Conduct clinical reviews of medical records during fraud investigations and program integrity initiatives.
Apply Medicare and Medicaid guidelines to determine appropriateness of payment coverage.
Compile investigative summary reports and provide training on medical terminology and policy interpretation.
CoventBridge Integrity Systems delivers investigative services, technology, and expertise that help healthcare and government organizations protect critical programs, strengthen oversight, and address fraud, waste, abuse, and operational risk. They are an equal opportunity employer committed to diversity and inclusion, maintaining a drug-free workplace.
Manage accounts receivable, including analysis of aged AR and identification of root cause issues.
Investigate, resolve, and appeal insurance claim denials, contacting payer representatives as needed.
Collaborate with internal teams and care center staff to drive optimal revenue cycle performance.
Privia Health is a technology-driven physician enablement company that partners with medical groups and health systems to optimize practices and improve patient experiences. It is led by top industry talent and physician leadership with a focus on scalable operations and cloud-based technology.
Coordinates utilization review and prior authorization requests, ensuring accurate entry into the UM platform.
Provides customer service to providers and members, confirming benefits and answering authorization questions.
Facilitates communication between reviewers, hospitals, and physicians to ensure timely decisions.
University of Utah Health Plans is a patient-focused organization that enhances health through patient care, research, and education. It is part of a nationally ranked academic medical center with five hospitals and eleven clinics, fostering a culture of collaboration and excellence.
Resolve unpaid, denied, or short-paid claims using company billing systems.
Review EOBs and payer correspondence; follow up via portal, phone, email, or fax.
Manage complex denials, appeals, and account resolution with clear documentation.
Hanger, Inc. is the world's premier provider of orthotic and prosthetic (O&P) services and products. With 160 years of clinical excellence, it operates the largest O&P patient care clinic network nationwide, helping people achieve new levels of mobility.
Receive medical claims from healthcare providers or patients and verify supporting documentation to ensure completeness.
Interpret Explanation of Benefits (EOB) and CMS-1500 forms, then evaluate claims against program-specific business rules for approval or rejection.
Provide support to customer inquiries via phone, email, or fax while maintaining HIPAA compliance and meeting daily productivity goals.
IQVIA is a leading global provider of clinical research services, commercial insights, and healthcare intelligence to the life sciences and healthcare industries. With operations in over 100 countries, they cultivate a diverse, collaborative culture focused on improving patient outcomes.
Review and abstract professional medical records to ensure accurate code assignment.
Assign ICD-10-CM, CPT, HCPCS, and modifiers per national and payer-specific guidelines.
Maintain coding quality, compliance, and productivity standards while staying current on updates.
Sprinter Health reimagines access to care by bringing it directly to patients' homes via technology. It has supported 2M+ patients across 22 states, completed 130,000+ visits, raised over $125M, and maintains a 92 NPS.
Review a variety of claim types including Radiology, Ambulance, Physical Therapy, and Surgical for medical necessity and coverage.
Document medical rationale for payment or denial decisions using Medicare guidelines and established criteria.
Educate internal and external staff on medical review, terminology, coverage determinations, and coding.
We transform 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 are built on integrity, collaboration, and excellence.
Perform medical reviews and utilization management to determine medical necessity for services and appeals.
Evaluate medical records and document decisions using clinical guidelines and protocol sets.
Educate members, providers, and staff on coverage determinations, medical terminology, and coding procedures.
Palmetto GBA is a healthcare administrator and one of the nation's largest medical claims processors. As part of BlueCross BlueShield of South Carolina, we've served clients for 70+ years and offer training and tuition assistance.
Partner with Clinical, Claims, and SIU teams to review claims for billing and coding issues.
Leverage internal AI tools and predictive models to identify anomalous billing patterns and support prepayment audits.
Collaborate with Data Science and Engineering to validate AI-flagged claims and refine machine learning models.
Clover Health is reinventing health insurance by combining the power of data with human empathy to keep members healthier. It is a fast-growing, remote-first startup with a mission-driven, collaborative culture focused on improving healthcare.
Review referred accounts to validate underpayments and analyze reimbursement variance reports.
Request additional payment from insurance companies and perform timely follow-up on all assigned accounts.
Escalate unresolved appeals, prepare monthly denial logs, and collaborate to recover underpayments.
