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Clinical Assessment
Responsibilities:
- Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services.
- Research and prepare documentation for retrospective review requests and appeals per regulatory and accreditation standards.
- Coordinate discharge planning and care across the health care continuum.
Requirements:
- Current unrestricted US Registered Nurse license and 3+ years of clinical nursing experience.
- 2+ years in US Healthcare utilization management or case management.
- MCG certification or HealthEdge HRCM/Guiding Care experience is a plus.
About the Role:
- Contact medical personnel to identify and recommend alternative treatment, service levels, and lengths of stay.
- Review benefits, member eligibility, and non-authorized services to resolve care coordination issues.
HealthEdge
HealthEdge provides AI-powered operational infrastructure for health insurance companies, covering claims administration, payment integrity, and care management. The company is experiencing significant momentum and investing in employees who directly shape the future of healthcare technology.