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.
Process referrals and prior authorizations, ensuring accurate and timely documentation.
Collaborate with clinical teams, physician offices, and insurance companies to resolve authorization issues.
Monitor denial reports, manage referral tracking, and communicate decisions to providers, staff, and patients.
Baystate Health is an integrated healthcare system serving western Massachusetts. With 12,000 employees and a community-focused culture, it includes five hospitals and offers career growth.
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.
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.
Coordinate interdisciplinary care plans and serve as a liaison between patients, providers, and insurance partners.
Provide telephonic nursing triage, health guidance, and on-call support according to agency protocols.
Manage lab results, referrals, prescription refills, and patient follow-up to ensure continuity of care.
Planned Parenthood of the Pacific Southwest provides sexual and reproductive healthcare across 20 health centers in Southern California. The organization fosters a collaborative, mission-driven culture with over 100 years of advocacy.
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.
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.
Clarity Pediatrics is a virtual clinic reimagining pediatric chronic care, starting with ADHD and expanding to obesity and overweight management. It is a fast-growing startup with a remote-friendly culture and a leadership team committed to clinical excellence.
Provide direct patient care using the nursing process, from assessment to evaluation.
Collaborate with the care team to monitor patients, adjust care plans, and ensure safety.
Maintain EHR documentation, administer treatments, and delegate to support staff.
Advocate Health is a top nonprofit, integrated health system in the US, formed from Advocate Aurora and Atrium Health. It serves 6 million patients and employs 155,000 teammates across 69 hospitals, with a culture focused on equitable care and innovation.
Provide patient-centered care navigation and telephonic clinical outreach to patients with chronic conditions.
Collaborate with PCPs, NPs, and care teams to coordinate treatment and support safe transitions home.
Serve as a key resource for patients, caregivers, and community agencies, implementing interventions that improve outcomes.
Vytalize Health is a healthcare company focused on value-based care for patients with chronic or serious conditions. It is a rapidly growing organization with an entrepreneurial, patient-forward culture, and you will play a key role in building a market leader.
Prepare, review, and submit accurate prior authorization requests to PBMs and health plans for anti-obesity medications.
Act as an escalation point to resolve complex coverage inquiries from Medical Providers, Member Services, and Client Success.
Maintain HIPAA compliance and accurately document hours using designated ADP pay codes.
Vida is a virtual, personalized obesity care provider that uses evidence-based treatment to help patients manage obesity and related conditions. It is trusted by Fortune 100 companies and fosters a diverse, inclusive culture.
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.
Perform medical record abstraction and chart review for assigned HEDIS measures.
Accurately enter abstraction results into MVP-designated systems.
Maintain required productivity and accuracy thresholds.
MVP Health Care is a not-for-profit health insurance company offering health plans across New York and Vermont. With over 40 years of experience, they have a people-centric culture and are recognized as a Best Place to Work.
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.
Manage prior authorization requests, reviewing clinical documentation and verifying ICD-10 and CPT codes.
Submit requests via payer portals, monitor pending cases, and follow up with insurers.
Investigate denials, prepare appeals, and coordinate with providers to prevent care delays.
Jobgether is an AI-powered job platform that matches candidates with relevant opportunities through objective review processes. It focuses on efficient recruitment and data privacy, using technology to support hiring decisions.
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.
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.
Coordinate clinical appointments, manage referrals, and proactively follow up with families to reduce gaps in care.
Provide evidence-based education to families on chronic condition management, medication regimens, and treatment plans.
Manage medication prior authorizations, coordinate with pharmacies, and document clinical interactions across EHR platforms.
Clarity Pediatrics is reimagining pediatric chronic care, starting with ADHD and expanding to obesity and overweight management. The company is a fast-growing startup with a leadership team committed to clinical excellence and a remote-friendly culture.
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.
Oversee daily clinical pharmacy functions including prior authorization reviews, override requests, and member/provider education calls.
Support staff training, quality improvement, and lead projects to optimize pharmacy operations and clinical outcomes.
Serve as a subject matter expert and make clinical decisions based on medical necessity and contract criteria.
Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. It replaces fragmented systems with a unified claims processing platform and uses AI-powered care delivery to serve millions of Americans, fostering a mission-driven, collaborative culture.