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.
Process referrals and prior authorizations, ensuring accurate and timely documentation.
Collaborate with clinical teams, physician offices, and insurance companies to resolve authorization issues.
Monitor denial reports, manage referral tracking, and communicate decisions to providers, staff, and patients.
Baystate Health is an integrated healthcare system serving western Massachusetts. With 12,000 employees and a community-focused culture, it includes five hospitals and offers career growth.
Conduct structured outreach to patients and caregivers throughout the treatment journey, providing program-approved education and support.
Identify barriers to treatment initiation and adherence, develop practical strategies, and escalate clinical or safety concerns as needed.
Accurately document interactions and outcomes while managing an assigned caseload and collaborating with case management teams.
We provide patient support programs that deliver individualized clinical education, treatment-support services, and care coordination to patients and caregivers. Our culture is supportive, dedicated, and teamwork-driven, and we are proud of our relentless focus on improving the lives of the patients we support.
Manage and triage patient vital signs remotely, using motivational interviewing to drive positive health behavior changes.
Perform monthly wellness calls with patients, collaborating with care teams to set patient-centric goals.
Escalate urgent care needs appropriately and meet program engagement metrics in a remote MST-based role.
Vivo Care is building a future where care is continuous, personal, and connected, challenging the status quo in healthcare. We are a fast-growing startup where everyone has a voice, fostering a culture of inclusion, collaboration, and innovation.
Conduct monthly clinical check-ins and structured symptom assessments for assigned patient panels.
Collaborate with providers to escalate clinical concerns and reinforce care plans.
Maintain accurate documentation across EHR and CCM platforms while meeting quality metrics.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, and holistic approach. The company thrives on innovation and evolution, with a culture that embraces change and focuses on improving patient outcomes.
Prepare, review, and submit accurate prior authorization requests to PBMs and health plans for anti-obesity medications.
Act as an escalation point to resolve complex coverage inquiries from Medical Providers, Member Services, and Client Success.
Maintain HIPAA compliance and accurately document hours using designated ADP pay codes.
Vida is a virtual, personalized obesity care provider that uses evidence-based treatment to help patients manage obesity and related conditions. It is trusted by Fortune 100 companies and fosters a diverse, inclusive culture.
Clarity Pediatrics is a virtual clinic reimagining pediatric chronic care, starting with ADHD and expanding to obesity and overweight management. It is a fast-growing startup with a remote-friendly culture and a leadership team committed to clinical excellence.
Manage pre-service authorization denials and coordinate reconsiderations, appeals, peer-to-peer reviews, and payer exception requests within applicable timeframes.
Interpret payer policies, medical necessity criteria, and coverage requirements to determine appropriate resolution pathways and obtain supporting documentation.
Collaborate with providers, payers, and internal teams to resolve complex cases, identify denial trends, and support process improvement.
IVX Health is a national provider of infusion and injection therapy for patients managing complex chronic conditions. They are a growing healthcare organization with a culture built on collaboration, innovation, and purpose, offering professional development and meaningful work.
You perform complex medication reconciliations and identify clinical red flags to prevent ER visits and readmissions.
You deliver high-touch engagement for high-risk patients through post-discharge follow-up and care coordination.
You collaborate with practices and document interventions across multiple EHRs to ensure care gaps are closed.
Aledade PBC is a public benefit corporation that empowers independent primary care by creating value-based contracts. Founded in 2014, we are the largest network of independent primary care in the country, with a remote-first culture that is collaborative and inclusive.
Serve as a primary point of contact for member inquiries through phone, chat, and other channels, providing compassionate and efficient support.
Coordinate complex scheduling, care workflows, and urgent requests while partnering with clinical providers and operations teams.
Build trust through empathetic communication, accurate documentation, and thoughtful problem solving to ensure a seamless care experience.
Tia is building a new model for women's healthcare that integrates primary care, gynecology, mental health, dermatology, and wellness across in-person and virtual settings. The company is a Series D venture-backed organization trusted by over 120,000 women across four markets, with a culture focused on excellence and continuous improvement.
Obtain managed care authorizations and verify patient insurance benefits prior to services.
Review office schedules daily and update EHR systems with authorization and insurance details.
Coordinate with staff and providers on denials, peer-to-peer reviews, and monthly re-verification of coverage.
Surgery Partners operates a network of surgical facilities and provides healthcare services across the United States. The company fosters a diverse and inclusive workplace, offering comprehensive benefits and professional development opportunities.
Manage end-to-end case activities for insurance verification, authorization, and reimbursement.
Serve as the single point of contact among patients, providers, payors, and internal teams.
Prioritize competing demands to ensure timely patient access to therapy.
PRO-Spectus supports patient services programs by navigating patient access from benefit verification through claims and reimbursement resolution. The company fosters a supportive, teamwork-driven culture focused on improving patients' lives.
Schedules patient visits, testing, procedures, and surgeries for referrals, ensuring timely and accurate coordination.
Verifies insurance, demographic, and eligibility information and ensures referral and authorization requirements are met.
Provides high-level customer service to patients, visitors, clinical staff, and colleagues, maintaining confidential information.
Carilion Clinic is a not-for-profit, mission-driven health system headquartered in Roanoke, Va., with award-winning hospitals, trauma centers, orthopedics and neurosciences institute, and multi-specialty physician practices. The culture emphasizes innovation, collaboration, learning, and making a difference in the community.
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.
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.
Review and respond to phone and fax inquiries from members, providers, and pharmacies for prior authorization.
Use multiple applications and follow procedures to accurately document and resolve inquiries.
Provide excellent customer service and meet or exceed call center metrics.
The Cigna Group is dedicated to improving the health and vitality of those we serve through Cigna Healthcare and Evernorth Health Services. We are a major healthcare organization focused on enhancing the lives of our clients, customers, and patients.
Manage prior authorization requests, reviewing clinical documentation and verifying ICD-10 and CPT codes.
Submit requests via payer portals, monitor pending cases, and follow up with insurers.
Investigate denials, prepare appeals, and coordinate with providers to prevent care delays.
Jobgether is an AI-powered job platform that matches candidates with relevant opportunities through objective review processes. It focuses on efficient recruitment and data privacy, using technology to support hiring decisions.
Oversee daily clinical pharmacy functions including prior authorization reviews, override requests, and member/provider education calls.
Support staff training, quality improvement, and lead projects to optimize pharmacy operations and clinical outcomes.
Serve as a subject matter expert and make clinical decisions based on medical necessity and contract criteria.
Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. It replaces fragmented systems with a unified claims processing platform and uses AI-powered care delivery to serve millions of Americans, fostering a mission-driven, collaborative culture.
Schedule patient appointments across clinics based on provider availability, patient needs, and location.
Manage referrals end-to-end, ensuring accurate patient, insurance, and documentation details.
Deliver a high-quality, patient-first experience while communicating proactively with patients and teams.
PT Solutions is a clinician-founded, mission-driven community expanding access to life-changing care through physical therapy and related services. Named a USA Today Top Workplace five years running, it has a supportive culture focused on professional development and human connection.
Take inbound calls from patients, providers, and members, handling everything from routine questions to emergent situations.
Support members with insurance needs, including changing primary care physicians, locating urgent care clinics, and getting prescription authorizations.
Provide 24/7 Triage Support and assign priority for a Registered Nurse to deliver health advice.
Carenet Health pioneers advancements across the healthcare consumer journey, interacting with 1 in 3 Americans daily to deliver positive healthcare experiences and improve outcomes. For over 30 years, the company has combined clinical expertise with data-driven technology, fostering a collaborative and innovative culture that empowers growth through trust, opportunity, and accountability.