze operational data, lead performance improvement initiatives, and communicate staffing and operational needs to Market Leadership.
Provide backup clinical coverage and support recruitment, onboarding, training, and professional development of team members.
WellBe provides comprehensive healthcare services focused on helping patients lead healthier, more meaningful lives. They are a value-based care organization with a patient-first approach, operating across multiple states with a culture centered on teamwork and clinical excellence.
Lead and develop a high-performing enrollment team to drive conversion rates and customer experience.
Coach team members through structured feedback and monitor key performance indicators for continuous improvement.
Maintain a personal enrollment caseload to stay connected with customer interactions and demonstrate best practices.
This company provides enrollment services to help individuals access important services and resources. It fosters a collaborative environment focused on innovation and continuous improvement, with a team dedicated to operational excellence.
Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies.
Collaborates with client personnel to resolve customer concerns and facilitates resolution of escalated cases.
Maintains written documentation per HealthHelp’s policy and ensures compliance with HIPAA, state, and federal regulations.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With three global headquarters, operations in 13 countries, 65 delivery centers, and more than 66,000 employees, WNS combines scale, expertise, and execution to create meaningful, measurable impact.
Lead and manage the scheduling team to maximize authorized ABA therapy hours for each client.
Monitor workflows, analyze data, and optimize processes to hit target utilization rates.
Collaborate with clinicians, BCBAs, and families to close gaps between authorized and delivered hours.
Finni Health is a mission-driven behavioral health company focused on providing ABA therapy services to children and families. They are a fast-growing team scaling their operations to improve behavioral health care access in New Mexico.
Lead quality monitoring initiatives across multi-channel crisis and support services.
Develop and implement performance measurement frameworks and operational audits.
Drive continuous improvement through data analysis and AI-enabled quality solutions.
The company provides behavioral health and crisis support services at scale through national service networks. It is a mission-driven organization with a collaborative culture focused on professional growth and innovation.
Support quality, safety, and compliance by identifying documentation and workflow improvements.
Process physician orders within the EMR and ensure verbal orders meet documentation requirements.
Manage end-of-episode documentation, including discharge reports and OASIS visits.
Adaptive Home Health is an AI-native physical care platform transforming US healthcare, starting with home health. The company combines a world-class AI team with healthcare veterans to build a new type of healthcare company that delivers care at the speed of an AI company.