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.
Lead clinical quality strategy and client audit readiness for high-stakes client and consultant engagements.
Build longitudinal quality assurance systems to monitor member journeys and ensure service reliability.
Drive AI-enabled quality surveillance and pattern detection to scale quality operations.
Included Health is a healthcare company that delivers integrated virtual care and navigation, breaking down barriers to provide high-quality care for every person. The company is remote-first and offers a comprehensive benefits package, aiming to raise the standard of healthcare for everyone.
Provide clinical and operational leadership to support timely, evidence-based coverage determinations in Utilization Management.
Coach reviewers on consistent application of medical-necessity criteria, medical policy, and benefit plan language.
Monitor daily workflow health, coordinate coverage plans, and communicate barriers and risks to the UM Manager.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. The company serves employers, health plans, and health systems with data-driven solutions and is on a mission to empower people to lead healthier lives.
Lead a remote team of outpatient coding auditors to identify overpayment opportunities and deliver accurate audit outcomes.
Oversee audit operations, ensuring consistency in APC/APG grouping, OPPS packaging, and outpatient coding policy application.
Manage team performance, productivity, and quality while providing coaching and professional development.
Machinify is a leading healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. Deployed by over 85 health plans and representing more than 270 million lives, the company fosters a culture of innovation and disruption.
Direct audit service delivery and manage teams to meet client needs and exceed expectations.
Drive audit productivity, cost management, and continuous improvement through metrics and innovation.
Lead staffing, people management, and contract negotiations to ensure compliance and growth.
Cotiviti provides payment accuracy and analytics solutions for healthcare and retail industries. The company is an equal opportunity employer and offers competitive benefits to a diverse team of professionals.
Lead and develop a team of Enrollment Specialists to hit daily and weekly performance targets through coaching, huddles, and 1:1s.
Keep operations on track by handling HR tasks like timecards and PTO, and coaching the team to follow processes seamlessly.
Drive continuous improvement by partnering with other leads to fix enrollment queue issues and surfacing opportunities to improve workflows and conversion.
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, it combines human support with AI and has a bold vision to become a household name in cancer care.
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.
Perform medical necessity reviews of clinical documentation to determine appropriateness of inpatient and outpatient services.
Develop relationships with medical providers and health plans to confirm adherence to policies and guidelines.
Stay updated on technology changes, regulatory issues, and medical practices through ongoing training.
Trend Health Partners is a tech-enabled payment integrity company that facilitates collaboration between payers and providers to reduce waste and improve healthcare access. It promotes a collaborative and innovative work environment as a dynamic, growing organization.
Lead and develop a clinical quality team, setting standards for provider quality and documentation integrity.
Own provider quality outcomes, termination process, and payor audit readiness across a network of 26,000+ providers.
Serve as clinical subject matter expert for cross-functional teams, ensuring clinical standards are applied in product and operations.
Grow Therapy is a three-sided marketplace that empowers therapists, insurance payors, and patients to improve mental healthcare access. The company has raised over $328 million, serves thousands of therapists and clients, and fosters an entrepreneurial, mission-driven culture.
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.
Manage and support a team of RN quality reviewers, providing day-to-day people management, performance feedback, and coaching.
Identify and report on clinical quality trends by analyzing chart audit findings and quality data to inform improvement priorities.
Collect, organize, and maintain quality audit data, ensuring accurate records and dashboards for real-time visibility into team performance.
Thyme Care is a market-leading value-based oncology care enabler that partners with health plans, providers, and employers to deliver better outcomes and lower costs for cancer patients. As a tech-native organization with a focus on human connection, they employ a team of dedicated professionals committed to reimagining cancer care.
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.
Banner Health is one of the largest nonprofit health care systems in the country, providing hospital services, primary care, research, and physician practices across multiple states. With 31 facilities and a focus on innovation, they recently earned Great Place To Work certification, reflecting their investment in employee happiness and fulfillment.
Perform Skilled Nursing Facility (SNF) medical claims audit reviews for Government and Commercial Payers.
Document findings referencing medical review guidelines and support audit findings during the appeals process.
Work collaboratively with the audit team to identify vulnerabilities and improve medical policies and workflows.
Machinify is a leading healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans and representing more than 270 million lives, the company uses a configurable, AI-powered platform combined with industry expertise to maximize financial outcomes and reduce healthcare costs.
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.
Supports clinical safety, accuracy, and oversight of integrated AI tools by reviewing AI-assisted outputs and surfacing risks.
Applies nursing judgment to review charts, calls, messages, and other member interactions to assess quality, safety, and member experience.
Assists with data collection and basic analysis for quality and safety work, and participates in cross-functional improvement efforts.
Included Health is a healthcare company delivering integrated virtual care and navigation. They are on a mission to raise the standard of healthcare for everyone, and offer members care guidance, advocacy, and access to personalized virtual and in-person care.
Manage team of employees responsible for collections, client invoicing, and HUB operations.
Ensure quality and productivity goals are met while maintaining audit quality.
Develop and maintain client relationships and identify process improvements.
ServiceLink is a mortgage services company that helps clients in the lending industry achieve strategic goals through technology and services. The company is committed to equal opportunity and offers ongoing training and support for employee advancement.
Conducts training for staff members related to Utilization Review process, clinical guidelines, and workflows.
Creates educational material by collaborating with key resources to incorporate clinical scenarios.
Reviews monthly quality audit findings and provides one-on-one coaching to staff for performance improvement.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With three global headquarters across four continents, operations in 13 countries, 65 delivery centers and more than 66,000 employees, the company combines scale, expertise and execution to create meaningful, measurable impact.
Plan, develop, and direct all aspects of onshore and offshore BPaaS activities to ensure operational efficiency and customer success.
Establish operational objectives, policies, and procedures in compliance with contracts and regulations, and develop strategies to achieve key performance measures.
Provide executive-level briefings to senior leadership and build collaborative relationships with client leadership to drive continuous improvement.
UST HealthProof is on a mission to reshape healthcare insurance by reducing administrative costs and building better healthcare experiences for health plans and their members. The company is run by leaders with strong health plan and technology backgrounds, fostering a supportive, start-up-like environment that nurtures individual growth.
Answer incoming calls and direct callers to the appropriate team member or document information in claim files.
Provide professional customer service, manage conflict effectively, and communicate with individuals related to claim files.
Complete outbound calls to report claims to insurance carriers and adhere to company policies and procedures.
Enterprise Mobility is a family-owned portfolio of brands and a leading provider of mobility solutions worldwide, operating a global network with 80,000 dedicated team members across nearly 100 countries. The company empowers its team with opportunities for growth and rewards hard work.
Conduct medical claim reviews using clinical information and established criteria to determine medical necessity and appropriate reimbursement.
Educate internal and external staff on medical reviews, coding procedures, and coverage determinations.
Participate in quality control activities and provide guidance to LPN team members.
Palmetto GBA is a healthcare service administrator and one of the nation's largest providers of high-volume medical claims and transaction processing. The company offers a diverse workforce, training programs for leadership, tuition assistance, and financial incentives.