Source Job

• Review medically complex claims, pre-authorization requests, appeals, and fraud and 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, we empower clients with tailored solutions, operating with integrity and collaboration.

• Perform clinical reviews for medical necessity, level of care, and authorization compliance.
• Prepare and submit high-quality appeals related to DRG downgrades and clinical validation denials.
• Apply payer-specific guidelines and document review findings accurately in designated systems.

CorroHealth helps clients exceed their financial health goals through scalable revenue cycle solutions and clinical expertise. The company builds long-term careers by investing in team members' professional development and personal growth.

• Review medical records to develop concise clinical reviews supporting authorization and reimbursement.
• Facilitate communication with payors to ensure appropriate utilization management decisions.
• Collaborate with interdisciplinary team to prevent denials and optimize patient care.

West Virginia University Health System is West Virginia’s largest health system, providing comprehensive healthcare services. With over 35,000 employees and 25 hospitals, it is the state's largest employer and offers a collaborative, patient-centered culture.

• 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.

• Review Home Health prior authorization requests using CMS guidelines and clinical judgment.
• Lead and mentor the Home Health UM nursing team, ensuring quality and compliance.
• Collaborate with cross-functional partners to optimize care and improve utilization.

Clover Health provides high-quality, affordable healthcare for America's seniors by combining data, technology, and preventive care. They are a mission-driven team with diverse expertise, focused on improving members' lives through innovation and empathy.

• Review OASIS documentation and plan of care to ensure compliance with regulations and accuracy.
• Evaluate patient visit frequency and utilization to align with clinical needs and provider orders.
• Collaborate with coding partners and escalate documentation improvement opportunities to leadership.

Graham Healthcare Group designs business and technology solutions to drive better care and outcomes in home health and hospice. As a subsidiary of a publicly traded company, they've been improving care coordination for over 20 years, focusing on patient-centered home care.

• Independently manage Medicare, Medicaid, and TriCare cost reports and coordinate audits.
• Lead the annual cost report peer-review process and manage provider appeals.
• Collaborate with internal stakeholders and external reimbursement organizations to ensure compliance.

They are a large health system providing patient-focused healthcare services. The organization is collaborative and mission-driven, with a focus on financial sustainability.

• Conducts redetermination reviews in compliance with Medicare rules.
• Responds to appeals and writes professional correspondence.
• Researches claims issues and submits educational referrals.

Broadway Ventures transforms challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As a small business focused on government and private sector clients, they foster integrity, collaboration, and excellence.

• Performs clinical evaluations on disability claims to substantiate medical necessity for absence.
• Communicates with employees and providers to discuss clinical status and provides follow-up recommendations.
• Acts as a clinical resource to claims examiners, ensuring accurate medical terminology and claim decisions.

Sedgwick is the world's leading risk and claims administration partner, helping clients navigate the unexpected with AI-enabled technology and expertise. With over 33,000 colleagues and 10,000 clients across 80 countries, they've been recognized as a Great Place to Work and offer a caring culture.

• Conduct medical necessity reviews for inpatient admissions and post-acute services using evidence-based guidelines.
• Lead peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate care decisions.
• Collaborate with utilization management and care management teams to ensure consistent, cost-effective care.

Our partner company provides utilization management services for Medicare Advantage members, focusing on evidence-based clinical decision-making. It operates with a collaborative, matrixed team and emphasizes regulatory compliance and patient-centered care.

• Provide timely medical reviews based on evidence-based criteria and clinical acumen.
• Clearly document all decisions and communicate with members and providers.
• Conduct peer-to-peer discussions with treating providers to explain review outcomes and alternatives.

Cohere Health uses a clinical intelligence platform and agentic AI to connect health plans and providers, optimizing care speed, cost, and quality. They are a growing company recognized as a top startup and backed by leading investors, fostering a supportive and diverse environment.

• Perform clinical medical record review and abstraction to support healthcare quality and compliance.
• Apply established review criteria consistently and document findings clearly and objectively.
• Work independently to complete accurate reviews within project deadlines while managing multiple priorities.

Health Services Advisory Group (HSAG) is transforming the delivery of healthcare in the United States. They are a growing team dedicated to improving healthcare quality, with a focus on community and collaboration.

• Review, analyze, and complete pre- and post-payment claim audits and appeals in accordance with client policies, CMS guidelines, and healthcare industry standards.
• Apply clinical judgment to evaluate documentation and determine the appropriateness and accuracy of claims.
• Analyze healthcare claims, reimbursement information, and supporting documentation to identify discrepancies and potential payment issues.

Our partner company focuses on ensuring healthcare claims are reviewed accurately, consistently, and in accordance with applicable policies and industry standards. It is a collaborative, fast-paced, and evolving environment with opportunities for professional development and career advancement.