Perform concurrent and retrospective reviews on all facility and appropriate home health services.
Monitor level and quality of care and proactively manage acutely and chronically ill patients.
Act as liaison to Plan Medical Director and coordinate interdisciplinary approach.
Curana Health is a national leader in value-based care for senior living communities and skilled nursing facilities. Founded in 2021, they serve 200,000+ seniors in 1,500+ communities across 32 states with a team of over 1,000 clinicians.
Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
Apply payer-specific guidelines and internal policies to support clear, defensible clinical narratives.
Meet assigned turnaround times and document findings accurately in designated systems.
CorroHealth helps clients exceed their financial health goals through scalable reimbursement solutions and clinical expertise, leveraging technology and analytics. The company builds long-term careers by investing in professional development and personal growth, fostering a culture of accountability and success.
Pulling, sorting, and analyzing data to determine member eligibility for the Population Health management Program.
Coordinating and providing care that is timely, effective, equitable, safe, and member-centric while following HMO processes.
Managing case assignments which includes outreach, documentation, monitoring for case progression, and case closure.
Guidehealth is a data-powered healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine. Guidehealth is a growing and innovative organization and employees are expected to adapt to evolving business needs.
Conduct compassionate advance care planning conversations with patients.
Educate patients and families about medical interventions in understandable terms.
Accurately document conversation details to generate state-specific advance care planning documents.
Aledade empowers independent primary care practices. Founded in 2014, they've become the largest network of independent primary care in the country and have a collaborative, inclusive and remote-first culture.
Support payer audits and medical record reviews, ensuring timely submission of documentation.
Manage medical review requests and appeals associated with CMS contractors and regulatory agencies.
Review clinical documentation using audit checklists and partner with teams to gather required records.
VitalCaring is a provider of home health and hospice services founded in 2021. They are a growing company focused on quality and compliance, with a mission to deliver exceptional patient care.
Provide exceptional care, disease management and health education to patients.
Support goal setting for individual patients asynchronously to help them better manage their chronic conditions.
Create personalized action plans with guidelines to reduce or eliminate unwanted behaviors.
Salvo Health is a new approach to help millions of Americans facing chronic health conditions, centered on chronic gut health and metabolic conditions from IBS to obesity. They bring multidisciplinary virtual care to patients at community specialty care practices. Salvo offers a competitive salary and health benefits, a remote work environment, flexible time-off, a larger sense of mission, and professional development and entrepreneurial opportunities.
Nurse conducts clinical review of cases not meeting criteria by performing clinical intake.
Adjudicates (closes), requests additional clinical information or escalates to Medical Directors.
Active PRC and USRN License required with 2 years Bedside Experience.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact.
Conduct outbound telephonic patient outreach and provide one-on-one coaching and support to patients managing chronic conditions.
Help patients execute personalized care plans and achieve their goals by providing education and coaching focused on behavior modification, nutrition, physical activity, and self-management strategies.
Document patient interactions, outcomes, and follow-up plans in the Cadence platform; identify barriers to care and connect patients with resources or internal support pathways.
Cadence is a clinical AI company that delivers continuous, proactive care for older adults with chronic conditions. They pair patients with a dedicated clinical team, integrate deeply into health system EMRs and workflows, and use their Clinical Intelligence platform.
Analyze denied insurance claims and apply clinical reasoning to determine appeal merit.
Draft persuasive, medically sound appeal letters to recover denied revenue.
Collaborate with legal team to ensure appeals are compelling and complete.
Ternium specializes in resolving complex healthcare insurance claim denials and delays for hospitals. They have a dedicated, mission-driven team and value diversity and inclusion.
Review clinical documentation and treatment trajectory to ensure care meets medical necessity standards.
Synthesize clinical documentation, medical record information, and outcomes data to make recommendations on next steps in care.
Partner cross-functionally to support high-quality, clinically appropriate care across the network.
