Must have at least 5 years' RN experience with current licensure, a bachelor's degree or equivalent, and at least 1 year of leadership with direct reports.
Responsible for overseeing RN denials management specialists, pre-bill utilization reviews, payer calls, workflow optimization, and collaboration with internal RCM teams.
Blends clinical expertise with revenue cycle management to protect the organization's bottom line, decrease A/R, and ensure compliance.
Supports and facilitates the design, development and implementation of Utilization Management data collection methodologies.
Displays and analyzes data to identify trends and works collaboratively to develop a plan of action.
Northside Hospital is an award-winning, state-of-the-art healthcare provider that is continually growing in Atlanta and beyond. As a large healthcare organization, they offer opportunities for healthcare professionals to join a team focused on expanding quality and reach of care.
Lead and inspire a remote team of Nurse Practitioners across multiple states, ensuring high-quality patient care and compliance.
Oversee provider performance, documentation quality, and risk adjustment accuracy while fostering a supportive team culture.
Guide training, coaching, and development, collaborating cross-functionally to refine workflows and drive operational success.
Sprinter Health is an on-demand mobile health service that sends medical professionals to patients' homes for blood draws, diagnostics, and wellness visits. The company has a rapidly growing team of visionary leaders passionate about increasing access to care and lowering healthcare costs.
Analyze denied insurance claims and apply clinical reasoning to determine appeal merit.
Draft persuasive, medically sound appeal letters to recover denied revenue.
Collaborate with legal team to ensure appeals are compelling and complete.
Ternium specializes in resolving complex healthcare insurance claim denials and delays for hospitals. They have a dedicated, mission-driven team and value diversity and inclusion.
Lead and oversee the Group Health Operations Management team, ensuring effective execution of utilization management services and operational workflows.
Drive achievement of key client performance metrics, including turnaround time, quality indicators, peer-to-peer success rates, and overturn rates.
Manage overall division profitability, including ownership of P&L performance and financial objectives.
Jobgether is a platform that uses AI-powered matching to connect candidates with job opportunities. They operate remotely and emphasize efficient, data-driven hiring processes.
Perform case reviews and process requests for elective services and durable medical equipment.
Collaborate with physicians, vendors, and providers to ensure regulatory compliance and timely service.
Provide high-quality customer service to members and healthcare professionals.
Elderplan provides Medicare and Medicaid managed care health plans designed to help people stay independent. They are part of MJHS, a supportive community committed to excellence, respect, and collaboration.
Perform concurrent and retrospective reviews on all facility and appropriate home health services.
Monitor level and quality of care and proactively manage acutely and chronically ill patients.
Act as liaison to Plan Medical Director and coordinate interdisciplinary approach.
Curana Health is a national leader in value-based care for senior living communities and skilled nursing facilities. Founded in 2021, they serve 200,000+ seniors in 1,500+ communities across 32 states with a team of over 1,000 clinicians.
Provide health care services regarding admissions, case management, discharge planning and utilization review.
Review admissions and service requests for medical necessity and reimbursement compliance.
Assess and coordinate discharge planning needs with healthcare team members.
UAB St. Vincent's, part of UAB Medicine, provides trusted healthcare in Alabama for over 125 years. With five hospitals and numerous clinics, the organization is guided by compassion and service, employing more than 4,800 people as one of Alabama's best hospitals.
Provide patient-focused telehealth clinical triage assessments and health education via phone, video, and chat.
Work independently to make clinical decisions, assess needs, and direct patients to appropriate care levels while documenting interactions.
Monitor performance metrics, participate in coaching sessions, and communicate with clients and team members.
Carenet Health is a behind-the-scenes partner for over 250 of the nation's premier health plans and health systems, providing telehealth and virtual care clinical triage assessments and health education. Named one of America's fastest-growing private companies by Inc. Magazine for eight consecutive years, the company is integrity-driven and focused on compassionate, evidence-based care.
Pulling, sorting, and analyzing data to determine member eligibility for the Population Health management Program.
Coordinating and providing care that is timely, effective, equitable, safe, and member-centric while following HMO processes.
Managing case assignments which includes outreach, documentation, monitoring for case progression, and case closure.
Guidehealth is a data-powered healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine. Guidehealth is a growing and innovative organization and employees are expected to adapt to evolving business needs.
Provides clinical oversight and medical necessity reviews for home health, DME, and related services using evidence-based guidelines.
Conducts peer to peer consultations and adverse determinations when clinical criteria are not met to support quality outcomes.
Collaborates with health plan leadership, participates in committees, and achieves SLA metrics for client performance guarantees.
CareCentrix provides clinical oversight and utilization management for home health, DME, home infusion therapy, and sleep medicine services. The company has an award-winning culture that values care, integrity, excellence, and innovation, operating with a drug-free workplace and equal opportunity commitment.
