Work remotely to enhance member management and maximize cost effectiveness.
Collaborate with clients and members to promote wellness and assist in achieving health goals.
Collect data, conduct clinical reviews, and ensure documentation complies with regulations.
Guidehealth is a data-powered healthcare company dedicated to operational excellence. They aim to make healthcare affordable and improve patient health, employing remotely-embedded Healthguides™ and a Managed Service Organization to build stronger connections with patients and providers.
Conducting in-depth telephonic assessments to understand each patient’s needs.
Developing individualized care plans and guiding patients through their treatment goals and care options.
Monitoring progress by phone, adjusting care plans, and ensuring patients stay connected to their providers.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They improve the health of patients, and restore the fulfillment of practicing medicine for providers leveraging remotely-embedded Healthguides™ and a centralized Managed Service Organization. Physician-led, Guidehealth empowers its partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.
Maintain oversight over a specified panel of members by performing ongoing assessments.
Create comprehensive care plans addressing members' needs and conducting regular follow-ups.
Ensure achievement of targeted goals related to patient outcomes and care plan realization.
Jobgether is a company that uses an AI-powered matching process to ensure applications are reviewed quickly, objectively, and fairly against the role's core requirements. Their system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company.
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. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers.
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.
Conduct coverage reviews based on member plan benefits and policies.
Document clinical review findings, actions, and outcomes.
Communicate and collaborate with providers for benefit determinations.
Capital Blue Cross promises to go the extra mile for their team and community. They foster a flexible environment where health and wellbeing are prioritized and employees consistently vote it as one of the "Best Places to Work in PA."
Jobgether is a platform that connects job seekers with companies. They use an AI-powered matching process to ensure applications are reviewed quickly and fairly.
Engage with members to support their chronic and/or complex health care needs.
Create and manage individualized care plans to meet healthcare goals.
Partner with members, families, providers, and resources to coordinate care.
Wellmark is a mutual insurance company owned by policy holders across Iowa and South Dakota, built on over 80 years of trust. They prioritize members' well-being and are committed to service, sustainability, and innovation.
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.
Review final 485/POCs for compliance and accuracy.
Cross-check orders, goals, frequencies, and documentation.
Approve or flag charts for correction.
Urrly uses AI to review every application against the same clear requirements for the role. Their goal is to create a more objective, consistent, and equal opportunity hiring process for all applicants.
Oversees daily operations of the Care Management unit and ensures process implementation.
Facilitates staff development, provides regular performance feedback, and identifies areas of improvement.
Evaluates performance metrics, supports staff in care planning, and promotes interdisciplinary collaboration.
Capital Blue Cross promises to go the extra mile for our team and our community. They offer a caring team of supportive colleagues and invest heavily in training and continuing education. Employees consistently vote them one of the “Best Places to Work in PA.”
Manage a defined caseload of enrolled CCM members.
Identify and address social determinants of health, including food access, housing resources, transportation, and community supports.
Partner closely with the RN and NP to surface barriers impacting care or engagement.
Pair Team is a tech-enabled medical group delivering whole-person care - clinical, behavioral, and social - by partnering with organizations deeply connected to the communities they serve. They're building a care model that empowers clinicians and care teams to do what they do best: provide compassionate, high-impact care.