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.
Serve as the main point of contact for patients and families transitioning from or seeking post-acute services.
Make clinical level-of-care determinations using discussions, medical records, and other clinical data.
Provide patient education on home health, hospice, palliative care, Medicare coverage, and billing.
Gentiva is a national leader in hospice, palliative, and home health care, providing compassionate care to patients in their homes. With nearly 600 locations and thousands of clinicians across 38 states, they offer a collaborative environment where inspiring achievements are recognized.
Act as a liaison for a patient panel of medically stable patients, coordinating care between internal and external providers.
Monitor and triage lab orders and results, providing education and medical management support to patients and families.
Triage emergent issues in a time-sensitive manner and coordinate care with hospitals for medical stabilization admissions.
Equip is the leading virtual, evidence-based eating disorder treatment program on a mission to ensure everyone with an eating disorder can access treatment that works. Founded in 2019, the company is fully virtual and has been recognized as one of the most influential companies of 2023, with a diverse and passionate team.
Provide clinical review and correspondence for utilization management, including medical necessity reviews and member communications.
Collaborate with Medical Directors to ensure evidence-based decisions that meet NCQA and CMS standards.
Maintain productivity and quality while working 100% remotely in a fast-paced environment.
Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With over 250 employees, the company fosters a supportive, growth-oriented environment and has been named to the Inc. 5000 list and a Top 5 LinkedIn Startup.
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.
Manage the member's clinical experience from request through desired outcome, including account activation and medical history drafting.
Coordinate video or phone consults with specialists and schedule monitors in advance, troubleshooting issues as needed.
Conduct ongoing follow-up post-consult and facilitate local recommendations, communicating with primary care physicians or specialists.
Transcarent is a health and care platform that combines medical, pharmacy, and point solutions with a generative AI-powered experience for health consumers. With over 1,700 employer and health plan clients serving 21 million Members, they foster a culture of People First, Care, Resilience, Results, and Humble and Human.
Conducts utilization review to determine medical necessity of admission and continued stay using established criteria.
Communicates with payers to secure authorization and negotiate medical necessity decisions.
Educates providers on documentation requirements and participates in strategies to reduce length of stay and readmissions.
OHSU is Oregon’s only public academic health center, providing patient care and conducting groundbreaking research while training health care professionals. As Portland’s largest employer, it offers a diverse and inclusive culture with opportunities for growth across Oregon and Southwest Washington.
Conduct telephonomic assessments of members' medical, psychosocial, physical, and spiritual needs.
Develop and revise Person-Centered Service Plans (PCSP) in response to changes in member condition.
Collaborate with interdisciplinary care teams and educate members on Advanced Directives and Health Care Proxy.
Elderplan and HomeFirst are Medicare and Medicaid managed care health plans designed to help keep people independent. MJHS is a supportive community of over 6,000 employees committed to excellence, respect, and providing high-quality, personalized health care services.
Coordinate care and collaborate with multiple disciplinary team members to improve the quality of care and clinical outcomes.
Conduct thorough assessments to determine unmet needs and develop individualized care plans.
Promote quality cost-effective outcomes with the goal of improved care coordination.
Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services. They strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships.
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.
Perform concurrent inpatient utilization review using InterQual criteria to determine medical necessity.
Engage in clinical collaboration with physicians and care teams to support appropriate level-of-care decisions.
Maintain documentation, comply with regulations, and ensure quality customer service.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations serving over 700 clients across 10 industries. With over 66,000 employees across 13 countries and 65 delivery centers, the company combines scale and expertise to create meaningful impact.
Conducts training for staff members related to Utilization Review process, clinical guidelines, and workflows.
Creates educational material by collaborating with key resources to incorporate clinical scenarios.
Reviews monthly quality audit findings and provides one-on-one coaching to staff for performance improvement.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With three global headquarters across four continents, operations in 13 countries, 65 delivery centers and more than 66,000 employees, the company combines scale, expertise and execution to create meaningful, measurable impact.
Analyze "trigger reports" to identify potential financial exposure early in the claims process.
Gather clinical information to evaluate liability and make recommendations to stakeholders.
Provide cost containment by managing Stop Loss claims and negotiating prices for medical services.
Ullico is the only labor-owned insurance and investment company and has been a partner of the labor movement for over 95 years. The company provides insurance products for members, leaders, and employers, as well as investments.
Serve as a resource for federal, state, and local hospice regulations, providing training and education to branch staff.
Perform clinical audits, site visits, and assess operational structures to recommend efficient solutions.
Support integration of new employees and branches, and develop operational workflows to improve clinical service delivery.
Enhabit Home Health & Hospice provides home health and hospice services across multiple states. The company has a large branch network and emphasizes a collaborative, supportive work culture with opportunities for growth.
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.
Coordinate and oversee the MDS process for all residents, ensuring accuracy, completeness, and regulatory compliance.
Collaborate with interdisciplinary teams to maximize reimbursement through accurate documentation and chart review.
Maintain knowledge of Medicare, Medicaid, and regulatory requirements, and educate staff on documentation best practices.
Limitlessli specializes in recruiting, hiring, and managing high-caliber remote staff for dynamic and growing healthcare facilities. We leverage our global network to connect clients with qualified professionals and offer tailored services to meet unique 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.
Lead and oversee the Group Health Operations Management team, ensuring effective execution of utilization management services and operational workflows.
Drive achievement of key client performance metrics, including turnaround time, quality indicators, peer-to-peer success rates, and overturn rates.
Manage overall division profitability, including ownership of P&L performance and financial objectives.
Jobgether is a platform that uses AI-powered matching to connect candidates with job opportunities. They operate remotely and emphasize efficient, data-driven hiring processes.
Provide patient-focused telehealth clinical triage assessments and health education via phone, video, and chat.
Work independently to make clinical decisions, assess needs, and direct patients to appropriate care levels while documenting interactions.
Monitor performance metrics, participate in coaching sessions, and communicate with clients and team members.
Carenet Health is a behind-the-scenes partner for over 250 of the nation's premier health plans and health systems, providing telehealth and virtual care clinical triage assessments and health education. Named one of America's fastest-growing private companies by Inc. Magazine for eight consecutive years, the company is integrity-driven and focused on compassionate, evidence-based care.
Collaborate with physicians, APPs, and interdisciplinary team members to manage a patient panel and address specialized needs post-hospitalization.
Perform assessments and develop comprehensive care plans based on individual patient values, goals, and preferences.
Coordinate patient care delivery with clinicians, network providers, contracted vendors, and community-based services.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic approach. The company provides interdisciplinary clinical resources and analytical tools to improve patient outcomes, operating with a team that values innovation and comprehensive care.