Review payer PA policy documents for specialty medications and interpret coverage criteria.
Translate policy language into standardized, structured data fields.
Flag ambiguous, conflicting, or unclear policy language.
Quantile Health is a New York-based AI startup focused on expanding patient access to medicines and cutting commercial research costs for the life science industry. They are a fast-growing company using AI agents.
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."
Conduct MTM and expanded clinical programs in accordance with the Centers for Medicare & Medicaid Services (CMS).
Develop appropriate clinical algorithms, pathways, and call scripts to support pharmacy staff in delivering MTM services.
Provide Medicare Part D clinical, operational and educational support by maintaining knowledge of all existing updates and regulations regarding the MTM program.
Navitus is an organization that was founded as an alternative to traditional pharmacy benefit manager (PBM) models. They are committed to removing cost from the drug supply chain to make medications more affordable for people; Navitus welcomes new ideas and shares a passion for excellent service to customers and each other.
Lead and manage daily prior authorization operations across all locations.
Oversee workload distribution and productivity; Track and mitigate revenue at risk.
Hire, train, coach, and develop authorization supervisors and authorization staff.
Metro Vein Centers specializes in state-of-the-art vein treatments. With over 60 clinics across 7 states, they deliver compassionate, results-driven care in a modern, patient-first environment.
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.
Manage the insurance claims process and provide customer service to clients.
Analyze and approve claims and determine coverage based on medical necessity.
Resolve discrepancies, secure proper reimbursement, and follow regulations and guidelines.
CommuniCare Family of Companies delivers person-centered care as a national leader in post-acute care. They operate over 150 facilities, employing more than 19,000 employees across six states, and are dedicated to improving the lives of seniors.
Review payer financial reconciliations for accuracy and adherence to agreed-upon methodologies.
Support for the development and deployment of audit procedures applied to payer data sets.
Partner across teams and with payers to resolve data discrepancies.
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 with a collaborative, inclusive, and remote-first culture.
Provide medication management for individuals, including reconciliation and adherence counseling.
Collaborate with the interdisciplinary care team to develop individualized care plans.
Monitor and evaluate medication regimens to ensure clinical criteria are met.
Shields Health Solutions provides integrated support to patients and physicians. They are focused on improving the quality of patient care through personalized relationships with patients and prescribers. They provide equal employment opportunities to all employees and applicants for employment, prohibiting discrimination and harassment of any type.
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.
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.
Oversees day-to-day adjudication operations and ensures a compliant operational environment.
Establishes and maintains reports that support the efficacy of each service authorization process activity.
Monitors encounter data submissions for accuracy and maintains documentation and troubleshooting processes to support data quality.
Habitat Health provides personalized, coordinated clinical and social care as well as health plan coverage through the Program of All-Inclusive Care for the Elderly (“PACE”) in collaboration with our leading healthcare partners, including Kaiser Permanente. They are redefining aging in place and building engaged, fulfilled care teams to deliver personalized care.
Set and execute Medicare agency strategy, partnering with the GM of Healthcare and Strategy & Ops to define a 3-year plan, annual OKRs, and a GTM strategy that drives 5–7x enrollment growth by 2026
Build and scale the brand and growth engine, partnering with Marketing to establish the agency brand and drive top-of-funnel demand across digital, advisor-assisted, and partner channels
Lead cross-functional operations and execution, aligning product, operations, and growth roadmaps while scaling efficiently through automation and AI
Propel empowers low-income Americans by simplifying access to government benefits with modern technology. They are a passionate team of 100 Propellers, all working to help their users get through the month, every month.
Shapes vital subfunction with strategic leadership and operational oversight.
Builds scalable processes for accuracy, timeliness, and quality of authorizations.
Collaborates across functions for data discrepancies and continuous process improvement.
Habitat Health provides personalized, coordinated clinical and social care as well as health plan coverage through the Program of All-Inclusive Care for the Elderly (“PACE”) in collaboration with their leading healthcare partners, including Kaiser Permanente. They build engaged, fulfilled care teams to deliver personalized care in their centers and in the home.
Receive and respond to prescription refill requests through various communication channels.
Verify the validity and accuracy of prescription refill requests, ensuring compliance with regulatory guidelines.
Prepare and dispense prescription refills accurately and efficiently, following established organizational protocols and procedures.
Carenet Health pioneers advancements for healthcare consumer experience. They interact with 1 in 3 Americans every day, delivering positive healthcare experiences and improving outcomes.
Skilled in maintaining contract compliance while generating pull through sales at the IDN-Corporate and hospital levels.
Serve as the expert in the company for your assigned accounts, owning your entire territory as noted.
Gain an accomplished understanding of the market and our competitors.
Dr. Reddy’s is dedicated to helping people lead longer and healthier lives by making medicines more affordable and discovering innovative treatment options. They are seeking dynamic and energetic individuals ready to inspire and make a difference for their community. At Dr. Reddy’s, they are deeply committed to building a diverse, equitable and inclusive workplace where everyone belongs
Working with a team of Intake Coordinators and Utilization Review Nurses to ensure quality and timely determinations.
Striving for continuous improvement and an excellent work-life balance to produce top-notch results.
Coordinating and providing care management that is timely, effective, efficient, equitable, safe, and member centered.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers.
Provides telephonic assessments of members’ medical, psychosocial, physical and spiritual needs.
Develops, implements, and monitors person centered service plan and ensures continuity of care across all healthcare settings.
Educates members on disease processes, preventative health, and quality of life interventions.
MJHS is a supportive community committed to excellence, respect, and providing high-quality, personalized health care services. They foster collaboration, celebrate achievements, and promote fairness for all with comprehensive compensation and benefits.
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.
Work with Transportation Providers and resolve service issues.
Coordinate and conduct monthly provider performance evaluations.
Manage day-to-day vendor interactions and ensure satisfaction.
Jobgether uses an AI-powered matching process to ensure your application is 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.