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.
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.
Managing the care of patient panel by leveraging experience and knowledge.
Establishing relationships with patients and families to provide support.
Serving as an advocate and community liaison for patients.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach. We are committed to improving patient outcomes and quality of life by delaying disease progression and shifting care to the home.
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.
Manage communications between patients and doctors and associated documentation.
Collaborate with Customer Service to troubleshoot patient requests pertaining to physician requirements.
Provide clinical feedback in response to patient inquiries involving medication, lab, side effects.
Hone is an online medical clinic transforming healthcare and enhancing longevity. They use scientific advancements to empower individuals to take control of their health. Hone is a remote-first employer with a focus on people and a culture that values collaboration and joy.
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.
Provides non-clinical administrative support to Case Managers and Care Coordinators.
Obtains and manages medical documents, ensuring accurate record retrieval.
Prioritizes tasks based on expedited requests with attention to detail.
Spectrum Healthcare Resources (SHR) delivers systems and processes designed to meet the unique needs of Military and VA Health Systems. They provide physician and clinical staffing and management services to United States Military Treatment Facilities, VA clinics and other Federal Agencies.
Assess referred concurrent denials and determine next steps for resolution.
Review medical record documentation to support denial management strategies.
Advocate for patients to ensure coverage and reimbursement.
They are currently looking for a Utilization Management Coordinator. By enhancing operational efficiencies and implementing educational initiatives, this role significantly impacts the financial and quality outcomes of healthcare delivery.
Provide case management to members including medical, social, psychological, physical, and spiritual needs.
Develop, implement, and monitor the care plan in conjunction with the PCP, caregivers, and other team members.
Help meet the member's needs.
Elderplan and HomeFirst are Medicare and Medicaid managed care health plans that are expanding services in response to patients' needs. At MJHS, they are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services.
Deliver coordinated, patient-centered virtual Care Management by telephone or video that improves members' health outcomes.
Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general.
Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family.
Included Health is a healthcare company that delivers integrated virtual care and navigation, aiming to raise the standard of healthcare for everyone. They break down barriers to provide high-quality care for every person, offering care guidance, advocacy, and access to personalized virtual and in-person 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.
Work independently to make clinical decisions on routine patient care matters.
Provide patient-focused care and guidance on the phone or online.
Monitor your own performance with dashboard metrics and look for ways to improve.
Carenet Healthcare Services provides telehealth and virtual care clinical triage assessments, health education and other services to diverse populations of patients and health plan members. They are known to connect nurses and clinical staff with consumers as a trusted, behind-the-scenes partner for health plans and health systems.
Serve as the remote support hub for Nurse Practitioners (NPs) practicing in Skilled Nursing Facilities (SNFs).
Improve NP efficiency and patient outcomes by owning clinical, data, and communication tasks.
Perform clinical triage, educate families, manage program data, and coordinate complex care.
HealthDrive delivers on-site dentistry, optometry, podiatry, audiology, behavioral health, and primary care services to residents in long-term care, skilled nursing, and assisted living facilities. They connect patients in need of vital healthcare to doctors committed to dignity and excellence.
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.
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.
Take inbound calls from patients, providers and members
Support members with their insurance needs, questions or concerns
Provide 24/7 Triage Support and assign priority for a Registered Nurse to provide health advice
Carenet Health pioneers advancements in healthcare consumer experience, interacting with 1 in 3 Americans daily. They integrate human touch with data-driven technology to improve healthcare, offering best-in-class clinical expertise and personalized solutions.
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.