Conduct clinical reviews of medical records to determine medical necessity and payer compliance.
Evaluate denial cases including appeals, audits, and no-authorization determinations.
Develop evidence-based clinical rationales aligned with payer and regulatory guidelines.
This partner company provides clinical review and healthcare reimbursement support services. The team is remote and operates in a fast-paced, performance-driven environment.
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established guidelines.
Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
Broadway Ventures delivers tailored solutions that drive operational success, sustainability, and growth for government and private sector clients. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), they empower clients with expert program management, cutting-edge technology, and innovative consulting solutions.
Review clinical documentation and treatment trajectory to ensure care meets medical necessity standards.
Synthesize clinical documentation, medical record information, and outcomes data to make recommendations on next steps in care.
Partner cross-functionally to support high-quality, clinically appropriate care across the network.
Rula is dedicated to treating the whole person and aims to create a world where mental health is no longer stigmatized. They are a remote-first company committed to providing quality, evidence-based, and compassionate care, empowering individuals to take charge of their mental health.
Review patient charts and documentation against defined coverage criteria.
Work with internal AI software that enables review productivity and apply structured processes to determine documentation sufficiency.
Produce clear, standardized written summaries of review outcomes and meet daily throughput and quality targets.
Verse Medical is building the modern software infrastructure to make hospital-quality care accessible everywhere. They're a well-funded Series C company, backed by notable investors, on a mission to heal a fragmented system by connecting providers, payors, and patients.
Performs activities related to insurance company notifications and obtaining certifications/authorizations related to Utilization Review.
Communicates clinical information and updates to insurance companies as requested or required to justify medical necessity.
Liaises with third-party payers regarding UR requirements and assists with complex authorization needs impacting patient transition planning.
Phoebe Putney Health System is southwest Georgia’s preferred career choice for professionals who want to improve the community’s health by joining a respected, cutting-edge team. They are one of the area’s premier employers, offering a close-knit culture, outstanding benefits and many ways to develop your career.
Review and process appeals submitted by members and providers, ensuring timely and accurate resolution.
Evaluate cases, determine next steps, and manage multiple priorities while meeting strict turnaround times.
Review clinical and medical records, summarize findings for Medical Director review, and operate within turnaround times as short as 24–72 hours.
BlueCross BlueShield of Tennessee has been helping Tennesseans find their own unique paths to good health since 1945. At BCBST, they empower their employees to thrive both independently and collaboratively, creating a collective impact on the lives of their members.
Nurse conducts clinical review of cases not meeting criteria by performing clinical intake.
Adjudicates (closes), requests additional clinical information or escalates to Medical Directors.
Active PRC and USRN License required with 2 years Bedside Experience.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact.
Manages medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.
Utilizes clinical background to address the clinical denials, as well as write sound, compelling factual arguments for appealing denials.
Responsible for maintaining a detailed knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria, as well as filing compliant appeals.
Shriners Children’s respects, supports, and values each other. They are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact and were named as the 2025 best mid-sized employer by Forbes.
Provide health assessments and treatment solutions via telephone, video, or chat functions.
Receive inbound phone calls from patients seeking answers to various medical conditions.
Stay up to date with current health trends and recommendations.
PWNHealth is a national clinician network improving early disease detection and prevention using advanced diagnostics and telehealth, serving all 50 states and Puerto Rico. They are a mission-driven company with a positive culture, backed by leading growth equity firms Spectrum Equity and the Blue Venture Fund (BVF).
Provide independent medical documentation review and functional capacity analysis to support RA determinations under the Rehabilitation Act of 1973 and aligned with EEOC.
No patient care, no medical exams, record based review only (paper file review).
Ability to clearly communicate medical findings in written form for non-clinical review.
AdNet/AccountNet, Inc. is an 8(a), WOSB, and WBE-owned management consulting firm founded in 1990. We blend the best people with the ongoing demands of the workplace by providing high-quality staffing and executive search services.
Supports clinical safety, accuracy, and oversight of integrated AI tools by reviewing AI-assisted outputs and surfacing risks.
Applies nursing judgment to review charts, calls, messages, and other member interactions to assess quality, safety, and member experience.
Assists with data collection and basic analysis for quality and safety work, and participates in cross-functional improvement efforts.
Included Health is a healthcare company delivering integrated virtual care and navigation. They are on a mission to raise the standard of healthcare for everyone, and offer members care guidance, advocacy, and access to personalized virtual and in-person care.
Provides nursing assessments within the standards outlined in the state Nurse Practice Act.
Provides clinical assessments and health education using telecommunications in accordance with protocols and guidelines.
Uses the nursing process to identify patient care needs, risk and safety issues, and appropriate health care referrals.
Carenet Health delivers patient-centric healthcare solutions. We foster a collaborative team of RNs across the country and are committed to creating an inclusive environment for all employees.
Pulling, sorting, and analyzing data to determine member eligibility for the Population Health management Program.
Coordinating and providing care that is timely, effective, equitable, safe, and member-centric while following HMO processes.
Managing case assignments which includes outreach, documentation, monitoring for case progression, and case closure.
Guidehealth is a data-powered healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine. Guidehealth is a growing and innovative organization and employees are expected to adapt to evolving business needs.
Evaluates member health metrics and professional resources to inform UM/CM initiatives and programs.
Refers members and providers to G.E.H.A resources and programs, as indicated, maximizing their health plan benefits.
Monitors and evaluates program effectiveness, tracks relevant metrics, and reports outcomes.
Government Employees Health Association (G.E.H.A) is a nonprofit member association providing health and dental benefits to millions of federal employees and retirees since 1937. G.E.H.A is headquartered in Lee's Summit, Missouri, offering hybrid and work-from-home options for many roles.