Lucile Packard Children's Hospital Stanford provides world-renowned pediatric care, combining advanced technologies and breakthrough discoveries with family-centered care. We support our caregivers with continuing education and state-of-the-art facilities, fostering a caring and committed team culture.
Provides administrative support to clinical teams including building medical management records and managing authorizations.
Conducts fax and telephonic outreach to members and providers for status updates and engagement.
Supports compliance monitoring and documentation in the medical management system.
Capital Blue Cross is a health insurance provider dedicated to improving the health and well-being of its members and communities. They are recognized as one of the "Best Places to Work in PA" with a culture focused on support, flexibility, and community involvement.
Provide subject matter expertise on Payment Integrity claims processing edits, vendor edits, and reimbursement policies.
Respond to internal and external inquiries and disputes while documenting industry standard coding rules and recommending policy changes.
Collaborate with partners to scope, prioritize, and deliver solutions using data insights and process improvements.
Oscar is a health insurance company built around a full stack technology platform and a relentless focus on serving members. Founded in 2012, the company fosters a culture of transparency, collaboration, and authenticity as an Equal Opportunity Employer.
Manage provider data and generate reports to support network operations and compliance.
Validate and audit provider records to ensure data accuracy and regulatory alignment.
Collaborate with cross-functional teams to resolve configuration issues and support network projects.
This company operates in the healthcare sector, focusing on provider network administration and data management. It fosters a collaborative, detail-oriented remote work environment that values data accuracy and continuous quality improvement.
Process and transmit electronic and paper claims to insurance companies, patients, and other responsible parties.
Follow up on unpaid claims, review rejections, and resolve payment questions with insurance providers.
Verify insurance benefits, analyze charges and payments, and support coordination of benefits for patient accounts.
Munson Healthcare is northern Michigan's largest healthcare system, operating eight award-winning community hospitals across 29 counties. The organization values excellence, teamness, positivity, and creativity, and is committed to creating exceptional experiences for patients and staff.
Process incoming medical referrals, enter accurate data into medical management systems, and assign appropriate healthcare providers.
Review referrals for benefits and medical necessity, escalate sensitive cases for clinical assessment, and apply ICD-10 and CPT codes.
Communicate with military treatment facilities and civilian providers, respond to inquiries, and manage referral tasks within established timelines.
This position is listed on behalf of a partner company that manages all applications and next steps. The company supports healthcare service delivery by ensuring medical referrals are processed accurately and efficiently within a structured, collaborative remote team.
Maintain excellent quality standards for client programs and adhere to program scripts and guidelines.
Effectively communicate and manage calls with empathy, accurately collecting information and explaining medical terminology.
Exhibit organizational skills by handling multiple projects simultaneously and safeguarding patient privacy under HIPAA.
Inizio Engage is a strategic healthcare engagement partner that helps clients improve treatment outcomes by reimagining how they engage with patients, payers, and providers. With over 7,000 experts worldwide, the company fosters a collaborative culture and has been recognized as a Best Place to Work.
Track MSSP performance metrics including attribution, cost, utilization, and quality.
Build actionable analytics and HCC risk models to identify spend anomalies and performance gaps.
Collaborate with ACO leaders and IT to translate data insights into strategic decisions.
Privia Health is a technology-driven physician enablement company that partners with medical groups and health plans to improve patient care and practice performance. Led by industry talent and physician leadership, it focuses on reducing healthcare costs and advancing value-based care.
Assigns ICD-10-CM, CPT/HCPCS codes and modifiers for outpatient encounters such as clinic, diagnostics, and EMS.
Ensures compliance with official coding guidelines, payer policies, and facility requirements while meeting quality benchmarks.
Collaborates with CDI, billing, and revenue integrity teams to improve documentation and optimize reimbursement.
Capital Health is a dynamic healthcare network that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. With more than 600 physicians and providers, the organization is accredited by DNV and emphasizes attracting top talent through competitive compensation and a collaborative culture.
Analyze hospital claims to identify discrepancies between expected and actual insurance reimbursements.
Investigate underpayments and payment variances by examining coding errors, billing discrepancies, and payer policies.
Collaborate with insurance carriers and internal stakeholders to resolve billing issues and improve revenue recovery outcomes.
This partner company specializes in healthcare revenue integrity, helping hospitals recover appropriate reimbursement for services. The team fosters a collaborative, inclusive culture focused on continuous improvement and professional development.