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.
Perform comprehensive medical record and claims review to make payment determinations for Medicare PART A.
Conduct in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles.
Make clinical judgment decisions based on clinical experience when applicable.
Empower AI provides federal agency leaders with tools to elevate their workforce's potential through meaningful transformation. Headquartered in Reston, Va., Empower AI leverages three decades of experience solving complex challenges in Health, Defense, and Civilian missions.
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.
Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs.
Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals.
Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance.
Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. They serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes and have a mission to empower people to lead healthier lives.
Perform comprehensive medical record and claims review to make payment determinations for Medicare Durable Medical Equipment.
Conduct in-depth claims analysis utilizing ICD-10-CM, AMA-CPT, and HCPCS Level II coding principles.
Make clinical judgment decisions based on clinical experience when applicable.
Empower AI provides AI tools for government to elevate workforce potential. They have three decades of experience solving complex challenges in Health, Defense, and Civilian missions and are headquartered in Reston, VA.
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.
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.
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.
Build trusting relationships with patients, families, and providers, addressing health questions and care needs.
Identify medical, behavioral, social, emotional, and financial needs to support whole‑person care.
Strengthen the connection between patients and healthcare providers by addressing barriers and facilitating communication.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence, with the goal to make great healthcare affordable, improve patient health, and restore fulfillment for providers. They leverage remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers.
Review clinical information for appropriateness, congruency, and accuracy.
Review and communicate OASIS edit recommendations to each clinician.
Provide customer service/education and act as a resource to Medicare Certified Offices.
BAYADA Home Health Care delivers home health care with compassion, excellence, and reliability. As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates, with 50 years of experience.
Review patient records to ensure documentation aligns with medical, legal, regulatory, and insurance standards.\n- Abstract appropriate supporting documentation into abstraction tool.\n- Collaborate with healthcare providers or internal staff to clarify unclear or incomplete documentation.
Capital Blue Cross promises to go the extra mile for its team and community, and its employees consistently vote it one of the “Best Places to Work in PA”. The company offers a flexible environment where health and wellbeing are prioritized and invests in training and continuing education.
Conduct targeted patient outreach to close care gaps and ensure timely care transitions.
Deliver high-touch engagement for high-risk patients to prevent readmissions through follow-up.
Collaborate with Practices to support interventions such as Transitional Care Management.
Aledade empowers independent primary care practices, helping them deliver better care and thrive in value-based care. Founded in 2014, they are the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.
Responsible for the coordination of services for members meeting established criteria, emphasizing education/self-management and promoting quality care and cost-effective outcomes.\n- Uses a collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor progress, and evaluate Member status.\n- Addresses medical, psychosocial, clinical needs, and behavioral health needs including members with mental health and substance use disorder needs, providing counseling and referrals to community/local/state programs.
Capital Blue Cross is committed to providing excellent service to both its team and the community. Employees have consistently voted it as one of the “Best Places to Work in PA”, which indicates a positive and supportive company culture.
Analyze and improve UM business workflows, including clinical assessments, rules, and documents.
Validate Health Services programs against business requirements and acceptance criteria.
Partner with medical directors and cross‑functional teams to review, evolve, and update InterQual and custom clinical criteria.
Wellmark is a mutual insurance company owned by its policy holders across Iowa and South Dakota, and it has built its reputation on over 80 years of trust. They are motivated by the well-being of their members and committed to sustainability and innovation.