Evaluate outpatient referrals and inpatient admissions for medical appropriateness.
Perform peer-to-peer discussions with providers and support utilization management processes.
Mentor UM nurses and contribute to clinical guideline development.
Clover Health is reinventing health insurance by combining data with human empathy to keep members healthier. It is a mission-driven company focused on providing high-quality, affordable healthcare for America's seniors.
Evaluate outpatient referrals and inpatient admissions for medical appropriateness and medical necessity.
Manage a team of UM Medical Directors and review complex or escalated cases.
Chair the UM Committee and support policy development, quality, and credentialing.
Clover Health provides healthcare plans for America's seniors, using data and technology through the Clover Assistant to support physicians. The company is mission-driven and diverse, focused on improving members' lives through personalized care.
Provide clinical leadership in utilization management, including medical necessity reviews and prior authorization decisions.
Engage in peer-to-peer discussions with practitioners to explain clinical rationales and explore alternative care options.
Collaborate cross-functionally to improve utilization management processes, develop medical policies, and participate in quality improvement initiatives.
This healthcare organization specializes in utilization management and clinical oversight, ensuring medical necessity and quality care. It is a fast-growing company with a collaborative, member-focused culture and a remote-first work environment.
Lead, coach, and onboard Utilization Management nurses while managing daily workloads and escalations.
Ensure reviews and determinations are timely, accurate, and compliant with CMS and Clover policies.
Collaborate with Medical Directors and cross-functional teams to improve workflows and member outcomes.
Clover Health provides data-driven healthcare plans for seniors, using the Clover Assistant to support physician decisions. The company is a mission-driven team of diverse experts focused on improving members' quality of life.
Review a variety of claim types including Radiology, Ambulance, Physical Therapy, and Surgical for medical necessity and coverage.
Document medical rationale for payment or denial decisions using Medicare guidelines and established criteria.
Educate internal and external staff on medical review, terminology, coverage determinations, and coding.
We transform 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, we are built on integrity, collaboration, and excellence.
Perform clinical reviews to evaluate medical necessity, level of care, and benefit coverage for members.
Apply internal policies, MCG, and NCCN guidelines to deliver timely and compliant utilization management decisions.
Escalate complex cases and build audit-ready documentation for Medical Director review.
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. Their mission-driven culture empowers diverse perspectives to drive real impact on people's health.
Review, investigate, and appeal denied hospital insurance claims using clinical documentation and payer policies.
Develop evidence-based appeal letters addressing medical necessity, level-of-care, and charge discrepancies.
Collaborate with nursing, revenue integrity, and financial teams to resolve denials and prevent future rejections.
This partner company is a healthcare system that provides hospital services and focuses on revenue integrity. It supports fully remote work and values clinical expertise, collaboration, and financial sustainability.
Audit medical claims for government payers, applying medical review guidelines and documenting findings.
Generate letters articulating audit findings and support them during the appeals process.
Collaborate with the audit team and clients to improve medical policies and minimize appeals.
Machinify is a healthcare intelligence company providing AI-powered payment solutions for health plans. It serves over 85 health plans and more than 270 million lives, with a culture focused on innovation and reducing healthcare costs.