Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established coverage guidelines.
Educate teams on medical review processes and support quality control activities.
Broadway Ventures is a veteran-owned small business delivering mission-critical support to federal health and defense customers. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it is built on integrity, collaboration, and excellence.
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.
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.
Perform medical necessity and level of care reviews using clinical judgment and guidelines.
Obtain member information via telephone and fax to assess condition and apply evidence-based criteria.
Meet decision-making SLAs and refer members for further care engagement when needed.
Oscar Health is a technology-driven health insurance company focused on simplifying healthcare for its members. We are a mission-driven organization with a diverse team, committed to innovation and equity in healthcare.
Conduct comprehensive reviews of home health pre-claim review packages for Medicare compliance.
Document review outcomes with clinical rationale and meet a 7-business-day turnaround.
Maintain 98% accuracy and complete required training and quality assurance sessions.
Broadway Ventures is a consulting firm providing program management, technology, and innovative solutions to government and private sector clients. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it emphasizes integrity, collaboration, and excellence in its 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.
Conduct medical necessity reviews and continued stay reviews using approved clinical criteria to support quality and financial outcomes.
Collaborate with liaisons, physicians, and revenue cycle teams to manage denials, appeals, and appropriate levels of care.
Maintain documentation, monitor utilization trends, and facilitate patient care planning across the care team.
Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They empower associates to challenge the status quo and put people first, fostering a collaborative and innovative culture.
Performs pre-admission, admission, and continued stay reviews using approved medical necessity criteria.
Coordinates patient care and communicates with physicians, patients, caregivers, and third-party payers.
Manages patient progression through the healthcare system and proactively works with payers to secure certification and minimize denials.
Ochsner Health is a leading not-for-profit healthcare provider in the Gulf South, with 46 hospitals and 370+ care centers. It employs more than 38,000 team members and has been recognized as a top workplace and the No. 1 hospital in Louisiana.
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.
Review appeals of adverse benefit determinations within federal and state regulatory timeframes.
Apply medical policy, coding guidelines, and contractual requirements to assess coverage decisions.
Collaborate with medical divisions and respond to state insurance department inquiries regarding benefit complaints.
Arkansas Blue Cross and Blue Shield is a health insurance provider serving Arkansas. It is consistently ranked as one of the best places to work in Central Arkansas, with an inclusive culture and an average employee tenure of 10 years.
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.
Perform prospective, concurrent, and retrospective reviews of healthcare services to ensure medical necessity and appropriate level of care.
Contact medical and support personnel to recommend alternative treatment plans and coordinate care across the healthcare continuum.
Research and resolve issues related to benefits, eligibility, and appeals while delivering targeted education to providers.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, covering claims administration, payment integrity, and care management. The company is experiencing significant momentum and investing in employees who directly shape the future of healthcare technology.
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.
Review and verify healthcare claims for accuracy, coding, eligibility, and coverage.
Approve or deny claims according to policy terms and regulations, and resolve discrepancies.
Process claims efficiently, meet performance targets, and maintain accurate records.
Blue Cross and Blue Shield of Kansas is a health insurance company providing coverage to Kansans. With over 80 years in the community, it fosters an inclusive, family-first culture and supports professional growth.
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.
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.
Oversee medical necessity reviews for home health, acute, post-acute, and outpatient services for Medicare Advantage populations.
Collaborate with treating physicians, nursing teams, and external agencies to promote evidence-based care and appropriate resource utilization.
Apply CMS regulations, coverage determinations, MCG criteria, and medical policies in a fully remote, part-time physician leadership role.
Jobgether is an AI-powered job matching platform that connects candidates with employers. It uses objective screening to share top-fitting applicants with hiring companies, emphasizing data privacy and human oversight throughout the recruitment process.
Perform concurrent medical record reviews on nursing units to clarify patient documentation.
Prompt physicians to resolve missing, unclear, or conflicting documentation for appropriate reimbursement.
Provide education to patient care providers on clinical documentation standards and coding requirements.
Virginia Mason Franciscan Health provides a full spectrum of health care services across the Puget Sound region, with a legacy of compassionate care and innovation. With 10 hospitals and nearly 300 care sites, the organization is dedicated to healing the whole person through rigorous research, education, and collaboration.
Perform quality audits on clinical documentation across clinical departments.
Collaborate with leadership to develop corrective action plans and provide 1:1 coaching.
Support organizational readiness for NCQA and other regulatory audits.
Oscar is the first health insurance company built around a full stack technology platform, focusing on serving members with a concierge-level experience. It started in 2012 and is an Equal Opportunity Employer cultivating an authentic, inclusive environment.