Reviews pre-admissions for correct classification and admission order.
Performs Utilization Review for each patient on their assigned daily census using established medical necessity guidelines.
Communicates with payers regarding authorization and medical necessity, utilizing excellent negotiating skills.
Oregon Health & Science University values a diverse and culturally competent workforce. They are an equal opportunity, affirmative action organization that does not discriminate against applicants.
Act as the lead clinical liaison for partner providers across multiple regions
Advocate for the clinical value of care models and address provider inquiries
Stay updated on regulatory standards to ensure compliant, high-quality care
Jobgether uses an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Their system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company.
Complete timely review of healthcare services using appropriate medical criteria to support determinations.
Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers.
Review daily inpatient and observation admissions to determine appropriate status.
Collaborate with physicians, case management, and insurance partners.
Utilize electronic medical records to support documentation, review, and reporting.
Logan Health aims to deliver quality, compassionate care for all, reimagining health care through connection, service and innovation. They value kindness, collaboration, trust, and strive for excellence in a supportive, mission-driven nursing culture.
Working with a team of Intake Coordinators and Utilization Review Nurses to ensure quality and timely determinations.
Striving for continuous improvement and an excellent work-life balance to produce top-notch results.
Coordinating and providing care management that is timely, effective, efficient, equitable, safe, and member centered.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers.
Serve as the Medicare coverage determinations and redeterminations subject matter expert.
Create and uphold robust policies and procedures for coverage determinations and redeterminations in accordance with CMS guidelines.
Recruit, onboard, train, and manage Medicare PA and Appeals pharmacists and technicians.
Judi Health provides a comprehensive suite of solutions for employers and health plans. Together with our clients, they’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve.
Serve as a mentor for existing Program Directors and nursing leadership staff.
Act as interim Program Director during the recruitment process for new Program Directors.
Plan, develop, manage, update, and evaluate all aspects of the vocational nursing program.
Unitek Learning helps thousands of students launch and accelerate their careers every year. As a rapidly growing and highly successful company, Unitek is also a great place to pursue a rewarding and challenging career with a competitive salary, generous benefits, unlimited growth potential, and a collegiate work environment.
Shapes vital subfunction with strategic leadership and operational oversight.
Builds scalable processes for accuracy, timeliness, and quality of authorizations.
Collaborates across functions for data discrepancies and continuous process improvement.
Habitat Health provides personalized, coordinated clinical and social care as well as health plan coverage through the Program of All-Inclusive Care for the Elderly (“PACE”) in collaboration with their leading healthcare partners, including Kaiser Permanente. They build engaged, fulfilled care teams to deliver personalized care in their centers and in the home.
Supervise, direct and evaluate a diverse group of health care professionals to assure effectiveness of care coordination activities.
Develop audit plans and tools for teams to ensure compliance with state contracts on performance metrics and to ensure member needs are met.
Interview, hires, mentors, evaluates, coaches and manage performance for a diverse care coordination team.
Humana Inc. is committed to putting health first for its teammates, customers, and company. Through Humana insurance services and CenterWell healthcare services, they aim to make it easier for the millions of people they serve to achieve their best health.
Serve as the vendor’s lead clinical subject matter expert on clinical denials management and prevention.
Partner with provider clients to design and implement best practices for denial prevention and appeal workflows.
Conduct complex clinical case reviews for DRG validation, identifying and defending clinically appropriate DRG assignments.
EnableComp provides Specialty Revenue Cycle Management solutions for healthcare organizations. They leverage over 24 years of expertise and their E360 RCM ™ platform to improve financial sustainability for hospitals, health systems, and ambulatory surgery centers. EnableComp is a multi-year recipient of the Top Workplaces award recognized as Black Book's #1 Specialty Revenue Cycle Management Solution provider in 2024.
Imagine Pediatrics is a tech-enabled, pediatrician-led medical group reimagining care for children with special health care needs. They deliver specialized virtual and in-home care, working alongside families and providers, enhancing existing care teams with compassion and commitment.
Lead and develop high-performing Field Reimbursement Managers and Nurse Case Managers.
