Provide telephonic case management and utilization review for assigned consumers.
Develop, implement, and monitor individualized care plans to ensure quality and cost-effective outcomes.
Collaborate with healthcare providers, payors, and internal teams to coordinate care.
Cottingham & Butler helps clients through life's toughest moments by providing insurance and benefits solutions. The company fosters a culture of continuous improvement, seeking to hire, train, and grow the best professionals in the industry.
Provides active care management and coordinates action plans for members.
Evaluates outcomes and ensures accurate documentation of clinical information.
Serves as member advocate and promotes enrollment in care management programs.
BlueCross BlueShield of South Carolina is a leading health insurance company and administrator of government contracts. With an A+ rating and a diverse family of subsidiaries, they are the largest insurer in South Carolina and employ a dedicated team focused on outstanding customer service.
Assess, plan, implement, and coordinate comprehensive care plans to meet individual health needs and ensure cost-effective healthcare delivery.
Serve as a liaison facilitating collaboration among patients, families, physicians, and providers to promote quality of care.
Provide specialized education on disease-specific conditions and remain current with medical trends and procedures.
Arkansas Blue Cross and Blue Shield is a health insurance company providing healthcare coverage and services. They are consistently ranked as a top workplace in Central Arkansas with an inclusive culture and average employee tenure of 10 years.
Provide comprehensive case management services including assessing client needs, developing care plans, coordinating services, and monitoring progress.
Collaborate with healthcare professionals, insurance companies, and stakeholders to ensure seamless care coordination and favorable outcomes.
Maintain accurate documentation, educate clients and families on self-management, and stay current with industry best practices.
MVP Health Care is a not-for-profit health plan provider focused on creating a healthier future through innovation and equity. For over 40 years, they have served New York and Vermont communities with high-quality health plans and have been recognized as a Best Place to Work.
Act as the primary point of contact for patients, healthcare providers, and program stakeholders.
Manage patient access, reimbursement, and therapy support processes.
Build trusted relationships with healthcare professionals and ensure coordinated care.
A healthcare services organization that partners with patients and providers to navigate complex treatment processes. The culture is purpose-driven, collaborative, and inclusive, with an emphasis on improving health outcomes.
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 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.
Responsible for using assessment and communication skills to engage patients in need of clinical support, determine priorities, and deliver patient-centered care.
Identify patient education needs through telephonic assessment and collaborate with healthcare teams to coordinate care and keep patients stable at home.
Serve as point of contact for patients, families, and providers, implementing interventions to improve health outcomes and reduce costs.
Vytalize Health is a value-based healthcare company that coordinates care for patients with chronic conditions, aiming to improve outcomes and lower costs. It is a rapidly growing organization with a startup culture, offering a dynamic environment.
Implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center.
Functions within the multidisciplinary team to secure complex pre-authorizations and prevent/appeal clinical denials.
Utilizes clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided.
The Ohio State University is a top-20 public university with one of America’s leading academic health centers. They are a team of dedicated colleagues with access to boundless resources.
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.
Perform clinical reviews and conduct peer-to-peer discussions.
Participate in inter-rater reliability activities and clinical rounds.
Serve as a clinical resource and subject matter expert to clinical and non-clinical staff.
Devoted Health is a healthcare company that aims to improve the health and well-being of older Americans through a data and AI-driven care platform. The company values diversity, collaboration, and a supportive work environment, and is an equal opportunity employer.
Processes referral requests and authorizations for patients, ensuring timely and accurate scheduling.
Communicates with physicians, employers, and payors to coordinate specialist referrals and obtain necessary information.
Maintains high standards of quality and patient experience while meeting production requirements.
Concentra operates over 500 medical centers and 130 onsite clinics nationwide, focusing on providing high-quality healthcare to improve the health of America's workforce. The company emphasizes a culture of outstanding patient experience and customer service.
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.
Complete biopsychosocial assessments to identify clinical, behavioral, and social needs.
Proactively identify and resolve care gaps in patient records, ensuring timely clinician review.
Coordinate referrals, follow-up appointments, and community-based care support services.
Knownwell provides weight-inclusive healthcare for all, offering weight management, primary care, nutrition counseling, and health coaching. They are backed by $50M in funding, scaling fast to expand access to evidence-based obesity care nationwide.
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.
Provide telephone support to patients, healthcare professionals, and funding organizations regarding access, reimbursement, compliance, and support programs.
Manage assigned patient cases and projects while following established operational processes and service standards.
Maintain accurate case documentation within program databases, ensuring all activities and interactions are properly recorded.
This role is posted on behalf of a partner company, which manages all applications and next steps. The company focuses on healthcare support and improving patient access to therapies, with a collaborative culture and opportunities for professional growth.
Manage a personal caseload end-to-end, planning diaries to meet service and customer needs.
Deliver holistic biopsychosocial assessments and develop vocational rehabilitation plans.
Build strong relationships with members through telephone, video, and face-to-face assessments.
Legal & General is a leading UK financial services group and major global investor, providing retirement and protection solutions. It serves approximately 12.8 million policyholders and workplace members with a focus on lifelong financial journeys and a supportive culture.
Manage a docket of workers' compensation cases to resolution.
Prepare clients for depositions and attend depositions.
Respond to client inquiries requiring attorney negotiation and move matters towards resolution.
We are a leading employment and workers' compensation law firm dedicated to advocating for employees' rights. We foster a dynamic and collaborative work environment where professionals can grow while making a meaningful impact.
Conduct medical risk assessments by analyzing clinical data, case management notes, and treatment plans to evaluate underwriting outcomes and financial exposure.
Partner strategically with underwriting teams to prioritize requests, apply evidence-based criteria, and advise on complex claims to influence underwriting decisions.
Manage relationships with internal clients, TPAs, and vendors, ensuring data integrity, accurate reporting, and clear communication of risk conclusions.
Crum & Forster provides property & casualty, accident & health, specialty and standard commercial lines insurance solutions. With 3,000 employees and a financial strength rating of A+ by AM Best, the company is consistently recognized as a great place to work, earning multiple workplace and wellness awards.