Rula is dedicated to treating the whole person and aims to create a world where mental health is no longer stigmatized. They are a remote-first company committed to providing quality, evidence-based, and compassionate care, empowering individuals to take charge of their mental health.
Provides nursing assessments within the standards outlined in the state Nurse Practice Act.
Provides clinical assessments and health education using telecommunications in accordance with protocols and guidelines.
Uses the nursing process to identify patient care needs, risk and safety issues, and appropriate health care referrals.
Carenet Health delivers patient-centric healthcare solutions. We foster a collaborative team of RNs across the country and are committed to creating an inclusive environment for all employees.
Evaluates member health metrics and professional resources to inform UM/CM initiatives and programs.
Refers members and providers to G.E.H.A resources and programs, as indicated, maximizing their health plan benefits.
Monitors and evaluates program effectiveness, tracks relevant metrics, and reports outcomes.
Government Employees Health Association (G.E.H.A) is a nonprofit member association providing health and dental benefits to millions of federal employees and retirees since 1937. G.E.H.A is headquartered in Lee's Summit, Missouri, offering hybrid and work-from-home options for many roles.
Conduct clinical reviews of medical records to determine medical necessity and payer compliance.
Evaluate denial cases including appeals, audits, and no-authorization determinations.
Develop evidence-based clinical rationales aligned with payer and regulatory guidelines.
This partner company provides clinical review and healthcare reimbursement support services. The team is remote and operates in a fast-paced, performance-driven environment.
Support care navigation for oncology members by facilitating treatment, symptom tracking, and re-education.
Collaborate with RNs and providers to coordinate care plans, referrals, and authorizations.
Maintain regular contact with members via phone, text, email, and video calls for follow-up and support.
Renalogic helps clients manage the human and financial costs of chronic kidney disease. We hire people who are humble, hungry, and smart, and our 96% client retention shows we're building a company we're proud of.
Supports clinical safety, accuracy, and oversight of integrated AI tools by reviewing AI-assisted outputs and surfacing risks.
Applies nursing judgment to review charts, calls, messages, and other member interactions to assess quality, safety, and member experience.
Assists with data collection and basic analysis for quality and safety work, and participates in cross-functional improvement efforts.
Included Health is a healthcare company delivering integrated virtual care and navigation. They are on a mission to raise the standard of healthcare for everyone, and offer members care guidance, advocacy, and access to personalized virtual and in-person care.
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, courteously, 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 are a high-technology health plan that expands benefits, increases access and transparency, and features a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL) with more than 3,000 corporate employees and 15,000 agents.
Supervise day-to-day operations of assigned Utilization Management staff.
Provide full people management for assigned Utilization Management teams, including hiring and performance management.
Drive team performance against key metrics, including engagement, productivity, and quality scores.
Personify Health has created a personalized health platform, bringing health plan administration, wellbeing solutions, and care navigation together. Their data-driven solutions aim to reduce costs while improving health outcomes, empowering people to lead healthier lives.
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established guidelines.
Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
Broadway Ventures delivers tailored solutions that drive operational success, sustainability, and growth for government and private sector clients. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), they empower clients with expert program management, cutting-edge technology, and innovative consulting solutions.
Provides clinical oversight and medical necessity reviews for home health, DME, and related services using evidence-based guidelines.
Conducts peer to peer consultations and adverse determinations when clinical criteria are not met to support quality outcomes.
Collaborates with health plan leadership, participates in committees, and achieves SLA metrics for client performance guarantees.
CareCentrix provides clinical oversight and utilization management for home health, DME, home infusion therapy, and sleep medicine services. The company has an award-winning culture that values care, integrity, excellence, and innovation, operating with a drug-free workplace and equal opportunity commitment.
Provide empathetic, non-judgmental care while maintaining clear emotional boundaries
Accurately document consult outcomes to support safe and effective prescribing
Montu is Australia's largest healthtech business focusing on alternative healthcare. Founded in 2019, it supports patients, doctors, and pharmacies, and is known for its rapid growth and being named #1 on LinkedIn’s Top Startups Australia 2024.