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 and validate assigned assessments (SOC, ROC, Recert, Transfer, Discharge) for accuracy and completeness.
Identify and correct errors impacting reimbursement, quality measures, or compliance before submission.
Provide actionable feedback and education to field clinicians to improve documentation and process outcomes.
Adaptive Home Health is a Texas-based home health agency building a higher-acuity, patient-centered care model. They use technology to streamline documentation and QA workflows, supporting clinical operations and compliance teams in a remote-first environment.
Conduct telephonic nursing assessments and triage using clinical protocols.
Provide health education and care recommendations to patients.
Collaborate with remote RNs to meet quality and performance metrics.
Carenet Health delivers telephonic clinical assessments, health education, and utilization management services. They are a growing, collaborative company with a nationwide remote team of registered nurses.
Conduct clinical and billing reviews of claims, itemized bills, and UB-04 forms to ensure accuracy.
Perform utilization reviews to assess medical necessity and validate charges against policies.
Mentor reviewers, meet productivity targets, and maintain active RN licensure with CEUs.
Our partner is a healthcare services company that conducts medical claims and utilization reviews to ensure accurate billing and appropriate care. They offer a collaborative, quality-focused remote environment with opportunities for professional development.
You ensure prior authorization requests are completed in a manner that meets contractual requirements using evidence-based standards.
You participate in the Utilization Management (UM) Care Programs.
You evaluate medical records and health care data to interpret and apply policies and regulations.
Central California Alliance for Health is an award-winning regional Medi-Cal managed care plan that provides health insurance for children, adults, seniors and people with disabilities in Mariposa, Merced, San Benito and Santa Cruz counties. We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation.
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.
Audit medical summaries, timelines and record classifications against source records.
Write clinical review guidelines and gold-standard examples for research and engineering teams.
Flag clinically significant omissions, causation issues and prior-history findings.
Brighterway builds AI-native claims software and administration for casualty claims, starting with workers' compensation medical-legal review. The team is small, technical, and close to customers, with everyone shipping and talking directly to users.
Conduct clinical reviews of inpatient admissions and continued stays using approved medical necessity criteria.
Collaborate with physicians, care managers, and payer teams to resolve utilization concerns and prevent denials.
Support quality improvement initiatives, maintain accurate documentation, and communicate review outcomes effectively.
This role is with a partner company focused on healthcare utilization management, helping hospitals improve patient outcomes and ensure appropriate resource use. The team operates as a distributed remote group supporting care coordination, revenue integrity, and clinical compliance.
Perform prospective, concurrent, and retrospective utilization review to ensure medical necessity and appropriate level of care.
Research and respond to appeals, coordinate discharge planning, and analyze care patterns.
Collaborate with providers and internal teams to resolve benefit and eligibility issues.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, helping them modernize operations and compete effectively. The company is expanding and investing in its people, offering opportunities to shape the future of healthcare technology.
Conduct ESRD medical record reviews comparing documentation to EQRS and NHSN data.
Classify discrepancies by type and severity, including missing data, incorrect values, and wrong fields.
Participate in quality control activities and support special projects as assigned.
Broadway Ventures transforms challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As a small, veteran-owned business, we empower government and private clients with tailored solutions built on integrity, collaboration, and excellence.
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.
Audit skilled nursing facility (SNF) medical claims for medically appropriate services using applicable guidelines and policies.
Document findings, generate audit letters, and support audit findings during the appeals process.
Work collaboratively with the audit team, clients, and contractors to improve medical policies and audit workflows.
Machinify is a healthcare intelligence company with expertise across the payment continuum, delivering value, transparency, and efficiency to health plan clients. Deployed by over 85 health plans representing more than 270 million lives, the company combines an AI-powered platform with best-in-class expertise to drive down healthcare costs.
Conduct monthly clinical check-ins and structured symptom assessments for assigned patient panels.
Collaborate with providers to escalate clinical concerns and reinforce care plans.
Maintain accurate documentation across EHR and CCM platforms while meeting quality metrics.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, and holistic approach. The company thrives on innovation and evolution, with a culture that embraces change and focuses on improving patient outcomes.
Review inpatient medical records to validate DRG coding accuracy.
Apply clinical judgment to identify discrepancies, coding errors, and overpayments.
Document evidence-based audit findings and meet quality standards.
The company specializes in healthcare claims auditing and analytics, improving accuracy and consistency in payments. It is a collaborative, fully remote environment that values precision, teamwork, and continuous improvement.
Analyze and summarize medical records, highlighting relevant clinical findings for attorneys.
Prepare medical chronologies and long-term care assessments to support case evaluations.
Provide objective, evidence-based medical insights and coordinate with expert witnesses.
The partner company provides specialized legal nurse consulting services to attorneys, analyzing medical records and supporting injury-related cases. This role offers flexible, part-time contract work in a fully remote environment.
Manage patient messages through the telehealth platform and address routine clinical questions within your nursing scope.
Escalate complex medical concerns, coordinate with providers, and ensure timely follow-ups.
Maintain accurate documentation, follow HIPAA protocols, and work independently in a fast-paced remote environment.
LumiMeds is a fast-growing U.S.-based telehealth startup focused on weight management and long-term metabolic health. It is an early-stage, remote-first company with a globally distributed team that values clarity, accountability, and initiative.
Review and abstract medical records for new patients, ensuring charts are complete and accurate before initial appointments.
Analyze medical documentation to identify relevant clinical information and serve as a resource for moderately complex cases.
Collaborate with intake leadership to support departmental goals, quality standards, and continuous improvement.
The hiring company supports healthcare teams by providing accurate medical record abstraction and patient intake services. It fosters a remote, collaborative culture that values professional development and meaningful patient impact.
Conduct clinical reviews of medical records during fraud investigations and program integrity initiatives.
Apply Medicare and Medicaid guidelines to determine appropriateness of payment coverage.
Compile investigative summary reports and provide training on medical terminology and policy interpretation.
CoventBridge Integrity Systems delivers investigative services, technology, and expertise that help healthcare and government organizations protect critical programs, strengthen oversight, and address fraud, waste, abuse, and operational risk. They are an equal opportunity employer committed to diversity and inclusion, maintaining a drug-free workplace.
Conduct timely post-discharge outreach and assessments for high-risk patients.
Coordinate telephonic care, medication reconciliation, and patient education.
Connect patients with community resources and collaborate with care teams.
UnityPoint Health is a healthcare system delivering coordinated care and services across clinics and hospitals. Recognized as a top workplace in healthcare, it fosters a culture of belonging and team member support.
Provide timely, efficient, and accurate triage response and documentation according to nursing standards and physician protocols.
Evaluate patient needs, coordinate with clinical team members, and schedule patients for visits as needed.
Act as a clinical resource to non-clinical personnel and provide patient education on care, medications, and health promotion.
Piedmont Healthcare is a comprehensive healthcare system serving patients across Georgia. It operates as a large corporate organization supporting multiple ambulatory practices and contact center operations with a focus on patient-centered care.