Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes.
Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process.
Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
Virtua Health strives to connect individuals to the care they need, building a healthier community in South Jersey. They are a Magnet-recognized health system with over 14,000 colleagues, including over 2,850 doctors, physician assistants, and nurse practitioners.
Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity.
Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers.
Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times.
Judi Health offers full-service health benefit management solutions to employers, TPAs, and health plans, and Judi® the industry’s leading proprietary Enterprise Health Platform (EHP). Together with our clients, they’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve.
Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
Guide timely care determinations using CMS regulations and evidence-based practices.
Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
HJ Staffing is seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. The company has not provided any information about its size/employees and culture but is likely a medium to large medical or staffing company.
Appeal denied claims through Redetermination, Reconsideration, or Administrative Law Judge processes, following laws.
Proactively investigate patient charts by reading documents and conduct computer-based research.
Solventum is a new healthcare company with a history of tackling major challenges to improve lives and support healthcare professionals. They focus on innovative solutions at the intersection of health, material, and data science and are guided by empathy and clinical intelligence.
Processes acute and post-acute inpatient medical or behavioral health and select intensive outpatient higher level of care requests through review of the submitted request and applicable clinical records
Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination, and with Care Management staff on discharge planning and transition of care activities.
Identifies and refers members with complex needs to the appropriate population health and/or care management program.
Capital Blue Cross promises to go the extra mile for our team and our community. Our employees consistently vote us one of the “Best Places to Work in PA, and we foster a flexible environment where your health and wellbeing are prioritized.
Performing physician-level utilization management reviews for behavioral health services across all applicable levels of care.
Conducting peer-to-peer consultations with treating psychiatrists and other behavioral health providers.
Serving as a consultative clinical resource to behavioral health utilization management nurses, care managers, and operational leaders.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and AI, they leverage remotely-embedded Healthguides™ and a centralized Managed Service Organization.
Conduct comprehensive coding reviews to ensure accuracy in code 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's clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. The Coherenauts who succeed here are empathetic and believe diverse, inclusive teams make the most impactful work.
Serve as the vendor’s lead clinical subject matter expert on clinical denials management and prevention.
Partner with provider clients to design and implement best practices for denial prevention and appeal workflows.
Conduct complex clinical case reviews for DRG validation, identifying and defending clinically appropriate DRG assignments.
EnableComp offers specialty revenue cycle management solutions for healthcare organizations, leveraging industry expertise and its E360 RCM intelligent automation platform. EnableComp has received the Top Workplaces award multiple times and was recognized as Black Book's #1 Specialty Revenue Cycle Management Solution provider in 2024 and is among the top one percent of companies to make the Inc. 5000 list of the fastest-growing private companies in the United States for the last eleven years.
Support clinical staff by gathering data to complete the medical necessity review process.
Create and send letters to providers and/or members to communicate information.
Collaborate with care management teams and stakeholders to provide optimal service.
Wellmark is a mutual insurance company owned by policy holders across Iowa and South Dakota, and they’ve built their reputation on over 80 years’ worth of trust. They are motivated by the well-being of their members, putting them first and committing to sustainability and innovation.
Develop, maintain, and execute complex inpatient coding audit processes.
Design and deliver clinical coding education and training programs.
Partner with staff to resolve audit findings and improve coding accuracy.
CRD Careers is a boutique recruitment agency specializing in Sales and HR placements. We connect growth-minded companies with high-impact professionals who drive real results. This company's approach is precise, people-first, and built for long-term success.
Execute payer enrollment applications from credentialing approval through payer confirmation.
Coordinate CAQH profile maintenance and attestations in alignment with Medallion workflows and payer requirements.
Track enrollment status, follow up with payers, and escalate delays or issues to the Payer Enrollment Manager.
Spring Health aims to eliminate barriers to mental health by delivering the right care at the right time through their clinically validated technology, Precision Mental Healthcare. They partner with over 450 companies and are valued at $3.3 billion.
Review and refine AI-generated clinical summaries and indicators related to medical necessity.
Collaborate with Product and Data Science teams to define and validate clinical logic.
Translate clinical knowledge into prompts and guidelines for large language models.
SmarterDx builds clinical AI that is transforming how hospitals translate care into payment. Founded by physicians in 2020, their platform connects clinical context with revenue intelligence, helping health systems recover millions in missed revenue, improve quality scores, and appeal every denial.
Prepare and submit credentialing and enrollment packets.
Maintain accurate provider files and track expirations.
Provide assistance to the billing team during staff absences.
Modena Health and Modena Allergy & Asthma are leading medical practices specializing in allergy, asthma, and immunology care, with clinics across Southern California and Arizona and plans for national expansion. They are physician-led and technology-enabled, committed to transforming allergy care while advancing clinical research and expanding access to cutting-edge medicine.