Perform prospective, concurrent, and retrospective reviews of healthcare services to ensure medical necessity and appropriate level of care.
Contact medical and support personnel to recommend alternative treatment plans and coordinate care across the healthcare continuum.
Research and resolve issues related to benefits, eligibility, and appeals while delivering targeted education to providers.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, covering claims administration, payment integrity, and care management. The company is experiencing significant momentum and investing in employees who directly shape the future of healthcare technology.
Performs pre-admission, admission, and continued stay reviews using approved medical necessity criteria.
Coordinates patient care and communicates with physicians, patients, caregivers, and third-party payers.
Manages patient progression through the healthcare system and proactively works with payers to secure certification and minimize denials.
Ochsner Health is a leading not-for-profit healthcare provider in the Gulf South, with 46 hospitals and 370+ care centers. It employs more than 38,000 team members and has been recognized as a top workplace and the No. 1 hospital in Louisiana.
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.
Perform medical reviews and utilization management to determine medical necessity for services and appeals.
Evaluate medical records and document decisions using clinical guidelines and protocol sets.
Educate members, providers, and staff on coverage determinations, medical terminology, and coding procedures.
Palmetto GBA is a healthcare administrator and one of the nation's largest medical claims processors. As part of BlueCross BlueShield of South Carolina, we've served clients for 70+ years and offer training and tuition assistance.
Coordinates utilization review and prior authorization requests, ensuring accurate entry into the UM platform.
Provides customer service to providers and members, confirming benefits and answering authorization questions.
Facilitates communication between reviewers, hospitals, and physicians to ensure timely decisions.
University of Utah Health Plans is a patient-focused organization that enhances health through patient care, research, and education. It is part of a nationally ranked academic medical center with five hospitals and eleven clinics, fostering a culture of collaboration and excellence.
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.
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.
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.
Oversee medical necessity reviews for home health, acute, post-acute, and outpatient services for Medicare Advantage populations.
Collaborate with treating physicians, nursing teams, and external agencies to promote evidence-based care and appropriate resource utilization.
Apply CMS regulations, coverage determinations, MCG criteria, and medical policies in a fully remote, part-time physician leadership role.
Jobgether is an AI-powered job matching platform that connects candidates with employers. It uses objective screening to share top-fitting applicants with hiring companies, emphasizing data privacy and human oversight throughout the recruitment process.