Source Job

• Conduct clinical reviews for inpatient admissions and post-acute settings using evidence-based guidelines and CMS criteria.
• Serve as the primary physician reviewer for escalated or complex cases requiring high-level medical judgment.
• Partner with care management teams to identify utilization trends and develop interventions to reduce unnecessary admissions or extended stays.

It appears to be a healthcare organization. They ensure timely and appropriate care determinations for their Medicare Advantage members.

• Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
• Guide timely care determinations using CMS regulations and evidence-based practices.
• Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.

HJ Staffing is seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. The company has not provided any information about its size/employees and culture but is likely a medium to large medical or staffing company.

• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
• Provide medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
• Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.

Centene is committed to helping people live healthier lives. They provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well. Centene values diversity and is an equal opportunity employer.

• Performing physician-level utilization management reviews for behavioral health services across all applicable levels of care.
• Conducting peer-to-peer consultations with treating psychiatrists and other behavioral health providers.
• Serving as a consultative clinical resource to behavioral health utilization management nurses, care managers, and operational leaders.

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and AI, they leverage remotely-embedded Healthguides™ and a centralized Managed Service Organization.

• Review medically complex claims, pre-authorization requests, appeals, and fraud/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 (SDVOSB), they empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth.

• Provide support to the Utilization Management Nurse and RN Appeals Writer.
• Help prevent clinical denials related to lack of clinical authorization and untimely notifications.
• Investigate root cause of clinical denials and document them in Epic and follow-up of appeal outcome.

Piedmont Healthcare provides healthcare services. They value diverse teams, a shared purpose, and schedule flexibility.

• Answers first level calls in Utilization Review.
• Evaluates certification requests by reviewing group specific requirements.
• Triage the call to determine if a Utilization Review Nurse is needed.

Cottingham & Butler sells a promise to help clients through life’s toughest moments by hiring, training, and growing the best professionals. The company culture is guided by the theme of “better every day” constantly pushing themselves to be better than yesterday.

• Independently resolve a broad range of member inquiries across Maven Managed Benefits, fertility programs, and Maven Wallet workflows.
• Interpret and clearly explain benefits design, eligibility, and coverage to members, identifying edge cases and ensuring alignment with plan rules.
• Manage end-to-end reimbursement and payment workflows, including reviewing documentation, identifying discrepancies, guiding members on next steps.

Maven Clinic is the world's largest virtual clinic for women and families on a mission to make healthcare work for all. More than 2,000 employers and health plans trust Maven's end-to-end platform to improve clinical outcomes, reduce healthcare costs, and provide equity in benefits programs. Maven Clinic is a recipient of over 30 workplace and innovation awards.

• Review and refine AI-generated clinical summaries and indicators related to medical necessity.
• Collaborate with Product and Data Science teams to define and validate clinical logic.
• Translate clinical knowledge into prompts and guidelines for large language models.

SmarterDx builds clinical AI that is transforming how hospitals translate care into payment. Founded by physicians in 2020, their platform connects clinical context with revenue intelligence, helping health systems recover millions in missed revenue, improve quality scores, and appeal every denial.