Source Job

• Complete timely review of healthcare services using appropriate medical criteria to support determinations.
• Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
• Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers.

• Conduct clinical reviews for inpatient admissions and post-acute settings using evidence-based guidelines and CMS criteria.
• Serve as the primary physician reviewer for escalated or complex cases requiring high-level medical judgment.
• Partner with care management teams to identify utilization trends and develop interventions to reduce unnecessary admissions or extended stays.

It appears to be a healthcare organization. They ensure timely and appropriate care determinations for their Medicare Advantage members.

• Conduct coverage reviews based on member plan benefits and policies.
• Document clinical review findings, actions, and outcomes.
• Communicate and collaborate with providers for benefit determinations.

Capital Blue Cross promises to go the extra mile for their team and community. They foster a flexible environment where health and wellbeing are prioritized and employees consistently vote it as one of the "Best Places to Work in PA."

• Provide support to the Utilization Management Nurse and RN Appeals Writer.
• Help prevent clinical denials related to lack of clinical authorization and untimely notifications.
• Investigate root cause of clinical denials and document them in Epic and follow-up of appeal outcome.

Piedmont Healthcare provides healthcare services. They value diverse teams, a shared purpose, and schedule flexibility.

• Working with a team of Intake Coordinators and Utilization Review Nurses to ensure quality and timely determinations.
• Striving for continuous improvement and an excellent work-life balance to produce top-notch results.
• Coordinating and providing care management that is timely, effective, efficient, equitable, safe, and member centered.

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers.

• Answers first level calls in Utilization Review.
• Evaluates certification requests by reviewing group specific requirements.
• Triage the call to determine if a Utilization Review Nurse is needed.

Cottingham & Butler sells a promise to help clients through life’s toughest moments by hiring, training, and growing the best professionals. The company culture is guided by the theme of “better every day” constantly pushing themselves to be better than yesterday.

• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
• Assess payment determinations using clinical information and established guidelines.
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.

Broadway Ventures transforms challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), they empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth.

• Performing physician-level utilization management reviews for behavioral health services across all applicable levels of care.
• Conducting peer-to-peer consultations with treating psychiatrists and other behavioral health providers.
• Serving as a consultative clinical resource to behavioral health utilization management nurses, care managers, and operational leaders.

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and AI, they leverage remotely-embedded Healthguides™ and a centralized Managed Service Organization.