Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
Guide timely care determinations using CMS regulations and evidence-based practices.
Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
HJ Staffing is seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. The company has not provided any information about its size/employees and culture but is likely a medium to large medical or staffing company.
Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes.
Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process.
Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
Virtua Health strives to connect individuals to the care they need, building a healthier community in South Jersey. They are a Magnet-recognized health system with over 14,000 colleagues, including over 2,850 doctors, physician assistants, and nurse practitioners.
Processes acute and post-acute inpatient medical or behavioral health and select intensive outpatient higher level of care requests through review of the submitted request and applicable clinical records
Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination, and with Care Management staff on discharge planning and transition of care activities.
Identifies and refers members with complex needs to the appropriate population health and/or care management program.
Capital Blue Cross promises to go the extra mile for our team and our community. Our employees consistently vote us one of the “Best Places to Work in PA, and we foster a flexible environment where your health and wellbeing are prioritized.
Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
Provide medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.
Centene is committed to helping people live healthier lives. They provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well. Centene values diversity and is an equal opportunity employer.
Partner directly with customers to deploy and configure AI agents for clinical documentation, scheduling, billing, communications, and workflow automation
Maintain AI governance frameworks that ensure safe, reliable agent operations in production healthcare environments
Work hands-on with foundation model APIs (OpenAI, Claude, Gemini) and the Canvas SDK to troubleshoot and optimize agent behavior
We're accelerating everyday medicine with an EMR platform built for healthcare automation. We create modern, elegant front- and back-end tooling to enable new ways for developers and clinicians to integrate data, automate workflows, and collaborate to solve healthcare's toughest challenges. We are institutionally backed and funded by notable health tech companies.