Review Home Health prior authorization requests using CMS guidelines and clinical judgment.
Lead and mentor the Home Health UM nursing team, ensuring quality and compliance.
Collaborate with cross-functional partners to optimize care and improve utilization.
Clover Health provides high-quality, affordable healthcare for America's seniors by combining data, technology, and preventive care. They are a mission-driven team with diverse expertise, focused on improving members' lives through innovation and empathy.
Manage care for high-risk members by identifying needs and coordinating clinical, community, and in-network resources.
Perform utilization management reviews, ensure quality oversight, and support accreditation readiness.
Collaborate with multidisciplinary teams to analyze member outcomes and drive continuous improvement.
They are a health plan focused on improving outcomes for high-risk members through care coordination and quality initiatives. Their team values collaboration, clinical excellence, and mission-driven work to enhance community health.
Review patient records to improve quality and completeness of clinical documentation, ensuring accuracy for severity of illness and level of services.
Collaborate with providers, coders, and care team members to ensure comprehensive patient documentation and compliant documentation clarification.
Develop and deliver clinical documentation improvement education to providers, and monitor documentation requests to support revenue cycle integrity.
ProMedica is a mission-driven, not-for-profit health care organization serving communities across nine states with acute and ambulatory care, a dental plan, and academic business lines. The organization employs over 1,300 health care providers and has more than 2,300 physicians with privileges, committed to clinical excellence and addressing social determinants of health.
Review medical records to develop concise clinical reviews supporting authorization and reimbursement.
Facilitate communication with payors to ensure appropriate utilization management decisions.
Collaborate with interdisciplinary team to prevent denials and optimize patient care.
West Virginia University Health System is West Virginia’s largest health system, providing comprehensive healthcare services. With over 35,000 employees and 25 hospitals, it is the state's largest employer and offers a collaborative, patient-centered culture.
Serves as a subject matter expert in clinical documentation quality, risk adjustment, and HCC coding integrity.
Performs prospective reviews of medical records to validate chronic conditions and ensure documentation accuracy.
Utilizes Epic and OurPractice Advisories to support accurate coding, HCC capture, and compliance.
UASI is a clinical documentation improvement consulting firm dedicated to improving the quality and accuracy of clinical documentation. They offer a collaborative, mission-driven environment with opportunities for professional growth.
Set daily direction for your UM team, establishing priorities and reinforcing expectations.
Coach reviewers on criteria application, guiding consistent use of medical-necessity criteria.
Monitor workflow health daily, tracking intake volume and turnaround risk.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. The team is on a mission to empower people to lead healthier lives.
Complete pre-charting and post-charting of comprehensive home health assessments in MatrixCare EMR.
Ensure documentation accuracy, compliance with regulatory standards, and strict confidentiality per HIPAA.
Collaborate with nurses to review and finalize patient records while maintaining strong attention to detail.
Limitlessli specializes in recruiting, hiring, and managing high-caliber remote staff through a global network. They connect clients with qualified professionals and offer tailored services to meet unique business needs.
Support the development and management of clinical guidelines by coordinating with physicians and committees.
Manage program workflows, documentation, and communications to ensure efficient execution.
Maintain compliance with healthcare regulations and contribute to impactful quality and safety initiatives.
The company supports the development and management of clinical guidelines to advance quality, safety, and evidence-based healthcare practices. They foster a collaborative, mission-driven culture focused on innovation, integrity, and professional growth.
Review medically complex claims, pre-authorization requests, appeals, and fraud and 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, we empower clients with tailored solutions, operating with integrity and collaboration.
Leverage your experience as a Practice Manager or Clinic Nurse to assist physician offices in improving quality initiatives.
Implement clinical quality improvement activities and generate reports from electronic health records to identify care gaps.
Provide process improvement interventions and educational support to close gaps in day-to-day workflows.
Health Services Advisory Group (HSAG) transforms healthcare delivery in the United States through quality improvement initiatives. As a growing team, they focus on improving the quality of healthcare for communities across multiple states and territories.
Conduct medical necessity reviews for inpatient admissions and post-acute services using evidence-based guidelines.
Lead peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate care decisions.
Collaborate with utilization management and care management teams to ensure consistent, cost-effective care.
