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.
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.
Reviewing cases, educating patients on appropriate care.
Managing health care costs for the dependents of our Nation’s Active Duty and eligible retirees.
Working remotely Monday through Friday, 8 hours per day.
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 and VA clinics.
Assess, plan, coordinate, and monitor patient care.
Develop, implement, and monitor individualized care plans.
Coordinate care across providers, facilities, and community resources.
Limitlessli specializes in recruiting, hiring, and managing high-caliber remote staff for dynamic and growing healthcare facilities. They connect clients with highly qualified professionals, offering tailored services to meet unique business needs, leveraging an extensive global network.
Performs concurrent inpatient utilization review using InterQual criteria to determine if requests meet medical necessity criteria.
Engages in clinical collaboration with physicians, hospitalists, and care teams to obtain clinical information.
Maintains knowledge of regulations, accreditation requirements, and payer-specific guidelines.
WNS Healthhelp, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. They bring together deep domain excellence with AI-powered platforms and analytics to help businesses innovate, scale, adapt and build resilience. With more than 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact.
Provide first level review for all outpatient and ancillary pre-certification requests.
Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
Complete documentation for all reviews in Eldorado/Episodes and maintain confidentiality.
Personify Health created a personalized health platform bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. Their team is on a mission to empower people to lead healthier lives.
Conduct thorough reviews of medical records to support program eligibility determinations.
Apply established clinical criteria and program-specific guidelines to evaluate medical necessity and eligibility determinations.
Accurately abstract and document relevant clinical findings, diagnoses, procedures, and treatment history from the medical record.
Daymark Health is a value-based oncology company redefining the cancer care experience for patients, providers, and health plans. Daymark’s comprehensive, personalized cancer care platform empowers patients with dedicated care navigation, symptom-focused support, behavioral health care, and social resources.
Triage patient care needs over the phone, providing medical advice, and coordinating with healthcare providers to address urgent concerns.
Use motivational interviewing and active listening skills to understand patient needs and effectively communicate to identify/resolve issues.
Implement strategies to prevent hospital re-admissions, including patient education, follow up telephonic touchpoints, and care coordination.
VitalCaring is a leading provider of home health and hospice services. Founded in 2021, it has over 65 locations across the country and is committed to fostering a culture of support, growth, and excellence for its team.
Conduct in-depth telephonic assessments to understand patient needs.
Develop individualized care plans and guide patients through treatment goals.
Document clearly and accurately in the EHR and care-management systems.
Guidehealth is a data-powered healthcare company. They aim to make healthcare affordable and improve patient health with AI and predictive analytics. They operate with agility, encouraging cross-training and development to ensure employees thrive.
Responsible for supporting nursing communities within the geographic location assigned.
Audits clinical services, reviews outcomes, and strategizes to improve resident care.
Works alongside the management teams at each building to develop and implement processes, identify and resolve issues, while also managing staff.
Tutera Senior Living & Health Care is guided by one single purpose: To live the YOUNITE philosophy in every decision, every day. Based on genuine respect, YOUNITE is how they get to know residents and team members on a personal level and offer stability as a family-owned company founded in 1985.
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.
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.
Coordinate and implement medical case management to facilitate case closure.
Assess appropriate utilization of medical treatment and services.
Review medical records and assess data to ensure appropriate case management process.
Berkley Medical Management Solutions (BMMS) provides managed-care service for W.R. Berkley Corporation, focusing on injured worker’s return to work. BMMS was started in 2014 and combines clinical practices, return-to-work strategies, and software for workers’ compensation cases.
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.
Perform in-depth reviews of medical claims utilizing the UB-04 and detailed itemized statements.
Verify the accuracy of itemized charges to be reimbursed according to client policy and industry standards.
Validate automatic system denials and create additions to enhance efficient processing of IBR claims.
Machinify is a healthcare intelligence company delivering value, transparency, and efficiency to health plan clients. They have a fully configurable and content-rich, AI-powered platform along with best-in-class expertise, deployed by over 85 health plans, including many of the top 20, representing more than 270 million lives.
Provide clinical insight to support attorneys in healthcare legal cases.
Organize and manage electronic medical records for efficient case review.
Conduct medical literature research and prepare summaries for case allegations.
TLC Management's mission is grounded in compassionate care, accountability, and doing what’s right—every time. As a multi‑state senior care organization, they are committed to supporting our communities with strong clinical practices, ethical leadership, and thoughtful decision‑making.
Provide real-time phone support for field nurses during patient visits.
Help troubleshoot common issues related to equipment, medication handling, documentation, and pharmacy protocols.
Support nurse adherence to therapy standards and pharmacy protocols.
Float is a full-stack platform for Specialty Pharma home infusion, aiming to make healthcare safer, easier, and more efficient. They connect nurses with patients for home medication visits and have facilitated over 82,000 patient visits, scaling their platform and operations.
Perform comprehensive medical record and claims review to make payment determinations for Medicare PART A.
Conduct in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles.
Make clinical judgment decisions based on clinical experience when applicable.
Empower AI provides federal agency leaders with tools to elevate their workforce's potential through meaningful transformation. Headquartered in Reston, Va., Empower AI leverages three decades of experience solving complex challenges in Health, Defense, and Civilian missions.
Provides remote nursing support to assist in the delivery of patient care through telehealth services.
Works under the supervision of the Regional Telehealth Nurse Manager and in collaboration with onsite clinical staff to assess patient needs.
Supports the nursing process by assisting with assessment, planning, implementation, and evaluation of care.
Wellpath provides healthcare services to unique individuals in correctional facilities. They focus on clinical care and saving lives, offering training and development opportunities for healthcare team members.