Perform in-depth medical claim reviews using UB-04 and itemized statements.
Verify itemized charge accuracy based on policy and industry standards.
Validate system denials and suggest system enhancements for efficiency.
Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. They bring together an AI-powered platform, are deployed by over 85 health plans, and represent more than 270 million lives.
Perform chart scrubbing and clinical documentation audits to ensure completeness and accuracy.
Review records to validate ICD-10 diagnosis coding and supporting clinical documentation.
Ensure compliance with PDPM (Patient-Driven Payment Model) and CMS guidelines.
Limitlessli specializes in recruiting, hiring, and managing high-caliber remote staff for dynamic and growing healthcare facilities. Leveraging their extensive global network, they connect clients with highly qualified professionals, offering tailored services to meet clients' unique business needs.
Oversee the RN Reviewer team including one RN Team Lead
Manage the daily timeliness report and ensure all cases meet expected turnaround times
Monitor the nurse productivity reports daily and provide feedback to the nurses, managing performance to ensure consistency
Cohere Health's clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. They work with over 660,000 providers and handle over 12 million prior authorization requests annually.
Enhance the quality of member management and maximize satisfaction.
Assist in navigating the health care system as a collaborative health partner.
Promote wellness, problem-solve, and assist members in realization of their personal health-care related goals.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers.
Participate in provider case reviews to identify trends and deficits.
Coach providers and participate in client meetings to support expectations.
Contribute to workflow design, QA improvements, and risk management.
Amwell transforms healthcare with technology and people. They aim to provide convenient, affordable, and effective care, serving large healthcare organizations in the U.S. and worldwide.
Complete timely review of healthcare services using appropriate medical criteria to support determinations.
Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make great healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages Healthguides™ and a Managed Service Organization to build stronger connections with patients and providers.
Serve as the vendor’s lead clinical subject matter expert on clinical denials management and prevention.
Partner with provider clients to design and implement best practices for denial prevention and appeal workflows.
Conduct complex clinical case reviews for DRG validation, identifying and defending clinically appropriate DRG assignments.
EnableComp provides Specialty Revenue Cycle Management solutions for healthcare organizations. They leverage over 24 years of expertise and their E360 RCM ™ platform to improve financial sustainability for hospitals, health systems, and ambulatory surgery centers. EnableComp is a multi-year recipient of the Top Workplaces award recognized as Black Book's #1 Specialty Revenue Cycle Management Solution provider in 2024.
Provides quality driven telephonic clinical assessments, health education, and utilization management services.
Provides assessments to individuals using telecommunications in accordance with computer-based algorithms, protocols, and guidelines.
Uses clinical knowledge to assess, disposition, make recommendations for care, provide education and health information.
Carenet Health values the expertise and dedication of their team members. They are committed to offering an appealing compensation package and creating an inclusive environment for all employees.
Reviews pre-admissions for correct classification and admission order.
Performs Utilization Review for each patient on their assigned daily census using established medical necessity guidelines.
Communicates with payers regarding authorization and medical necessity, utilizing excellent negotiating skills.
Oregon Health & Science University values a diverse and culturally competent workforce. They are an equal opportunity, affirmative action organization that does not discriminate against applicants.
Audit patient medical records using clinical, coding, and payer guidelines to ensure accurate reimbursement.
Provide clear, evidence-based rationale for code recommendations or reconsiderations to providers or payers.
Collaborate with team leaders to ensure thorough review of DRG denials.
Machinify is a healthcare intelligence company delivering value, transparency, and efficiency to health plan clients. They deploy a configurable, AI-powered platform and best-in-class expertise, serving over 85 health plans representing more than 270 million lives.
Partner with Clinical, Claims, and Payment Integrity peers to review claims for DRG related issues.
Proactively identify overpayments to ensure accurate claims payments on inpatient services.
Participate in collaborative discussions with MDs to verify the clinical rationale behind billed procedures.
