Lead prospective claim review audits related to clinical DRG coding compliance and readmissions programs.
Act as Subject Matter Expert to counsel other team members across Clover on clinical coding guidelines.
Collaborate with teams across Clover to ensure provider understanding of Payment Integrity recommendations.
Clover Health is reinventing health insurance by combining the power of data with human empathy to keep their members healthier. 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.
Conduct chart audits for patient encounters, ensuring accurate medical record documentation.
Identify opportunities to improve documentation quality and clinical compliance.
Support the contact center by addressing patient questions and providing education.
Planned Parenthood South Atlantic provides reproductive health care. They are committed to equitable and transparent pay practices and value their employees.
Supports coding and documentation quality assurance.
Performs internal audits to assess compliance and quality.
Researches coding, billing, and charging compliance issues.
Presbyterian Healthcare Services is dedicated to improving the health of patients, members, and communities. They are a locally owned, not-for-profit healthcare system with nine hospitals, a statewide health plan, and a growing multi-specialty medical group, employing nearly 14,000 individuals.
Responsible for submission of the patient’s medical record to CMS or their delegated representatives, other contracted agencies, patients, and privately subpoenaed charts.
Provide administrative support to the Director of Home Health in compliance with organization policies and procedures and applicable laws and regulations.
Develop and maintain tracking tools to assist management with monitoring progress on compliance and accreditation standards.
By The Bay Health, established in 1975, is a non-profit that set the standard for hospice in the U.S. by emphasizing the role of the patient in making important medical decisions. Their spectrum of home-based services includes Skilled Home Health Care, Palliative Care, Adult Hospice Care and Pediatric Care.
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 transforms challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), they empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth.
Responsible for planning and executing quality and oversight activities to ensure operational compliance.
Responsible for internal and external case audits for Capital and our delegated UM vendors.
Responsible for educating staff on findings, and the audit tool ensuring a consistent approach.
Capital Blue Cross promises to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”
Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs.
Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals.
Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance.
Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. They serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes and have a mission to empower people to lead healthier lives.
Performing deep-dive audits of medical records (up to 500+ pages per file).
Identifying treatment gaps and missing billing.
Drafting persuasive liability narratives and provider-by-provider chronologies.
ACD Legal Support provides elite, settlement-ready medical demand solutions for law firms. They are a systems-driven organization that values medical accuracy and the identification of Value Leakage in personal injury files.
Work with clients performing coding audit and/or review services on a variety of Inpatient facility record types
Identify trends based on coding audit and review findings and formulate recommendations for corrective action plans
Perform necessary research to provide to the client to support findings.
UASI is recognized as a Top Workplace. With over 40 years of experience and enduring partnerships with our valued clients, we are proud of the stability we’ve built and the long-term success of our dedicated team.
Supervise a team of appeals and grievances coordinators; develop/implement strategies to improve team performance and efficiency.
Receive, document, and manage member and provider appeals and grievances in accordance with Dignity Health MSOs policies and standards. Prepare and present reports on appeals and grievances activity.
Maintain detailed and accurate records of all appeals and grievances, including documentation of investigations, outcomes, and communications.
Dignity Health MSO offers management and business services that leverage economies of scale across provider types and geographies, leading the effort in developing Dignity Health’s Medicaid population health care management pathways. They focus on coordinating patient care while containing costs and improving quality of service. The company offers a Total Rewards package that integrates competitive pay with flexible Health & Welfare benefits and a generous employer-matched 401k retirement plan.
Coordinate case management activities related to medication optimization, adherence, and therapeutic appropriateness
Collaborate with providers, PBMs, and pharmacy partners to support evidence-based medication use and access
Conduct member outreach, education, and follow-up to support adherence and understanding
Point C is a national third-party administrator (TPA) delivering customized self-funded benefit programs with local market presence. They focus on cost containment strategies with innovative solutions. They are driven by a clear and impactful mission.
Identifies, documents, and evaluates business risks, recommending improvements.
Prepares detailed audit reports for executive management, conveying evaluations and recommendations.
BlueCross BlueShield of South Carolina is a leading health insurance company and administrator of government contracts. They have been in business for over seven decades with strong roots in the South Carolina community and an A+ (Superior) A.M. Best rating.
Responsible for the Care Coordination staff for case reviews and UR appeals.
Coordinates worklists and completion of cases on audit review, retro authorization and appeals.
Northside Hospital is an award-winning and state-of-the-art healthcare provider that is constantly growing. They are expanding the quality and reach of their care to patients and communities, creating more opportunity for healthcare professionals in Atlanta and beyond.
Ensure payroll practices comply with labor standards and regulations.
Perform audits to ensure payroll accuracy.
Provide guidance on payroll compliance issues.
Lucile Packard Children’s Hospital Stanford is known for blending advanced technologies and breakthroughs with family-centered care. They provide caregivers with continuing education and state-of-the-art facilities.
Evaluates certification requests by reviewing the group specific requirements.
Triage the call to determine if a Utilization Review Nurse is needed to complete the call.
Cottingham & Butler sells a promise to help their clients through life’s toughest moments. Their culture is guided by the theme of “better every day” constantly pushing themselves to be better than yesterday.
Conducts medical necessity reviews to determine appropriate patient class designation.
Performs timely reviews using InterQual Criteria and clinical nursing judgement.
Communicates with the provider team regarding patient class designation and medical necessity.
Emory Healthcare fuels professional journeys with benefits, resources, mentorship, and leadership programs. They offer a supportive environment for career growth.
Review and audit medical claims for accuracy and compliance.
Listen to customer service phone calls for accuracy and professionalism.
Prepare reports on audit findings and recommendations for process enhancements.
Point C is a National third-party administrator (TPA) delivering customized self-funded benefit programs. They focus on cost containment strategies with innovative solutions. The posting does not specify the number of employees or further details about the culture.
Coordinating payor denial and appeal follow up activities to ensure timely response from third party payors.
Communicating and coordinating with various individuals/distributions and assisting with monitoring of the day to day activities related to appeal follow up and denials.
Maintaining the hospital tracking tool/application that stores/communicates all denial and review activity.
Shriners Children’s is an organization that respects, supports, and values each other. They provide excellence in patient care, embracing multi-disciplinary education, and research with global impact and were named the 2025 best mid-sized employer by Forbes.
Serve as the primary point of contact for patients, families, facility partners, and providers.
Triage and prioritize urgent care requests, STAT tasks, and time-sensitive clinical communications.
Maintain accurate, compliant patient documentation within our EMR system.
Pine Park Health is a value-based primary care practice aiming to redesign healthcare for senior living residents. They operate in over 185 communities across Arizona, California, and Nevada, focusing on improving healthcare for seniors by providing regular prevention and screening.
Responsible for the coordination of services for members meeting established criteria, emphasizing education/self-management and promoting quality care and cost-effective outcomes.\n- Uses a collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor progress, and evaluate Member status.\n- Addresses medical, psychosocial, clinical needs, and behavioral health needs including members with mental health and substance use disorder needs, providing counseling and referrals to community/local/state programs.
Capital Blue Cross is committed to providing excellent service to both its team and the community. Employees have consistently voted it as one of the “Best Places to Work in PA”, which indicates a positive and supportive company culture.