Perform medical claims audit reviews with a focus on the Home Health sector, applying medical review guidelines and documenting findings.
Collaborate with the audit team to identify vulnerabilities, generate audit letters, and support findings during appeals.
Maintain knowledge of coding systems (ICD-10, CPT-4, HCPCS) and regulatory changes to ensure high-quality, deadline-driven work.
Machinify is a leading healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients using an AI-powered platform. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, the company fosters a collaborative, fast-paced remote culture.
Develop and maintain audit concepts by researching regulatory, coding, or payer policy changes and updating rule documents and code lists.
Perform QA reviews to ensure audit concepts comply with coding standards, payment methodologies, and payer policies prior to deployment.
Collaborate with cross-functional teams including operations, clinical, and client services to support policy execution and drive concept quality.
Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering value and efficiency to health plan clients. Deployed by over 85 health plans representing more than 270 million lives, we are a digital-first, AI-powered platform that reimagines what's possible in healthcare.
Perform detailed medical record reviews to validate DRG assignments and ensure billing accuracy.
Conduct clinical and coding audits to identify discrepancies and support cost containment.
Collaborate with quality teams and medical professionals to ensure compliance with payer regulations.
The company partners with healthcare organizations to ensure accuracy in medical coding and reimbursement. They offer a fully remote, supportive environment with comprehensive benefits and professional growth opportunities.
Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
Review inpatient and outpatient medical records to support appeal submissions and apply payer-specific guidelines.
Document review findings accurately and meet assigned turnaround times while maintaining quality standards.
CorroHealth helps clients exceed their financial health goals by providing scalable solutions and clinical expertise across the reimbursement cycle. The company fosters a supportive culture that invests in professional development and personal growth.
Perform daily audits on client data for completeness and accuracy of coding using clinical knowledge.
Respond to provider appeals and meet client turnaround time and KPI goals.
Utilize coding validation training to become familiar with claims payment policies and regulations.
Cotiviti is a healthcare analytics company that uses data-driven solutions to improve payment accuracy and quality in healthcare. The company offers a competitive benefits package and fosters a collaborative, fast-paced work environment.
Performs clinical quality assurance review of daily clinical validation reviews and communicates differing audit decisions to ensure accuracy.
Integrates healthcare auditing principles and uses industry knowledge to substantiate decisions, reviewing medical records and applying clinical criteria.
Serves as a mentor to other QA auditors and may flex into initial audit or appeals roles as needed.
Cotiviti provides healthcare auditing and recovery solutions to ensure high quality recoverable claims. As a company, it employs a sizable workforce and fosters a culture of compliance, accuracy, and continuous improvement through professional skepticism and mentorship.
Own first-level reviews of pre-certification requests for medical appropriateness and necessity.
Drive post-service reviews and manage the appeals process for non-certified services.
Coordinate smooth discharges and redirect care in-network to keep patients on track.
Personify Health created the first personalized health platform, bringing health plan administration, wellbeing solutions, and care navigation together in one place. Their team serves employers, health plans, and health systems with a mission to empower people to lead healthier lives.
Perform clinical reviews and conduct peer-to-peer discussions.
Participate in inter-rater reliability activities and clinical rounds.
Serve as a clinical resource and subject matter expert to clinical and non-clinical staff.
Devoted Health is a healthcare company that aims to improve the health and well-being of older Americans through a data and AI-driven care platform. The company values diversity, collaboration, and a supportive work environment, and is an equal opportunity employer.
Provide clinical leadership and medical oversight for audit programs involving governmental and commercial payer claims.
Evaluate medical necessity, level of care, coding accuracy, and documentation sufficiency using payer policies and clinical standards.
Support audit methodologies, clinical validation frameworks, and quality assurance to ensure regulatory alignment and defensibility.
Machinify is a leading healthcare intelligence company delivering value, transparency, and efficiency to health plan clients. Deployed by over 85 health plans representing more than 270 million lives, they bring an AI-powered platform alongside best-in-class expertise.
Audit outpatient and specialty claims to ensure coding accuracy, clinical validity, and medical necessity.
Utilize advanced coding knowledge and audit tools to identify billing issues and document findings.
Meet productivity and quality standards while recommending process improvements and new claim types.
Cotiviti is a healthcare analytics and auditing company that focuses on improving claims accuracy and reducing costs for clients. They are a mid-to-large sized employer with a culture that emphasizes quality, collaboration, and innovation in healthcare auditing.
Set daily direction for your UM team, establishing priorities and reinforcing expectations.
Coach reviewers on criteria application, guiding consistent use of medical-necessity criteria.
Monitor workflow health daily, tracking intake volume and turnaround risk.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. The team is on a mission to empower people to lead healthier lives.
Review Home Health prior authorization requests for medical necessity using CMS regulations and Clover clinical guidelines.
Perform initial and concurrent clinical reviews, ensuring appropriate care in the least restrictive setting.
Collaborate with providers and internal teams to support timely decision-making and positive member outcomes.
Clover Health is a healthcare company that uses data and technology to provide affordable, high-quality insurance plans for seniors. The company fosters a remote-first culture with a diverse and mission-driven team focused on improving member outcomes.
Assist with retrospective and concurrent coding for PACE Dual participants.
Conduct pre-visit chart preparations and post-visit chart reviews.
Oversee audits and participate in provider education programs to ensure compliance with CMS risk adjustment diagnosis coding guidelines.
WelbeHealth provides seniors with the opportunity to continue living in their homes through its PACE program. The company employs a collaborative interdisciplinary team approach and values diversity and inclusion.
Conducts baseline, routine, and focused audits comparing medical record documentation to reported CPT/HCPCS and ICD-10-CM codes.
Researches, interprets, and communicates federal and state laws and guidelines pertaining to CMS and Medicare.
Acts as an internal expert on coding issues to ensure compliance with state and federal regulations.
Privia Health is a technology-driven national physician enablement company that collaborates with medical groups, health plans, and health systems to optimize physician practices and improve patient experiences. The company is led by top industry talent and focuses on scalable operations and cloud-based technology to reduce healthcare costs.
Validate accuracy of CPT, HCPCS, revenue codes, and billed line-item charges on outpatient and inpatient facility claims.
Apply CMS guidance, coding guidelines, and industry standards during claim review, including hospital bill audits and itemized bill reviews.
Prepare appeal responses using applicable coding guidance and maintain required certifications and continuing education.
Trend Health Partners is a tech-enabled payment integrity company that facilitates collaboration between payers and providers to reduce waste and improve access to healthcare. They are a dynamic growing organization promoting a collaborative and innovative work environment.