Performs pre-admission, admission, and continued stay reviews using approved medical necessity criteria.
Coordinates patient care and communicates with physicians, patients, caregivers, and third-party payers.
Manages patient progression through the healthcare system and proactively works with payers to secure certification and minimize denials.
Ochsner Health is a leading not-for-profit healthcare provider in the Gulf South, with 46 hospitals and 370+ care centers. It employs more than 38,000 team members and has been recognized as a top workplace and the No. 1 hospital in Louisiana.
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.
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established coverage guidelines.
Educate teams on medical review processes and support quality control activities.
Broadway Ventures is a veteran-owned small business delivering mission-critical support to federal health and defense customers. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it is built on integrity, collaboration, and excellence.
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.
Review and analyze Medicare claims sampled by the Department of Justice to determine correct coding and payment based on coverage and utilization.
Conduct in-depth claims analysis to detect fraudulent or abusive billing practices using ICD-10, CPT-4, and CMS guidelines.
Complete summary reports and communicate findings internally while maintaining confidentiality and compliance with DOJ and CMS regulations.
Empower AI provides AI-powered solutions for federal government agencies, helping them transform their workforce and operations. Headquartered in Reston, Va., the company has three decades of experience in Health, Defense, and Civilian missions and is recognized as a 2024 Military Friendly Employer.
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.
Conduct medical necessity reviews and continued stay reviews using approved clinical criteria to support quality and financial outcomes.
Collaborate with liaisons, physicians, and revenue cycle teams to manage denials, appeals, and appropriate levels of care.
Maintain documentation, monitor utilization trends, and facilitate patient care planning across the care team.
Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They empower associates to challenge the status quo and put people first, fostering a collaborative and innovative culture.
Conduct comprehensive reviews of home health pre-claim review packages for Medicare compliance.
Document review outcomes with clinical rationale and meet a 7-business-day turnaround.
Maintain 98% accuracy and complete required training and quality assurance sessions.
Broadway Ventures is a consulting firm providing program management, technology, and innovative solutions to government and private sector clients. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it emphasizes integrity, collaboration, and excellence in its culture.
Oversee medical necessity reviews for home health, acute, post-acute, and outpatient services for Medicare Advantage populations.
Collaborate with treating physicians, nursing teams, and external agencies to promote evidence-based care and appropriate resource utilization.
Apply CMS regulations, coverage determinations, MCG criteria, and medical policies in a fully remote, part-time physician leadership role.
Jobgether is an AI-powered job matching platform that connects candidates with employers. It uses objective screening to share top-fitting applicants with hiring companies, emphasizing data privacy and human oversight throughout the recruitment process.
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 clinical audits for suspected fraud, waste, and abuse with high autonomy.
Document findings in formal reports, graphs, and audit logs, aligning with unit goals.
Develop and present FWA-related education to Oscar teams, ensuring compliance with regulations.
Oscar is a health insurance company built on a full stack technology platform, focused on serving members like a doctor in the family. Founded in 2012, it is a forward-thinking company that values diversity and innovation, with a culture of fostering belonging and support.
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.
Review prior authorization cases to ensure clinical and operational standards are met.
Audit AI outputs, third-party reviews, and internal decisions for accuracy and compliance.
Collaborate cross-functionally to refine workflows and improve patient access to treatment.
Generator Health operates a platform that streamlines prior authorization processes for patients and providers. They handle tens of thousands of patients weekly and emphasize collaboration and accuracy in a high-autonomy remote environment.
Perform prospective, concurrent, and retrospective reviews of healthcare services to ensure medical necessity and appropriate level of care.
Contact medical and support personnel to recommend alternative treatment plans and coordinate care across the healthcare continuum.
Research and resolve issues related to benefits, eligibility, and appeals while delivering targeted education to providers.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, covering claims administration, payment integrity, and care management. The company is experiencing significant momentum and investing in employees who directly shape the future of healthcare technology.
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 and evaluate denied claims using proprietary software to determine correct reimbursement.
Research and acquire medical records and supporting documentation for submission to payers.
Conduct telephone follow-up with payers to ensure prompt reimbursement.
EnableComp provides Specialty Revenue Cycle Management solutions for healthcare organizations using an intelligent automation platform. The company has over 24 years of industry expertise, is a multi-year Top Workplaces award recipient, and has been on the Inc. 5000 list for eleven years.
Provide high-quality consulting services including clinical and regulatory compliance audits to long-term care facilities nationwide.
Manage assigned client facilities with emphasis on service quality, cost-effectiveness, and timely delivery of consulting visits.
Collaborate with teams and maintain effective communication with leadership about customer issues and industry regulations.
Assembly Health is a healthcare company providing clinical consulting services to long-term care facilities nationwide. The team is motivated, client-focused, and committed to excellence and integrity.
Answer calls from new patients and call back signups quickly to set the tone for care.
Listen empathetically, learn about patient health and goals, and explain Mira Mace's services in plain language.
Confirm Medicare coverage, book first doctor visits, and follow up persistently while documenting accurately.
Mira Mace is a venture-backed company helping Medicare patients navigate healthcare with clarity and confidence. They are a small, mission-driven team focused on technology and patient-centered care.
Deliver direct patient care under the direction of physicians and nurse supervisors, including preparing patients for exams and assisting during treatments.
Coordinate tests, follow-up care, and record treatments in medical records, ensuring accurate documentation.
Educate patients and families, demonstrating competency in serving patients of all ages.
Wellstar is one of Georgia's largest and most integrated healthcare systems, providing personalized care to patients at every age and stage of life. With 24,000+ employees, it fosters an inclusive culture and is consistently ranked as a top workplace, including on the FORTUNE 100 Best Companies to Work For list.