Source Job

• 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.

• 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.

• 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.

• Performing timely utilization review of healthcare services using approved medical necessity criteria.
• Collaborating with medical directors, providers, and internal teams for compliant review processes.
• Ensuring accurate documentation and communication of determinations within regulatory timeframes.

Guidehealth is a data-powered, performance-driven healthcare company focused on making healthcare affordable and improving patient health. It is a physician-led organization using AI and predictive analytics, with a culture of accountability, growth, innovation, and empathy.

• Review medically complex claims, pre-authorization requests, appeals, and fraud and abuse referrals.
• Assess payment determinations using clinical information and established guidelines.
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.

Broadway Ventures transforms challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, we empower clients with tailored solutions, operating with integrity and collaboration.

• Provide Utilization Review and Case Management to Emergency Department patients with social or discharge needs.
• Offer hospital-wide Utilization Review and Case Management coverage as needed and time allows.
• Hold a valid RN state licensure; 3-5 years of nursing experience preferred.

Freeman Health System is a not-for-profit health system serving communities across Missouri, Arkansas, Oklahoma, and Kansas through a network of hospitals, physician clinics, and specialty services. The system is supported by over 7,000 employees and is the only Children's Miracle Network Hospital in a 70-mile radius.

• 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.

• 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.

• 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.

• 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.

• Engages members proactively and reactively to build trust and drive benefit and program engagement through motivational interviewing.
• Develops individualized care plans based on comprehensive clinical, psychosocial, and SDOH assessments, coordinating resources across the care continuum.
• Educates members and providers on benefits, digital health solutions, and self-management strategies while supporting utilization review and documentation.

Evry Health is a digital-first health plan focused on delivering comprehensive, member-centered care coordination for its fully insured commercial population. The company operates as a fully remote team with headquarters in Dallas, Texas, emphasizing a technology-forward and collaborative culture.

• 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.

• 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.

• Provide clinical education, focused interventions, and care transition support for members with low-acuity needs.
• Conduct in-person and virtual clinical exams, medication reconciliation, and chart reviews.
• Triage referrals and collaborate with care team to ensure timely follow-up and handoffs.

Cityblock Health is a tech-driven provider for communities with complex needs, offering personalized primary care, behavioral health, and social services. Founded in 2017 and backed by Alphabet, the company has a diverse, inclusive culture and is growing rapidly.

• Oversee the Complex Clinical Bill Review team, managing production expectations, SLAs, client communication, and team performance.
• Analyze and track internal business requirements, continuously evaluate functionality across programs, and perform requirements gathering to solve process issues.
• Monitor team performance metrics, identify growth opportunities, and coordinate system enhancements including JIRA and UAT testing.

Machinify is a leading healthcare intelligence company providing an AI-powered platform for health plan clients. They are deployed by over 85 health plans, representing more than 270 million lives, with a culture of innovation and efficiency.

• Serve as a key liaison between patients, providers, and pharmacies to ensure seamless care coordination.
• Own a queue of active clinical cases, reviewing them and driving each to resolution through persistent follow-up.
• Use sharp clinical judgment to separate real issues from noise and communicate clearly with all stakeholders.

GoldenScript is an AI-native pharmacy services platform that optimizes medication management for patients. The company is a small startup focused on clinical care coordination and patient outcomes.

• Analyze health plan reports and clinical data to identify members eligible for case management.
• Conduct comprehensive telephonic and virtual assessments to evaluate medical, behavioral, and social needs.
• Develop, implement, and monitor individualized care plans with measurable goals and interventions.

Duly Health and Care is a physician-led medical group offering a connected network of primary and specialty care, surgery centers, imaging, lab, and therapy services. They foster a collaborative culture centered on putting patients first and supporting team growth.

• Provide virtual comprehensive care to patients of all ages in an urgent care setting.
• Manage acute, chronic, and mental health conditions with a focus on quality and access.
• Collaborate with provider and support teams to deliver evidence-based care.

We are a healthcare company delivering integrated virtual care and navigation. We are on a mission to raise the standard of healthcare, though our company size is not specified.

• 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.