Supports the affiliate-level Utilization Management and denials processes by coordinating incoming requests for information from multiple payer sources.
Conducts maintenance and utilization of EPIC work queues that support obtaining authorization for patient stays; communicates with payers via telephone, fax, or email.
Acquires an understanding of third party authorizations, verification, and denials, and proceeds with notification/documentation to appropriate parties.
Microsoft OfficeCustomer ServiceCommunicationData AnalysisProblem Solving
Review incoming referral orders to assess patient’s needs based on diagnosis, insurance coverage or lack thereof, and previous treatments.
Verify patient information including demographics, insurance coverage and financial status; confirm patient eligibility for health care coverage and clarify any managed care arrangements.
Contact the patient prior to service to inform them of their estimate and collect any pre-payments at that time.
OHSU is Oregon's only public academic health center, caring for patients and leading groundbreaking research. As Portland's largest employer, they offer opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington.
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. They aim to make great healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages Healthguides™ and a Managed Service Organization to build stronger connections with patients and providers.
Processes acute and post-acute inpatient medical and select intensive outpatient higher level of care requests through clinical review.
Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies to requests.
Collaborates with UM department staff and Medical Directors to make a final determination, and with Care Management staff on discharge planning.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. At Capital, employees work alongside a caring team of supportive colleagues and are encouraged to volunteer in their community.
Coordinating payor denial and appeal follow up activities to ensure timely response from third party payors.
Communicating and coordinating with various individuals/distributions and assisting with monitoring of the day to day activities related to appeal follow up and denials.
Maintaining the hospital tracking tool/application that stores/communicates all denial and review activity.
Shriners Children’s is an organization that respects, supports, and values each other. They provide excellence in patient care, embracing multi-disciplinary education, and research with global impact and were named the 2025 best mid-sized employer by Forbes.
Evaluates certification requests by reviewing the group specific requirements.
Triage the call to determine if a Utilization Review Nurse is needed to complete the call.
Cottingham & Butler sells a promise to help their clients through life’s toughest moments. Their culture is guided by the theme of “better every day” constantly pushing themselves to be better than yesterday.
Develop collaborative relationships with insurance companies/payors to verify benefits and eligibility.
Enter and update patient demographics, guarantor, and insurance information in company systems.
Respond to inquiries from insurance companies and internal team members.
Equip is a virtual, evidence-based eating disorder treatment program ensuring everyone can access treatment. Founded in 2019, Equip has been fully virtual since its inception and is proud of their highly engaged team, with recognition from Time, Linkedin, and Lattice.
Provides non-clinical administrative support to Case Managers and Care Coordinators.
Obtains and manages medical documents, ensuring accurate record retrieval.
Prioritizes tasks based on expedited requests with attention to detail.
Spectrum Healthcare Resources (SHR) delivers systems and processes designed to meet the unique needs of Military and VA Health Systems. They provide physician and clinical staffing and management services to United States Military Treatment Facilities, VA clinics and other Federal Agencies.
Track and manage prior authorization requests, renewals, and extensions.
Verify member eligibility and benefits to confirm coverage requirements.
Upload, organize, and maintain member records and clinical documentation accurately and timely.
Leap is a benefits solution company focused on reshaping how life-changing therapies are delivered and financed. They are a fast-growing company that partners with Fortune 500 companies and leading TPAs, focusing on lower costs, improved access, and better care.
Performs complex secretarial and administrative duties.
Responsible for all clinic preparations and optimizing provider patient schedule.
Triages incoming calls, schedules patient appointments, and obtains pertinent medical information.
The University of Rochester is committed to education, research and making the world ever better. One of the world’s leading research universities, Rochester has a long tradition of breaking boundaries—always pushing and questioning, learning and unlearning.
Execute credentialing and enrollment workflows for new providers.
Maintain accurate provider and practice data in credentialing database.
Complete Medicare revalidations, Medicaid recredentialing, and commercial recredentialing per payer schedules.