Provide clinical review and correspondence for utilization management, including medical necessity reviews and member communications.
Collaborate with Medical Directors to ensure evidence-based decisions that meet NCQA and CMS standards.
Maintain productivity and quality while working 100% remotely in a fast-paced environment.
Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With over 250 employees, the company fosters a supportive, growth-oriented environment and has been named to the Inc. 5000 list and a Top 5 LinkedIn Startup.
Lead multiple Nurse Team Leads and nursing teams to deliver high standards of clinical care and efficiency.
Coach and mentor Nurse Team Leads, setting goals, providing feedback, and fostering accountability.
Champion NCQA-compliant workflows and use data to drive performance and compliance across teams.
Thyme Care is a market-leading value-based oncology care enabler that partners with health plans, providers, and employers to improve outcomes and lower costs for people with cancer. As a tech-native organization of several hundred employees, it combines high-touch human support with technology and AI, fostering a culture of compassion, trust, and growth.
Deliver virtual, patient-centered care with empathy and clinical excellence.
Triage patient concerns using evidence-based protocols and sound clinical judgment.
Coordinate laboratory follow-ups, referrals, and diagnostic services across the care team.
MyLaurel is a healthcare organization delivering virtual acute care support to vulnerable patients. They are a collaborative, high-performing team focused on transforming healthcare delivery.
Own end-to-end revenue cycle operations across Medicaid (in-network and out-of-network) within behavioral health programs.
Lead and manage performance of third-party billing vendors and/or internal billing staff, driving improvements in A/R days, denial rates, collections, and first-pass claim acceptance.
Ensure accurate charge capture, documentation alignment, and coding integrity in collaboration with clinical and administrative teams.
We are a mission-driven outpatient behavioral health organization focused on helping individuals and families recover from substance use disorders and co-occurring mental health conditions. Headquartered in North Carolina and expanding across multiple states, we are in a strong growth phase and focused on operational excellence, clinical integrity, and sustainable revenue cycle performance.
Act as a liaison for a patient panel of medically stable patients, coordinating care between internal and external providers.
Monitor and triage lab orders and results, providing education and medical management support to patients and families.
Triage emergent issues in a time-sensitive manner and coordinate care with hospitals for medical stabilization admissions.
Equip is the leading virtual, evidence-based eating disorder treatment program on a mission to ensure everyone with an eating disorder can access treatment that works. Founded in 2019, the company is fully virtual and has been recognized as one of the most influential companies of 2023, with a diverse and passionate team.
Manage the member's clinical experience from request through desired outcome, including account activation and medical history drafting.
Coordinate video or phone consults with specialists and schedule monitors in advance, troubleshooting issues as needed.
Conduct ongoing follow-up post-consult and facilitate local recommendations, communicating with primary care physicians or specialists.
Transcarent is a health and care platform that combines medical, pharmacy, and point solutions with a generative AI-powered experience for health consumers. With over 1,700 employer and health plan clients serving 21 million Members, they foster a culture of People First, Care, Resilience, Results, and Humble and Human.
Support payer audits and medical record reviews, ensuring timely submission of documentation.
Manage medical review requests and appeals associated with CMS contractors and regulatory agencies.
Review clinical documentation using audit checklists and partner with teams to gather required records.
VitalCaring is a provider of home health and hospice services founded in 2021. They are a growing company focused on quality and compliance, with a mission to deliver exceptional patient care.
Conduct clinical reviews of medical records to determine medical necessity and payer compliance.
Evaluate denial cases including appeals, audits, and no-authorization determinations.
Develop evidence-based clinical rationales aligned with payer and regulatory guidelines.
This partner company provides clinical review and healthcare reimbursement support services. The team is remote and operates in a fast-paced, performance-driven environment.
Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
Apply payer-specific guidelines and internal policies to support clear, defensible clinical narratives.
Meet assigned turnaround times and document findings accurately in designated systems.
CorroHealth helps clients exceed their financial health goals through scalable reimbursement solutions and clinical expertise, leveraging technology and analytics. The company builds long-term careers by investing in professional development and personal growth, fostering a culture of accountability and success.
Own the full AR cycle: payment posting, cash reconciliation, aging management, and payer follow-up across district, health plan, and member inquiries.
Investigate and resolve complex claim denials and rejections, submit corrected claims and appeals, and drive systemic fixes to improve clean claim rates.
Serve as internal subject matter expert on payer requirements, billing regulations, and compliance standards, fielding escalations from clinical and operations teams.
Cartwheel is building a new kind of mental health program for kids that puts schools at the center. Backed by top investors, it has grown to serve more than fifty school districts across six states and is driven by a mission to help millions of students experience joy.