Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies.
Collaborates with client personnel to resolve customer concerns and facilitates resolution of escalated cases.
Maintains written documentation per HealthHelp’s policy and ensures compliance with HIPAA, state, and federal regulations.
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, operations in 13 countries, 65 delivery centers, and more than 66,000 employees, WNS combines scale, expertise, and execution to create meaningful, measurable impact.
Perform clinical reviews and conduct peer-to-peer discussions.
Participate in inter-rater reliability activities and clinical rounds.
Serve as a clinical resource and subject matter expert to clinical and non-clinical staff.
Devoted Health is a healthcare company that aims to improve the health and well-being of older Americans through a data and AI-driven care platform. The company values diversity, collaboration, and a supportive work environment, and is an equal opportunity employer.
Review Home Health prior authorization requests for medical necessity using CMS regulations and Clover clinical guidelines.
Perform initial and concurrent clinical reviews, ensuring appropriate care in the least restrictive setting.
Collaborate with providers and internal teams to support timely decision-making and positive member outcomes.
Clover Health is a healthcare company that uses data and technology to provide affordable, high-quality insurance plans for seniors. The company fosters a remote-first culture with a diverse and mission-driven team focused on improving member outcomes.
Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
Review inpatient and outpatient medical records to support appeal submissions and apply payer-specific guidelines.
Document review findings accurately and meet assigned turnaround times while maintaining quality standards.
CorroHealth helps clients exceed their financial health goals by providing scalable solutions and clinical expertise across the reimbursement cycle. The company fosters a supportive culture that invests in professional development and personal growth.
Perform utilization review including precertification and concurrent reviews using medical necessity criteria.
Collaborate with medical directors and providers on complex cases and integrate AI tools into workflow.
Initiate referrals to disease management programs and participate in quality improvement initiatives.
Guidehealth is a data-powered healthcare company that uses AI and predictive analytics to improve healthcare affordability and patient outcomes. It is a physician-led organization with a culture of accountability, learning, innovation, and empathy.
Develop and coordinate individualized treatment plans and discharge services for patients.
Perform medical record reviews to assess admission appropriateness and ensure compliance with standards.
Support denials management and appeals for insurance claims to ensure quality care.
Northwestern Medicine is a healthcare system focused on patient-first care. We offer a supportive workplace with competitive benefits and a culture of growth.
Perform daily audits on client data for completeness and accuracy of coding using clinical knowledge.
Respond to provider appeals and meet client turnaround time and KPI goals.
Utilize coding validation training to become familiar with claims payment policies and regulations.
Cotiviti is a healthcare analytics company that uses data-driven solutions to improve payment accuracy and quality in healthcare. The company offers a competitive benefits package and fosters a collaborative, fast-paced work environment.
Provides high-quality triage and coordination of transfers from other facilities.
Monitors and responds to triage needs, completing direct referral acceptance processes.
Collaborates with referral sources, physicians, and nurses, reporting to the Director of Assessment and Referral.
Voyages Behavioral Health / PAM Health provides extended hospital care for chronically and critically ill patients through over 80 locations in 17 states, employing more than 11,000 people. The culture emphasizes compassionate care, team collaboration, and professional growth.
Ensure acute hospital admissions have appropriate level of care and meet medical necessity.
Monitor patient progress in plan of care for continued stay.
Provide clinical information to payer to authorize acute hospital stay and continued services.
Piedmont Healthcare is a healthcare organization focused on patient outcomes. It offers a supportive culture with diverse teams, schedule flexibility, and comprehensive benefits, fostering employee growth and well-being.
Perform medical claims audit reviews with a focus on the Home Health sector, applying medical review guidelines and documenting findings.
Collaborate with the audit team to identify vulnerabilities, generate audit letters, and support findings during appeals.
Maintain knowledge of coding systems (ICD-10, CPT-4, HCPCS) and regulatory changes to ensure high-quality, deadline-driven work.
Machinify is a leading healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients using an AI-powered platform. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, the company fosters a collaborative, fast-paced remote culture.
Perform prospective, concurrent, and retrospective utilization reviews for behavioral health services across multiple care settings.
Assess medical necessity and coordinate care with providers, members, and internal teams to ensure appropriate access and treatment.
Support discharge planning, benefit utilization, and regulatory compliance while improving overall care quality.
This company provides high-quality behavioral health coordination and utilization management services to improve member outcomes. They foster a supportive, collaborative environment focused on professional growth and clinical excellence.
Provide telephonic case management and utilization review for assigned consumers.
Develop, implement, and monitor individualized care plans to ensure quality and cost-effective outcomes.
Collaborate with healthcare providers, payors, and internal teams to coordinate care.
Cottingham & Butler helps clients through life's toughest moments by providing insurance and benefits solutions. The company fosters a culture of continuous improvement, seeking to hire, train, and grow the best professionals in the industry.
Perform monthly clinical check-ins and structured symptom assessments for assigned patient panels.
Collaborate with providers to escalate urgent issues and reinforce care plans within LPN scope.
Document all patient interactions in EHR and CCM platform while ensuring compliance with billing and quality metrics.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic approach. The company is committed to improving patient outcomes and quality of life, but specific employee size is not mentioned.
Administer multiple clinical assessments and screening tools to prioritize member needs and coordinate care.
Build trusting relationships with members through empathy and consistent engagement, serving as the care quarterback.
Utilize electronic systems and collaborate with the interdisciplinary team to optimize the member experience.
Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. The company delivers goal-centered care to reduce hospitalizations and improve quality of life, with a dynamic and inclusive team environment.
Implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center.
Functions within the multidisciplinary team to secure complex pre-authorizations and prevent/appeal clinical denials.
Utilizes clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided.
The Ohio State University is a top-20 public university with one of America’s leading academic health centers. They are a team of dedicated colleagues with access to boundless resources.
Provide telephonic case management to proactively drive return to work.
Perform utilization review and coordinate care with providers and adjusters.
Evaluate treatment plans and partner with adjusters to achieve optimal outcomes.
AmTrust Financial Services is a fast-growing commercial insurance company providing comprehensive telephonic case management. They foster a diverse and inclusive culture with a focus on attracting and retaining the best talent.
Identify, research, process, and resolve customer inquiries regarding health insurance benefits, claims, and eligibility.
Analyze medical records and apply medical necessity criteria to determine the appropriateness of benefit requests.
Maintain accurate records, meet quality and timeliness standards, and coordinate with internal departments and external organizations.
Blue Cross Blue Shield of Arizona provides health insurance products and services to individuals, families, and businesses, aiming to inspire health and make it easy. The company has been recognized as a Healthiest Employer and has transformed healthcare for over 80 years with teams in Phoenix, Tucson, Chandler, and Flagstaff.
Provide real-time virtual nursing assistance to on-site care teams nationwide.
Lead patient-centered care by coordinating a multidisciplinary team in a virtual environment.
Apply evidence-based practice to design, implement, and evaluate client plans of care.
St. Luke’s Health – Memorial Lufkin is a 279-bed facility and member of CommonSpirit Health, a national nonprofit health system serving East Texas. It provides over a quarter million patient services annually and is a Joint Commission Certified Primary Stroke Center.
Conduct telephonic outreach to Medicare members to improve medication adherence and HEDIS diabetes and blood pressure control.
Use motivational interviewing to assess health risks and engage members in behavior change.
Partner with members to identify opportunities for integration into internal/external programs and coordinate care.
CVS Health is building a world of health around every individual, shaping a more connected, convenient and compassionate health experience. They are a large company with passionate colleagues who care deeply, innovate with purpose, and prioritize safety and quality.
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.