Perform medical necessity and level of care reviews using clinical judgment and guidelines.
Obtain member information via telephone and fax to assess condition and apply evidence-based criteria.
Meet decision-making SLAs and refer members for further care engagement when needed.
Oscar Health is a technology-driven health insurance company focused on simplifying healthcare for its members. We are a mission-driven organization with a diverse team, committed to innovation and equity in healthcare.
Performing timely utilization review of healthcare services using approved medical necessity criteria.
Collaborating with medical directors, providers, and internal teams for compliant review processes.
Ensuring accurate documentation and communication of determinations within regulatory timeframes.
Guidehealth is a data-powered, performance-driven healthcare company focused on making healthcare affordable and improving patient health. It is a physician-led organization using AI and predictive analytics, with a culture of accountability, growth, innovation, and empathy.
Provide Utilization Review and Case Management to Emergency Department patients with social or discharge needs.
Offer hospital-wide Utilization Review and Case Management coverage as needed and time allows.
Hold a valid RN state licensure; 3-5 years of nursing experience preferred.
Freeman Health System is a not-for-profit health system serving communities across Missouri, Arkansas, Oklahoma, and Kansas through a network of hospitals, physician clinics, and specialty services. The system is supported by over 7,000 employees and is the only Children's Miracle Network Hospital in a 70-mile radius.
Conducts appeals reviews of new evidence disputing medical review audit findings.
Documents and reports appeals results accurately, upholding or overturning determinations.
Serves as a subject matter expert, supporting training and process improvements.
Machinify is a healthcare intelligence company offering an AI-powered platform for health plan payment and clinical review. It serves over 85 health plans and over 270 million lives, with a culture of innovation and continuous improvement.
Oversee the Complex Clinical Bill Review team, managing production expectations, SLAs, client communication, and team performance.
Analyze and track internal business requirements, continuously evaluate functionality across programs, and perform requirements gathering to solve process issues.
Monitor team performance metrics, identify growth opportunities, and coordinate system enhancements including JIRA and UAT testing.
Machinify is a leading healthcare intelligence company providing an AI-powered platform for health plan clients. They are deployed by over 85 health plans, representing more than 270 million lives, with a culture of innovation and efficiency.
Apply utilization criteria to monitor appropriateness of admissions and continued stay reviews.
Communicate with third-party payers for initial and concurrent clinical review.
Prepare appeals on denied cases when appropriate.
Northpoint Recovery Holdings is a leading behavioral healthcare provider offering evidence-based treatment for adults with substance use and co-occurring disorders. Operating under an in-network commercial insurance model, the company has grown to seventeen facilities across the Western US and is guided by core values of humility, heart, inspiration, and conviction.
Conduct complex medical review of Medicare claims for Inpatient Rehabilitation Facility services.
Perform pre-claim review determinations and evaluate Additional Documentation Request responses.
Communicate determinations to providers and meet production-driven turnaround requirements.
Broadway Ventures is a small business that provides program management, technology, and consulting solutions to government and private sector clients. As a Service-Disabled Veteran-Owned Small Business, they emphasize integrity, collaboration, and excellence.
Survey ambulatory care organizations across the United States within the scope of Joint Commission's Ambulatory Programs.
Engage health care staff in interactive dialogues to assess compliance and identify opportunities for improving care quality.
Prepare management reports that link standards deficiencies with systems vulnerabilities and communicate findings to leadership.
The Joint Commission accredits and certifies health care organizations to improve patient safety and quality of care. It employs a nationwide team of surveyors who work remotely and travel extensively.
Review appeals of adverse benefit determinations within federal and state regulatory timeframes.
Apply medical policy, coding guidelines, and contractual requirements to assess coverage decisions.
Collaborate with medical divisions and respond to state insurance department inquiries regarding benefit complaints.
Arkansas Blue Cross and Blue Shield is a health insurance provider serving Arkansas. It is consistently ranked as one of the best places to work in Central Arkansas, with an inclusive culture and an average employee tenure of 10 years.
Oversee system-level utilization management activities across the organization.
Ensure compliance with medical necessity criteria such as InterQual and Milliman.
Manage professional staff and review processes to optimize patient care.
Piedmont Healthcare is a healthcare system providing comprehensive medical services. It is a large organization focused on utilization management and quality care.
Perform quality audits on clinical documentation across clinical departments.
Collaborate with leadership to develop corrective action plans and provide 1:1 coaching.
Support organizational readiness for NCQA and other regulatory audits.
Oscar is the first health insurance company built around a full stack technology platform, focusing on serving members with a concierge-level experience. It started in 2012 and is an Equal Opportunity Employer cultivating an authentic, inclusive environment.
Own daily outreach and enrollment performance, including call volume, reach rate, and enrollment numbers.
Lead and develop the enrollment team through direct supervision, coaching, and performance management.
Drive quality, compliance, and scalability of enrollment processes and documentation.
Vynca is a healthcare company focused on transforming care for individuals with complex needs, providing comprehensive care for more quality days at home. The company fosters a close-knit community culture guided by values of Excellence, Compassion, Curiosity, and Integrity.