Our partner company provides utilization management services for Medicare Advantage members, focusing on evidence-based clinical decision-making. It operates with a collaborative, matrixed team and emphasizes regulatory compliance and patient-centered care.
Manage day-to-day operations for the outpatient clinical documentation improvement program across multiple facilities.
Liaise with physicians and leadership on coding rules, risk adjustment, and reimbursement guidelines.
Ensure compliant and accurate medical record documentation while facilitating standardization.
Henry Ford Health is an academic health system providing comprehensive care across Michigan. With 12 hospitals and hundreds of clinics, it is a large organization focused on collaboration and innovation.
Provides medical interpretation and clinical review for appropriateness of services, including Home Care Solutions, Skilled Nursing Facility, Durable Medical Equipment, rehabilitation, and discharge planning.
Advises executives on functional strategies related to OneHome initiatives and clinical priorities, exercising independent judgment on complex issues.
Ensures compliance with CMS guidelines, Medicare/Medicaid requirements, and Humana policies while supporting quality, utilization management, and care coordination.
Humana is a leading U.S. healthcare company providing insurance and healthcare services through its Humana insurance and CenterWell healthcare services. It is a large, publicly traded organization with a culture focused on the Humana Way, emphasizing collaboration, accountability, and improving member experiences.
Coordinate and provide care that is timely, effective, and member-centric while following HMO processes.
Manage case assignments including outreach, documentation, monitoring for case progression, and case closure.
Assist members in reaching wellness by addressing barriers, social determinants, and psychosocial issues.
Guidehealth is a data-powered healthcare company dedicated to making great healthcare affordable and improving patient outcomes. It is a physician-led, performance-driven organization with a culture of empathy, accountability, and continuous learning.
Performing timely utilization review of healthcare services using approved medical necessity criteria.
Collaborating with medical directors, providers, and internal teams for compliant review processes.
Ensuring accurate documentation and communication of determinations within regulatory timeframes.
Guidehealth is a data-powered, performance-driven healthcare company focused on making healthcare affordable and improving patient health. It is a physician-led organization using AI and predictive analytics, with a culture of accountability, growth, innovation, and empathy.
Conduct Skilled Nursing Facility medical claims audit reviews applying medical review guidelines.
Document findings and generate articulation letters for audit results.
Collaborate with audit team and clients to improve medical policies and workflows.
Machinify is a leading healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. Deployed by over 85 health plans representing more than 270 million lives, the company uses an AI-powered platform and best-in-class expertise to reimagine healthcare.
Eligibility Review: Review patient records and clinical documentation to determine eligibility for Form Health.
Record Collection: Manage requesting, faxing, and tracking medical records from external providers while ensuring HIPAA compliance.
File Communication: Maintain clear communication with patients and colleagues to keep them updated throughout the eligibility process.
Form Health is a virtual obesity medicine clinic that provides multi-disciplinary evidence-based obesity treatment through telemedicine. Founded in 2019, it is a venture-backed startup with an experienced clinical and leadership team, committed to a culture of inclusion and patient-first values.
Coordinate patient onboarding, device setup, and education on remote monitoring technology.
Monitor patient data, analyze trends, and escalate health changes to providers.
Collaborate with healthcare professionals to optimize care and ensure documentation accuracy.
Optima Medical is an Arizona-based medical group providing personalized healthcare with a focus on preventing leading causes of death. With 30 locations and over 130 providers serving 200,000 patients, they offer a supportive and positive work environment.
Conduct educational telephone calls to advise members of benefits, complete health needs assessments, and refer to population health management programs.
Reach out to members with gaps in care, encourage compliance, and assist with locating providers and scheduling appointments.
Manage system work queues, screen members for eligibility and history, and assign to clinical teams for intervention.
BlueCross BlueShield of Tennessee is the state's largest health benefit plan company, helping Tennesseans find paths to good health since 1945. They are a remote-first organization with many employees working from home, fostering a culture of innovation and collaboration.
Work with a multi-disciplinary team to ensure a high-quality patient experience.
Manage patient/provider messaging and coordinate care plans.
Provide administrative and communication support for the provider network.
Thirty Madison is now part of Remedy, revolutionizing healthcare accessibility. The company is dedicated to building a diverse, inclusive, and authentic workplace, with a focus on patient care and provider support.