Provides clinical oversight and medical necessity reviews for home health, DME, and related services using evidence-based guidelines.
Conducts peer to peer consultations and adverse determinations when clinical criteria are not met to support quality outcomes.
Collaborates with health plan leadership, participates in committees, and achieves SLA metrics for client performance guarantees.
CareCentrix provides clinical oversight and utilization management for home health, DME, home infusion therapy, and sleep medicine services. The company has an award-winning culture that values care, integrity, excellence, and innovation, operating with a drug-free workplace and equal opportunity commitment.
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.
Lead daily CDI operations, including staffing, workload balancing, and training for clinical documentation improvement.
Conduct real-time clinical reviews for complex cases and analyze data to ensure quality and accuracy.
Collaborate with physicians and staff to enhance documentation quality and compliance with coding guidelines.
Adventist HealthCare is a faith-based, not-for-profit healthcare organization providing comprehensive services including acute-care hospitals, rehabilitation, outpatient centers, and home care. With over 6,000 employees, they are the largest healthcare provider in Montgomery County, Maryland, focused on extending God's care through physical, mental, and spiritual healing.
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.
Deliver high-quality, patient-centered virtual primary care via video, chat, and secure messaging.
Manage chronic conditions, provide preventive care, and prescribe medications.
Collaborate with Nurse Practitioners and maintain compliance with regulations.
Curai harnesses artificial intelligence and clinical expertise to make healthcare more affordable, accessible, and effective. They are a mission-driven team of talented colleagues committed to building a diverse and inclusive workforce.
Deliver high-quality virtual urgent and primary care to patients of all ages, conducting examinations, evaluations, and treatment plans.
Maintain accurate patient records, order and interpret diagnostic tests, and collaborate with provider and support teams.
Provide scheduling flexibility including evenings, weekends, and holiday shifts, with a minimum of 32 hours per week.
Included Health delivers integrated virtual care and navigation, aiming to raise the standard of healthcare for everyone by breaking down barriers to provide high-quality care across acute, chronic, behavioral, and physical needs. The company operates as a new kind of healthcare company offering personalized virtual and in-person care, with a focus on inclusivity and community impact.
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.
Provide clinical assessments, treatment plans, and direct care for cancer patients via telehealth.
Collaborate with local clinicians and Color's care team to ensure evidence-based cancer care delivery.
Educate patients on treatment options and assist with clinical decision-making.
Color Health operates the nation's first Virtual Cancer Clinic, providing physician-led multidisciplinary cancer care across all 50 states. The company uses technology to transform how employers and health plans address cancer, focusing on screening, diagnosis, treatment, and survivorship.
Provide virtual primary care visits via telemedicine, working with a care team including a Health Coach to optimize patient outcomes.
Complete online charts accurately and promptly, assist in resolving patient inquiries, and follow organizational protocols.
Commit to at least 8 hours per week with schedules confirmed 24 hours in advance.
Parsley Health is a digital health company focused on transforming the health of people with chronic conditions using root cause resolution medicine. The company is the nation's largest healthcare provider in this space and values diversity, inclusion, and impact.
Conduct comprehensive MS-DRG and APR-DRG coding reviews to ensure accuracy in DRG assignment and reimbursement.
Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications.
Craft clear, concise, and well-supported audit findings, backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations.
Cohere Health provides an AI-powered clinical intelligence platform that streamlines access to quality care by improving payer-provider collaboration and cost containment. The company works with over 660,000 providers, handles over 12 million prior authorization requests annually, and has been named to the Inc. 5000 list and a Top 5 LinkedIn Startup for 2023 and 2024.
Analyze and audit inpatient claims for DRG validation, coding accuracy, and clinical appropriateness without a medical record.
Utilize proprietary auditing systems to make determinations and generate audit letters, meeting productivity and quality standards.
Identify new claim types and suggest process improvements while maintaining expert ICD-10 and DRG coding knowledge.
Cotiviti is a healthcare analytics and auditing company that helps payers and providers improve financial performance and clinical outcomes. It is a large organization with a culture focused on accuracy, compliance, and collaboration.
Analyze denied insurance claims and apply clinical reasoning to determine appeal merit.
Draft persuasive, medically sound appeal letters to recover denied revenue.
Collaborate with legal team to ensure appeals are compelling and complete.
Ternium specializes in resolving complex healthcare insurance claim denials and delays for hospitals. They have a dedicated, mission-driven team and value diversity and inclusion.
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.
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.