They are reinventing health insurance by combining data with human empathy to keep members healthier. Clover Health believes the healthcare system is broken, so they've created custom software and analytics to empower their clinical staff to intervene and provide personalized care to the people who need it most. They are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.
Review detailed claim reports from a variety of sources to predict current and future claim costs.
Research medical conditions and treatment options using available resources.
Document the medical review clearly, including an analysis of current clinical condition(s) and future annual claims projection.
Berkley Accident and Health is a risk management company that designs innovative solutions to address the unique challenges of each client. With an entrepreneurial culture and a strong emphasis on analytics, they help employers better manage their risk.
Coordinate and support the hospital’s Utilization Review and Case Management program.
Review patient charts and clinical documentation to verify medical necessity.
Monitor patient progress and coordinate care management strategies.
NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. With hospitals in Indiana, Michigan, Texas, and Arizona, they’re expanding access to their unique model of care across the United States.
Conduct quality audits of inpatient clinical determinations to ensure alignment with clinical guidelines and quality standards
Analyze QA findings and translate insights into actionable recommendations for operational leaders and cross-functional partners
Provide coaching and feedback to improve clinical decision accuracy, guideline adherence, and overall team performance
Cohere Health delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. They work with over 660,000 providers and are backed by leading investors such as Deerfield Management. The coherenauts who succeed there are empathetic teammates who are candid, kind, caring, and embody their core values and principles. Cohere is deeply invested in ensuring that they have a supportive, growth-oriented environment that works for everyone.
Conduct assessments, establish care goals, and deliver telephonic coaching and education to support clients in managing chronic conditions.
Perform first‑level Utilization Review for inpatient and outpatient services based on plan guidelines.
Document all condition management activities, track client progress, and report outcomes, savings, and quality improvements.
HealthCheck360 focuses on reducing medical costs while increasing employee engagement and productivity. They accomplish this by providing onsite biometric screenings, engaging participants through technology and programming, educating the participant with risk-specific targeted communications, and supporting positive behavior change through Health Coaching and Condition Management programs.
Evaluate hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
Guide timely care determinations using CMS regulations and evidence-based practices while collaborating with care management teams and external providers.
Conduct timely medical necessity determinations for inpatient admissions and post-acute settings.
HJ Staffing is urgently seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. This physician leader will play a critical role in ensuring the clinical integrity of inpatient and post-acute care reviews, evaluating medical necessity to support optimal outcomes and regulatory compliance.
Processes acute and post-acute inpatient medical and select intensive outpatient higher level of care requests through clinical review.
Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies to requests.
Collaborates with UM department staff and Medical Directors to make a final determination, and with Care Management staff on discharge planning.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. At Capital, employees work alongside a caring team of supportive colleagues and are encouraged to volunteer in their community.
Communicate and provide education to members and providers on insurance plan benefits and digital health solutions.
Employ active listening & motivational interviewing skills, and can handle difficult calls tactfully, professionally and document accordingly that can build patient trust and engagement.
Accurately track and document work on a variety of internal software tools and platforms.
Evry Health is on a mission to bring humanity to health insurance. They provide high-technology health plans that expand benefits, increase access and transparency, and feature a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL), which has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents.
Maintains the practice management system by entering accurate data, verifying and updating insurance and claims information, handles carrier correspondence, manages EOBs, and keys payments received into the system.
Prepares, reviews, submits, and follows up with clean claims to various companies/individuals.
Collects, posts, and manages patient account payments.
US Anesthesia Partners provides comprehensive anesthesia care. They are committed to clinical excellence and outstanding patient experience.
Follow VitalCaring billing Standard Operating Procedures and regulatory billing guidelines
Collaborate with your supervisor and the billing team to address payor and billing concerns
Ensure documentation accuracy and submit claims in accordance with Medicare and other payor requirements
VitalCaring is a leading provider of home health and hospice services. Founded in 2021, VitalCaring has grown into a leading provider of home health and hospice services, with over 65 locations across the country. They foster a culture of support, growth, and excellence.