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.
Manage a caseload of post-payment Workers' Compensation bills, including disputes and negotiations.
Conduct proactive outreach to medical providers to resolve disputes and negotiate reductions.
Ensure compliance with state-specific regulations and maintain productivity standards.
Reliant Health Partners is an innovative medical claims repricing service provider that helps employers achieve maximum health plan savings with tailored services. The company values diversity and inclusion, fostering a collaborative environment as an equal opportunity employer.
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.
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.
Manage end-to-end credentialing and payer enrollment for behavioral health providers and facilities.
Serve as subject matter expert on credentialing requirements, ensuring timely and compliant files.
Coordinate with HR, Talent Acquisition, and leadership to facilitate provider onboarding and resolve issues.
We are a leading provider of immediate-access behavioral health crisis care. We are physician-led and data-driven, with over 15 years of crisis care expertise, recognized as a national best practice.
Independently manage Medicare, Medicaid, and TriCare cost reports and coordinate audits.
Lead the annual cost report peer-review process and manage provider appeals.
Collaborate with internal stakeholders and external reimbursement organizations to ensure compliance.
They are a large health system providing patient-focused healthcare services. The organization is collaborative and mission-driven, with a focus on financial sustainability.
Provide outstanding customer service to families and coordinate information between physicians, insurance companies, and clinics.
Obtain insurance authorizations and research benefits, eligibility, and authorization requirements.
Communicate cost shares and financial responsibilities to families to help them make informed treatment decisions.
Cranial Technologies is the only company dedicated to researching and treating plagiocephaly (flat head syndrome) and correcting infant ear shapes with EarWell. They have treated over 500,000 babies and offer a remote, customer-focused culture.
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.
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.
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.
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.
Analyze collections and resolve non-payables for complex billing issues.
Follow up on insurance payer claims to ensure appropriate reimbursement.
Write appeals using established guidelines and communicate with insurance companies.
Ventra is a business solutions provider for facility-based physicians, specializing in Revenue Cycle Management. The company fosters a collaborative and fast-paced environment.
Provide professional and timely service to internal and external customers regarding benefit administration.
Resolve benefit service issues with internal staff and outside vendors.
Perform monthly reconciliation of Carrier invoices to report to customers.
OneSource Virtual (OSV) works exclusively with Workday customers to automate payroll, taxes, earned wage access, accounts payable, and benefits. With over 1,500 customers and 92% retention, OSV offers a values-based culture and professional development.
Provide efficient, courteous service to members, providers, and other customers via phone, email, and more.
Resolve routine and moderately complex inquiries about enrollment, billing, benefits, claims, and other topics.
Research inquiries, interpret policies, and ensure accurate, timely responses to meet customer satisfaction.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association providing health insurance and related services. They value a flexible, supportive work culture and prioritize employee growth, consistently being voted one of the “Best Places to Work in PA.”
Manage multiple channel interactions professionally and efficiently.
Address provider inquiries with accuracy and focus on first call resolution.
Maintain positive relationships and exceed quality and productivity goals.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association focused on improving the health and well-being of its members and communities. It has been consistently voted one of the Best Places to Work in PA and fosters a flexible, supportive culture with emphasis on professional growth and community involvement.
Contact insurance companies to collect outstanding accounts receivable and follow up on appeals.
Process and refile claims, audit adjustments, and resolve manual tasks assigned for follow-up.
Maintain an accuracy rating of 97% or greater and identify trends to leadership.
US Anesthesia Partners is a healthcare organization that provides anesthesia services and manages related billing and accounts receivable. The company emphasizes professionalism, accuracy, and teamwork in a remote work environment.
Review and evaluate denied claims using proprietary software to determine correct reimbursement.
Research and acquire medical records and supporting documentation for submission to payers.
Conduct telephone follow-up with payers to ensure prompt reimbursement.
EnableComp provides Specialty Revenue Cycle Management solutions for healthcare organizations using an intelligent automation platform. The company has over 24 years of industry expertise, is a multi-year Top Workplaces award recipient, and has been on the Inc. 5000 list for eleven years.
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.
Perform follow-up status requests through telephone, internet, and fax requests.
Process incoming and outgoing mail, scanning, and document consolidation and indexing.
Maintain a working knowledge of internal policies and client systems and credentials.
Ternium specializes in resolving complex healthcare insurance claim denials and delays, empowering hospitals by optimizing their revenue cycle. They have a dedicated team of professionals focused on delivering outstanding results for healthcare providers.
Performing timely utilization review of healthcare services using approved medical necessity criteria.
Collaborating with medical directors, providers, and internal teams for compliant review processes.
Ensuring accurate documentation and communication of determinations within regulatory timeframes.
Guidehealth is a data-powered, performance-driven healthcare company focused on making healthcare affordable and improving patient health. It is a physician-led organization using AI and predictive analytics, with a culture of accountability, growth, innovation, and empathy.