Conduct medical claim reviews using clinical information and established criteria to determine medical necessity and appropriate reimbursement.
Educate internal and external staff on medical reviews, coding procedures, and coverage determinations.
Participate in quality control activities and provide guidance to LPN team members.
Palmetto GBA is a healthcare service administrator and one of the nation's largest providers of high-volume medical claims and transaction processing. The company offers a diverse workforce, training programs for leadership, tuition assistance, and financial incentives.
Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies.
Collaborates with client personnel to resolve customer concerns and facilitates resolution of escalated cases.
Maintains written documentation per HealthHelp’s policy and ensures compliance with HIPAA, state, and federal regulations.
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, operations in 13 countries, 65 delivery centers, and more than 66,000 employees, WNS combines scale, expertise, and execution to create meaningful, measurable impact.
Ensure acute hospital admissions have appropriate level of care and meet medical necessity.
Monitor patient progress in plan of care for continued stay.
Provide clinical information to payer to authorize acute hospital stay and continued services.
Piedmont Healthcare is a healthcare organization focused on patient outcomes. It offers a supportive culture with diverse teams, schedule flexibility, and comprehensive benefits, fostering employee growth and well-being.
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 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.
Perform medical necessity reviews of clinical documentation to determine appropriateness of inpatient and outpatient services.
Develop relationships with medical providers and health plans to confirm adherence to policies and guidelines.
Stay updated on technology changes, regulatory issues, and medical practices through ongoing training.
Trend Health Partners is a tech-enabled payment integrity company that facilitates collaboration between payers and providers to reduce waste and improve healthcare access. It promotes a collaborative and innovative work environment as a dynamic, growing organization.
Perform utilization review including precertification and concurrent reviews using medical necessity criteria.
Collaborate with medical directors and providers on complex cases and integrate AI tools into workflow.
Initiate referrals to disease management programs and participate in quality improvement initiatives.
Guidehealth is a data-powered healthcare company that uses AI and predictive analytics to improve healthcare affordability and patient outcomes. It is a physician-led organization with a culture of accountability, learning, innovation, and empathy.
Review Home Health prior authorization requests for medical necessity using CMS regulations and Clover clinical guidelines.
Perform initial and concurrent clinical reviews, ensuring appropriate care in the least restrictive setting.
Collaborate with providers and internal teams to support timely decision-making and positive member outcomes.
Clover Health is a healthcare company that uses data and technology to provide affordable, high-quality insurance plans for seniors. The company fosters a remote-first culture with a diverse and mission-driven team focused on improving member outcomes.
Provide clinical and operational leadership to support timely, evidence-based coverage determinations in Utilization Management.
Coach reviewers on consistent application of medical-necessity criteria, medical policy, and benefit plan language.
Monitor daily workflow health, coordinate coverage plans, and communicate barriers and risks to the UM Manager.
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. The company serves employers, health plans, and health systems with data-driven solutions and is on a mission to empower people to lead healthier lives.
Review inpatient and outpatient medical records to ensure accurate and compliant clinical documentation.
Collaborate with physicians and clinical teams to clarify diagnoses and support proper coding.
Maintain productivity targets and contribute to provider education initiatives to improve documentation quality.
Jobgether is an AI-powered job matching platform that connects candidates with hiring companies. It processes applications using AI to ensure fair review and shares top candidates with employers.
Auditing claims for medically appropriate services in inpatient and outpatient settings using medical review guidelines.
Documenting findings with reference to appropriate policies and rules.
Generating letters articulating audit findings.
Machinify is a healthcare intelligence company delivering value and efficiency to health plan clients across the US. Deployed by over 85 health plans representing over 270 million lives, the company uses an AI-powered platform and best-in-class expertise to reimagine healthcare cost reduction.
Evaluates hospital records for diagnostic coding accuracy and clinical documentation alignment.
Conducts DRG validation, readmission, and level-of-care reviews using evidence-based guidelines.
