Monitor federal and state laws impacting government programs.
Provide cross-functional guidance for compliance with legal requirements.
Coordinate and support compliance audits, ensuring timely responses.
CareCentrix is focused on healthcare at home, aiming to simplify care delivery and management. They offer services like home health, durable medical equipment, and home infusion, managing care for over 19 million members across the U.S. and Puerto Rico.
Review and analyze claims, member, and group data.
Establish the correct order of liability for clients’ members.
Input accurate claim recovery information into software tools.
Cotiviti delivers comprehensive payment accuracy services that help organizations improve their healthcare outcomes. Team members enjoy a competitive benefits package and are encouraged to embody Cotiviti's core values.
Manage Medicare and Medicaid enrollment activities.
Oversee state-level entity enrollment for all jurisdictions.
Manage the vendor contract workflow.
Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. They deliver goal-centered care focused on alleviating physical symptoms and emotional stress for individuals and their caregivers; through their leading-edge care model they are shaping the future of community-based palliative care nationwide.
Research compliance program benchmarks and requirements.
Write/maintain compliance policies and program descriptions.
Assist compliance vendor oversight activities.
SmithRx is a rapidly growing, venture-backed Health-Tech company aiming to disrupt the PBM sector. They have a mission-driven and collaborative culture that inspires employees to transform the U.S. healthcare system.
Evaluate hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
Guide timely care determinations using CMS regulations and evidence-based practices while collaborating with care management teams and external providers.
Conduct timely medical necessity determinations for inpatient admissions and post-acute settings.
HJ Staffing is urgently seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. This physician leader will play a critical role in ensuring the clinical integrity of inpatient and post-acute care reviews, evaluating medical necessity to support optimal outcomes and regulatory compliance.
Review all assigned OASIS assessments for accuracy, completeness, and consistency.
Validate diagnosis coding and sequencing per CMS guidelines.
Identify and correct errors impacting reimbursement, quality measures, or compliance.
They are responsible for coding, reviewing, validating, and correcting OASIS assessments to ensure clinical accuracy, regulatory compliance, and optimal reimbursement. This is an adaptive, remote-friendly role designed to scale with agency census and workflow needs.
Build trusting relationships with patients, families, and providers, addressing health questions and care needs.
Identify medical, behavioral, social, emotional, and financial needs to support whole‑person care.
Strengthen the connection between patients and healthcare providers by addressing barriers and facilitating communication.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence, with the goal to make great healthcare affordable, improve patient health, and restore fulfillment for providers. They leverage remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers.
Design and/or enhance targeted and annual risk assessments.
Construct specific and effective auditing and monitoring workplans based on risks identified.
Analyze compliance outcomes and ensure detected issues are referred for remediation.
SmithRx is a rapidly growing, venture-backed Health-Tech company aiming to disrupt the expensive and inefficient Pharmacy Benefit Management (PBM) sector. With hundreds of thousands of members onboarded, they foster a mission-driven and collaborative culture, dedicated to transforming the U.S. healthcare system.
Lead an exhaustive audit of clinical and business operations to identify and remediate regulatory vulnerabilities.
Act as the authorized signatory for all legal compliance documents.
Partner with Product and Engineering to embed "Compliance by Design" into the patient platform.
Wheel is evolving the traditional care ecosystem by equipping the nation's most innovative companies with a premier platform to deliver high-quality virtual care at scale. They offer proven strategies and cutting-edge technologies to foster consumer engagement, build brand loyalty, and maximize return on investment.
Follow VitalCaring billing Standard Operating Procedures and regulatory billing guidelines
Collaborate with your supervisor and the billing team to address payor and billing concerns
Ensure documentation accuracy and submit claims in accordance with Medicare and other payor requirements
VitalCaring is a leading provider of home health and hospice services. Founded in 2021, VitalCaring has grown into a leading provider of home health and hospice services, with over 65 locations across the country. They foster a culture of support, growth, and excellence.
Complete timely review of healthcare services using appropriate medical criteria to support determinations.
Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make great healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages Healthguides™ and a Managed Service Organization to build stronger connections with patients and providers.
Processes acute and post-acute inpatient medical and select intensive outpatient higher level of care requests through clinical review.
Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies to requests.
Collaborates with UM department staff and Medical Directors to make a final determination, and with Care Management staff on discharge planning.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. At Capital, employees work alongside a caring team of supportive colleagues and are encouraged to volunteer in their community.
Partner with Sales on strategic opportunities involving quality measurement and Star Ratings solutions.
Lead product demonstrations showcasing HEDIS performance analytics, care gap identification, and quality improvement capabilities.
Articulate how Cotiviti's solutions address NCQA HEDIS certification requirements.
Cotiviti is a healthcare analytics company. They focus on improving healthcare outcomes and reducing costs through data-driven solutions, serving health plans and providers. Cotiviti values diversity and inclusivity, and they are an equal opportunity employer.
Answer incoming calls and schedule patient appointments.
Verify patient dental insurance benefits by contacting insurance carriers.
Assist with onboarding new staff and manage employee schedules.
20four7VA connects offshore independent contractors with clients worldwide, particularly in developed markets. They focus on providing high-quality, task-specific services to improve business efficiency for their clients.
Conduct audits comparing medical record documentation to reported codes.
Research, interpret and communicate federal and state laws and guidelines pertaining to CMS and Medicare.
Provide feedback, education, training, and technical support with regard to proper documentation guidelines, service selection, charge capture, supervision and coding principles.
Privia Health is a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems to optimize physician practices, improve patient experiences, and reward doctors for delivering high-value care in both in-person and virtual settings. Their platform consists of scalable operations and end-to-end, cloud-based technology that reduces unnecessary healthcare costs, achieves better outcomes, and improves the health of patients and the well-being of providers.
Assist in drafting, reviewing, and revising contracts to ensure accuracy and compliance.
Support negotiations by preparing documentation and analyzing proposed terms.
Maintain centralized systems for tracking contract status, renewals, and compliance requirements.
Teleios Collaborative Network (TCN) appears to be an organization focused on healthcare and committed to anti-racism, diversity, equity, and inclusion. They aim to foster a safe and transformational environment for staff and patients.
Track and manage prior authorization requests, renewals, and extensions.
Verify member eligibility and benefits to confirm coverage requirements.
Upload, organize, and maintain member records and clinical documentation accurately and timely.
Leap is a benefits solution company focused on reshaping how life-changing therapies are delivered and financed. They are a fast-growing company that partners with Fortune 500 companies and leading TPAs, focusing on lower costs, improved access, and better care.
Researches requests for review of resolvable claims from providers.
Compiles information related to member appeals that request an Executive Review.
Provides copies of necessary documents and submits information to the Appeals and Policy Manager for review.
PEHP Health & Benefits is a division of the Utah Retirement Systems that serves Utah’s public employees through competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. They embrace both a public mission and a commitment to creating customer value.
Review encounter documentation to confirm reported services.
Resolve pre-bill edits to confirm correct coding (modifier, diagnosis, CPT, and HCPCS review).
Educate providers on correct coding and documentation guidelines.
Northwestern Medicine is committed to prioritizing every patient interaction to cultivate a positive workplace. Because of its patient-first approach, the company stands as a leader in the healthcare industry with competitive benefits that take care of its employees.
Ensure timely resolution and completion of payer enrollment.
Streamline processes and workflows for the onboarding department.
Work with internal and external stakeholders to resolve complex provider enrollment issues.
Privia Health collaborates with medical groups, health plans, and health systems to optimize physician practices and improve patient experiences. The Privia Platform consists of scalable operations and end-to-end, cloud-based technology.