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.
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.
Provide Utilization Review and Case Management to Emergency Department patients with social or discharge needs.
Offer hospital-wide Utilization Review and Case Management coverage as needed and time allows.
Hold a valid RN state licensure; 3-5 years of nursing experience preferred.
Freeman Health System is a not-for-profit health system serving communities across Missouri, Arkansas, Oklahoma, and Kansas through a network of hospitals, physician clinics, and specialty services. The system is supported by over 7,000 employees and is the only Children's Miracle Network Hospital in a 70-mile radius.
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.
Coordinate and provide care that is timely, effective, and member-centric while following HMO processes.
Manage case assignments including outreach, documentation, monitoring for case progression, and case closure.
Assist members in reaching wellness by addressing barriers, social determinants, and psychosocial issues.
Guidehealth is a data-powered healthcare company dedicated to making great healthcare affordable and improving patient outcomes. It is a physician-led, performance-driven organization with a culture of empathy, accountability, and continuous learning.
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established coverage guidelines.
Educate teams on medical review processes and support quality control activities.
Broadway Ventures is a veteran-owned small business delivering mission-critical support to federal health and defense customers. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it is built on integrity, collaboration, and excellence.
Guide patients through complex health concerns and help them achieve wellness goals while addressing social determinants of health.
Build trusting relationships through empathetic listening and create comprehensive care plans for consistent action.
Work 100% remotely as a 1099 contractor, setting your own hours and interacting with patients via video or phone.
Solace pairs patients with expert healthcare advocates to navigate the complex U.S. healthcare system and improve health outcomes. A lean, mission-driven Series C startup founded in 2022, its U.S.-based team is intense, urgent, and passionate about redefining healthcare.
Build meaningful relationships with patients and families to create personalized care plans addressing medical, behavioral, and social needs.
Coordinate care across providers and settings while educating and empowering members to navigate the healthcare system confidently.
Collaborate with an interdisciplinary team, using data for insight and maintaining compliance while prioritizing compassion and connection.
Guidehealth is a data-powered, performance-driven healthcare company using AI and predictive analytics to improve healthcare affordability and patient outcomes. It is a physician-led, fully remote organization with a collaborative, agile culture focused on innovation and empathy.
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.
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.
Engages members proactively and reactively to build trust and drive benefit and program engagement through motivational interviewing.
Develops individualized care plans based on comprehensive clinical, psychosocial, and SDOH assessments, coordinating resources across the care continuum.
Educates members and providers on benefits, digital health solutions, and self-management strategies while supporting utilization review and documentation.
Evry Health is a digital-first health plan focused on delivering comprehensive, member-centered care coordination for its fully insured commercial population. The company operates as a fully remote team with headquarters in Dallas, Texas, emphasizing a technology-forward and collaborative culture.
Review patient information and medical histories to provide online patient care and education.
Participate in patient visits and answer questions through our telehealth platforms.
Follow established protocols and collaborate with the healthcare team, all conducted 100% remotely.
Florida Telehealth Medical Group is an innovative telemedicine company currently operating in 49 states. We treat tens of thousands of patients every month and are growing rapidly.
Conduct comprehensive reviews of home health pre-claim review packages for Medicare compliance.
Document review outcomes with clinical rationale and meet a 7-business-day turnaround.
Maintain 98% accuracy and complete required training and quality assurance sessions.
Broadway Ventures is a consulting firm providing program management, technology, and innovative solutions to government and private sector clients. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it emphasizes integrity, collaboration, and excellence in its culture.
Oversee system-level utilization management activities across the organization.
Ensure compliance with medical necessity criteria such as InterQual and Milliman.
Manage professional staff and review processes to optimize patient care.
Piedmont Healthcare is a healthcare system providing comprehensive medical services. It is a large organization focused on utilization management and quality care.
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.
Perform quality audits on clinical documentation across clinical departments.
Collaborate with leadership to develop corrective action plans and provide 1:1 coaching.
Support organizational readiness for NCQA and other regulatory audits.
Oscar is the first health insurance company built around a full stack technology platform, focusing on serving members with a concierge-level experience. It started in 2012 and is an Equal Opportunity Employer cultivating an authentic, inclusive environment.
Review prior authorization cases to ensure clinical and operational standards are met.
Audit AI outputs, third-party reviews, and internal decisions for accuracy and compliance.
Collaborate cross-functionally to refine workflows and improve patient access to treatment.
Generator Health operates a platform that streamlines prior authorization processes for patients and providers. They handle tens of thousands of patients weekly and emphasize collaboration and accuracy in a high-autonomy remote environment.
Review OASIS documentation and plan of care to ensure compliance with regulations and accuracy.
Evaluate patient visit frequency and utilization to align with clinical needs and provider orders.
Collaborate with coding partners and escalate documentation improvement opportunities to leadership.
Graham Healthcare Group designs business and technology solutions to drive better care and outcomes in home health and hospice. As a subsidiary of a publicly traded company, they've been improving care coordination for over 20 years, focusing on patient-centered home care.
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.