Integrated Dermatology is a leading national dermatology practice that acquires and partners with dermatology practices across the United States. The culture at ID is filled with hard-working, dynamic individuals who come together to ensure the success of our partner dermatologists.
Assess referred concurrent denials and determine next steps for resolution.
Review medical record documentation to support denial management strategies.
Advocate for patients to ensure coverage and reimbursement.
They are currently looking for a Utilization Management Coordinator. By enhancing operational efficiencies and implementing educational initiatives, this role significantly impacts the financial and quality outcomes of healthcare delivery.
Resolve claims rejections and denials in work queues as assigned.
Resolve outstanding claims based on an accounts receivable report.
Submit appeals to payors for non-payment of claims as needed.
Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in multiple states. They offer a variety of programs designed to ensure patients receive the highest quality of care by a team they know and trust.
Coordinate with insurance representative on claims and accidents
Prepare and present reports summarizing accidents, utility hits, damages, injuries and near misses
MasTec Communications Group provides engineering, construction, and design and management solutions that meet the growing telecommunications needs throughout the United States. They are a fast-growing team of professionals committed to safety and quality service.
Acts as initial service ambassador to referral sources, physicians, patients, caregivers and other external customers providing the highest quality service.
Responsible for the initial entry, verification, and maintenance of information regarding new patients in all applicable software programs.
Processes private insurance verifications, verifies eligibility of Medicare, Medicaid and third party payers and any other duties as directed.
CommonSpirit Health at Home is a full-service health care organization that believes the best place for someone to get better is in their own home. As a faith-based organization, they are committed to finding new ways to improve the health of their patients and the health of the communities they serve.
Review and analyze claims, member, and group data.
Establish the correct order of liability for clients’ members.
Input accurate claim recovery information into software tools.
Cotiviti delivers comprehensive payment accuracy services that help organizations improve their healthcare outcomes. Team members enjoy a competitive benefits package and are encouraged to embody Cotiviti's core values.
Facilitate damage and vehicle claims company-wide.
Coordinate with insurance representatives on claims and accidents.
Prepare and present reports summarizing accidents, utility hits, damages, injuries, and near misses.
Jobgether leverages AI-powered matching to connect job seekers with employers, ensuring applications are reviewed quickly and fairly. They aim to streamline the hiring process by identifying top-fitting candidates for various roles, passing a shortlist on to the hiring company.
Assess, plan, coordinate, and monitor patient care.
Develop, implement, and monitor individualized care plans.
Coordinate care across providers, facilities, and community resources.
Limitlessli specializes in recruiting, hiring, and managing high-caliber remote staff for dynamic and growing healthcare facilities. They connect clients with highly qualified professionals, offering tailored services to meet unique business needs, leveraging an extensive global network.
Coordinate the end-to-end provider enrollment process for physicians, nurse practitioners, and physician assistants joining the medical group.
Prepare and submit enrollment applications to Medicare, Medicaid, and other applicable payers to establish billing privileges.
Maintain accurate provider data within internal systems (e.g., NPPES, PECOS, CAQH, and iCIMS/HRIS) to ensure consistency across platforms.
Curana Health is dedicated to radically improving the health, happiness, and dignity of older adults. They are a national leader in value-based care, serving 200,000+ seniors in 1,500+ communities across 32 states and employing more than 1,000 clinicians plus other professionals.
Contacts insurance companies for status on outstanding claims.
Processes and follows up on appeals to insurance companies.
Works outstanding accounts receivable from assigned work queues.
US Anesthesia Partners is dedicated to providing high-quality anesthesia services. They offer equal employment opportunities to all employees and applicants.
Support the collection, validation, and maintenance of payer data necessary for various sales campaigns.
Create and maintain reports and dashboards to track payer contract performance and "smart MA growth" metrics.
Ensure data hygiene and accuracy for all outreach efforts.
Aledade empowers independent primary care practices to deliver better care to their patients and thrive in value-based care. They are the largest network of independent primary care in the country, founded in 2014, and fostering a collaborative, inclusive, and remote-first culture.