Source Job

• Provides medical interpretation and clinical review for appropriateness of services, including Home Care Solutions, Skilled Nursing Facility, Durable Medical Equipment, rehabilitation, and discharge planning.
• Advises executives on functional strategies related to OneHome initiatives and clinical priorities, exercising independent judgment on complex issues.
• Ensures compliance with CMS guidelines, Medicare/Medicaid requirements, and Humana policies while supporting quality, utilization management, and care coordination.

Humana is a leading U.S. healthcare company providing insurance and healthcare services through its Humana insurance and CenterWell healthcare services. It is a large, publicly traded organization with a culture focused on the Humana Way, emphasizing collaboration, accountability, and improving member experiences.

• 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.

• Conduct utilization review to determine medical necessity of admission and continued stay using established criteria.
• Collaborate with payers to secure authorization and work with multidisciplinary teams to reduce length of stay and readmissions.
• Provide clinical data for denial management, appeal letter writing, and trend identification to improve processes.

OHSU is Oregon's only public academic health center, providing patient care, groundbreaking research, and training health professionals. As Portland's largest employer, we offer diverse opportunities in a system of hospitals and clinics, committed to building an anti-racist, multicultural institution.

• Applies approved utilization criteria to monitor appropriateness of admissions and continued stay reviews.
• Communicates with third-party payers for initial and concurrent clinical review to ensure medical necessity.
• Tracks length of stay and resource utilization to identify at-risk patients and supports appeals on denied cases.

University of Utah Health is a patient-focused healthcare organization dedicated to enhancing health and well-being through patient care, research, and education. It is a nationally ranked Level 1 Trauma Center with five hospitals and eleven clinics, fostering a culture of collaboration, excellence, and respect.

• Provide medical management and utilization management decisions within scope of authority, ensuring compliance with regulations and client expectations.
• Conduct medical necessity reviews for rehabilitation services including physical therapy, occupational therapy, speech therapy, chiropractic, and acupuncture.
• Support delegated appeals processes, quality assurance, and telehealth consultation while collaborating with senior medical directors and clinical teams.

Our partner is a healthcare organization that provides physician-led clinical oversight across utilization management, medical necessity review, quality management, and virtual healthcare support. The company operates with a collaborative team of senior medical leadership and clinical staff, offering a remote work environment and part-time opportunities.

• Set daily direction for your UM team, establishing priorities and reinforcing expectations.
• Coach reviewers on criteria application, guiding consistent use of medical-necessity criteria.
• Monitor workflow health daily, tracking intake volume and turnaround risk.

Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. The team is on a mission to empower people to lead healthier lives.

• 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.

• Complete assigned medication utilization reviews and medical necessity appeals for commercial and governmental clients.
• Provide peer-to-peer support to physicians and prescribers regarding clinical programs and utilization review decisions.
• Actively participate in developing utilization management criteria and clinical policy revisions.

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including pharmacy benefit management and health benefit management. They are rebuilding trust in healthcare in the U.S. and deploying infrastructure for better care, but no specific employee size or culture details are provided.

• 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.

• Provide medical review and clinical determinations based on evidence-based criteria for therapy programs.
• Support clinical content team in reviewing guidelines and literature, and conduct peer-to-peer discussions with providers.
• Demonstrate professionalism and accountability in a fast-paced, team-oriented environment.

Cohere Health provides a clinical intelligence platform and agentic AI-powered solutions that connect health plans and providers, optimizing care speed, cost, and quality. The company is rapidly scaling, backed by leading investors, and has been named to the Inc. 5000 list and a Top 5 LinkedIn Startup for 2023 & 2024.

• Perform daily charge audits and coding reviews for accurate CPT, ICD-10, and HCPCS code assignment.
• Submit clean claims daily through Apero and the clearinghouse.
• Monitor and resolve claim system rejections to avoid timely-filing issues.

Dreem Health is a digital sleep clinic that provides home-based testing and telehealth visits. They are part of an international team that values trust, collaboration, and compassion.

• Provide final signatory approval of promotional and non-promotional materials in line with the PMCPA Code of Practice.
• Attend Brand Team Meetings to communicate Medical Review Advisory agenda and ensure compliance.
• Independently review and approve materials, making risk-based evaluations and ensuring adherence to ABPI standards.

AbbVie discovers and delivers innovative medicines to address serious health issues across immunology, oncology, and neuroscience. It is a large global pharmaceutical company committed to operating with integrity and driving innovation, serving the community.

• Perform quality assurance audits on utilization management reviews to ensure accuracy and compliance.
• Analyze data from multiple sources to identify trends, discrepancies, and process improvement opportunities.
• Collaborate with leadership and operations teams to develop training materials and support quality initiatives.

HealthEdge provides AI-powered operational infrastructure for health insurance companies to help them compete effectively. The company is experiencing strong growth and is investing in its people to shape the future of healthcare technology.

• Conduct coverage reviews and render determinations based on member benefits and medical policies.
• Document clinical findings and actions in accordance with regulatory and accreditation requirements.
• Engage in peer-to-peer discussions with providers and collaborate on benefit determinations.

Capital Blue Cross is a health insurance company that provides coverage and services. They are consistently voted as one of the Best Places to Work in Pennsylvania, reflecting a positive culture.

• Analyze medical records to validate ICD-10-CM, ICD-10-PCS, CPT-4, HCPCS II coding and MS-DRG assignment on acute inpatient and outpatient claims.
• Conduct in-depth claims analysis using coding principles and electronic health information systems to ensure assigned codes are supported by documentation.
• Meet quality and production standards and ensure compliance with quality management systems and ISO requirements.

Empower AI provides AI for government, helping federal agencies transform their workforce. With three decades of experience in Health, Defense, and Civilian missions, it is headquartered in Reston, VA and recognized as a 2024 Military Friendly Employer.

• 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.

• Ensures prior authorization requests meet contractual requirements and are reviewed using evidence-based standards.
• Performs concurrent or retrospective review of acute in-patient care services using established criteria.
• Participates in Utilization Management Care Programs.

Central California Alliance for Health is a regional non-profit health plan providing accessible, quality health care guided by local innovation to members in five California counties. The organization employs over 500 dedicated employees in a respectful, diverse, professional, and fun culture.

• 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.

• 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.