Produces clear clinical summaries and supports utilization management and peer review activities.
The company provides medical record review and utilization management services to ensure accurate coding and appropriate reimbursement. It is a remote-first organization with a focus on clinical integrity and quality assurance.
Provide medical necessity reviews using evidence-based guidelines and clinical expertise.
Conduct peer-to-peer discussions with treating providers and document decisions in workflow tools.
Support clinical content team with evidence-based literature and operational improvements.
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. Backed by leading investors and recognized on the Inc. 5000 list, the company fosters a supportive, growth-oriented culture with diverse teams.
Review patient charts to ensure fit for the app, reconciling diagnoses, prescriptions, and records.
Support medication management by reviewing lists and helping patients communicate with clinical teams.
Assist the Medical Director in developing programs and providing product feedback.
Nuna builds an AI health coach that helps patients and families manage chronic conditions with motivational interviewing and real-life support. They are a small team focused on transforming chronic disease care outside the clinic.
Identify, research, process, and resolve customer inquiries regarding health insurance benefits, claims, and eligibility.
Analyze medical records and apply medical necessity criteria to determine the appropriateness of benefit requests.
Maintain accurate records, meet quality and timeliness standards, and coordinate with internal departments and external organizations.
Blue Cross Blue Shield of Arizona provides health insurance products and services to individuals, families, and businesses, aiming to inspire health and make it easy. The company has been recognized as a Healthiest Employer and has transformed healthcare for over 80 years with teams in Phoenix, Tucson, Chandler, and Flagstaff.
Review appeals for commercial and Part D plans, rendering determinations based on clinical guidelines and regulatory requirements.
Serve as a clinical reviewer and subject matter support, performing independent research and retrospective case reviews.
Assist with CMS client audits, investigate appeal determination questions, and support clinical training activities.
MedImpact delivers leading edge pharmaceutical and technology related solutions that improve the value of healthcare, providing transparency and choice. Privately-held for over three decades, it is one of the leading pharmacy benefit managers in America, committed to making prescription benefits understandable and accessible.
Perform detailed medical record reviews to validate DRG assignments and ensure billing accuracy.
Conduct clinical and coding audits to identify discrepancies and support cost containment.
Collaborate with quality teams and medical professionals to ensure compliance with payer regulations.
The company partners with healthcare organizations to ensure accuracy in medical coding and reimbursement. They offer a fully remote, supportive environment with comprehensive benefits and professional growth opportunities.
Serve as a clinical subject matter expert supporting product and AI teams to evaluate new features for clinical safety and risk.
Conduct first-line clinical risk assessments across high-impact areas like documentation workflows and medication management.
Partner cross-functionally with product, engineering, regulatory, and clinical teams to guide safe innovation throughout the product lifecycle.
Our partner operates in healthcare technology, and we use an AI-powered matching process to connect candidates with roles. The environment is mission-driven and highly collaborative, focusing on improving outcomes across long-term and post-acute care settings.
Manage patient physiological markers and provide clinical triage.
Conduct wellness calls and collaborate with care teams to set health goals.
Drive patient engagement and ensure adherence to RPM program standards.
Vivo Care is building a platform to make healthcare continuous, personal, and truly connected. It is a fast-growing startup with a culture of inclusion, collaboration, and innovation.
Oversee clinical enrollment for members, guiding them through protocols and eligibility for the most appropriate program.
Collaborate with a cross-functional team of nurses, health coaches, and providers to ensure a seamless member experience.
Utilize nursing judgment, motivational interviewing, and data tools to drive behavior change and improve health outcomes.
Twin Health is the only company applying AI Digital Twin technology to prevent and improve chronic metabolic diseases like type 2 diabetes and obesity. With more than $100 million raised and over 100 employees, Twin has been recognized as an Innovator of the Year and a Most Loved Workplace, backed by leading venture firms.