Oversee the comprehensive field-based Nurse Case Management and Access Program for Dyne.
Foster a coaching culture that enables deeper connection with patients, caregivers, and HCPs.
Dyne Therapeutics is focused on delivering functional improvement for people living with genetically driven neuromuscular diseases. They are advancing clinical programs for myotonic dystrophy type 1 (DM1) and Duchenne muscular dystrophy (DMD), and preclinical programs for facioscapulohumeral muscular dystrophy (FSHD) and Pompe disease.
Serve as primary relationship lead for assigned health plan partners
Own internal revenue and performance targets tied to your payer markets
Analyze operational and program data to identify risks and growth opportunities
Mae is a venture-backed digital health solution on a mission to improve the health and quality of life for mothers, babies, and those who love them. Mae has created a space where complete digital care meets culturally-competent on-the-ground support.
Own the care delivery product strategy by identifying and prioritizing high-impact opportunities.
Set vision and investment direction for how care is delivered on the Maven platform.
Lead and mentor a team of Product Managers , supporting their growth.
Maven is the world's largest virtual clinic for women and families. They provide clinical, emotional, and financial support all in one platform, spanning fertility & family building, maternity & newborn care, parenting & pediatrics, and menopause & midlife. Maven has over 2,000 employees and is recognized for innovation and industry leadership, with multiple workplace awards.
Appoint all clinical chairs, clerkship directors, and clinical managers at all sites.
Manage faculty and site performance and review.
Ross University School of Medicine (RUSM) expands access and opportunity to students on the path to becoming skilled physicians who are determined to make an impact in global communities. RUSM has graduated more than 15,000 alumni who practice in the U.S. and Canada.
Lead the design and execution of the Medicare Advantage Transformation plan.
Direct cross-functional workstreams to implement key MA initiatives.
Monitor key performance indicators for the MA business line.
Aledade empowers independent primary care practices to deliver better care and thrive in value-based care. Founded in 2014, they are the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.
Lead health plan partnerships across Medicaid and related lines of business.
Serve as the senior relationship owner for a portfolio of managed care health plan partners.
Identify performance risks early and lead cross-functional action plans to improve outcomes.
Zócalo Health is a tech-enabled, community-oriented primary care organization serving people who have historically been underserved by the healthcare system. Founded in 2021, the company is backed by leading healthcare and mission-aligned investors and is scaling rapidly across states and populations.
Responsible for quality assurance, accuracy and overall integrity of the UAS-NY assessment data and visit documentation completed by core team nurses as well as, business partners’ nurses.
Performing assessment audits, identifying trends that require staff retraining, and implementing corrective action plans in collaboration with Clinical management staff.
Responsible for ongoing orientation, training and education of Assessment Nurses conducting UAS-NY assessments, and participate in establishing educational modules for staff orientation and re-training.
Elderplan and HomeFirst are Medicare and Medicaid managed care health plans that are expanding services in response to patients' and members' needs. MJHS is a supportive community committed to excellence, respect, and providing high-quality, personalized health care services.
Execute the strategic FMA training plan supporting the therapeutic area Business Unit and new product launch initiatives.
Develop and refine the GMA new hire FMA learning curriculum for their therapeutic area (i.e., Nephrology/Immunology).
Lead virtual classrooms, competency assessments & certifications (live and virtual) and serve as a key presenter and co-author of the Peak Performers series.
Otsuka is a global healthcare company committed to developing and commercializing innovative products in neuroscience, nephrology, and digital medicine. The company employs 34,400 people worldwide, including 2,200 in the U.S., and is dedicated to defying limitations for patients and earning recognition as a Great Place to Work.
Own the post-onboarding education roadmap and programming calendar.
Translate data insights into targeted education plans and measurable adoption strategies.
Design cohort-based learning models (role-based, topic-based, and performance-based).
Midi is a virtual care company focused on women’s health and whole-person care, delivering high-quality care through a tech-forward platform. As they grow, Midi aims to scale post-onboarding education to maintain clinical excellence and practice consistency.