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.
Performs utilization review to determine medical necessity criteria compliance and facilitates resolution of escalated cases.
Collaborates with clients and physician reviewers, ensuring adherence to all HIPAA, state, federal, and regulatory standards like URAC & NCQA.
Utilizes various computer systems to manage cases, engages in provider communication, and participates in quality management programs while prioritizing independent work.
WNS, part of Capgemini, is an AI-powered leader in intelligent operations and transformation, serving over 700 clients across industries like Healthcare and Financial Services. It is a large global company with over 66,000 employees, combining deep domain expertise with AI platforms to create lasting business value.
Supervise day-to-day operations of assigned Utilization Management staff.
Provide full people management for assigned Utilization Management teams, including hiring and performance management.
Drive team performance against key metrics, including engagement, productivity, and quality scores.
Personify Health has created a personalized health platform, bringing health plan administration, wellbeing solutions, and care navigation together. Their data-driven solutions aim to reduce costs while improving health outcomes, empowering people to lead healthier lives.
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.
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.
Perform telephonic symptom assessment and triage using evidence-based protocols to ensure appropriate care and disposition.
Document patient interactions accurately in the EMR and educate callers on virtual care, provider referrals, and available community resources.
Deliver excellent customer service while maintaining confidentiality, sound judgment, and effective communication with diverse populations.
UnityPoint Health is committed to team members and has been recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare. They champion a culture of belonging where everyone feels valued and respected, honoring the ways people are unique and embracing what brings us together.
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.
Communicate and provide education to members and providers on insurance plan benefits and digital health solutions.
Employ active listening & motivational interviewing skills, and can handle difficult calls tactfully, courteously, professionally and document accordingly that can build patient trust and engagement.
Accurately track and document work on a variety of internal software tools and platforms.
Evry Health is on a mission to bring humanity to health insurance. They are a high-technology health plan that expands benefits, increases access and transparency, and features a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL) with more than 3,000 corporate employees and 15,000 agents.
Management and oversight of a quality team conducting quality assurance activities.
Responsible for the successful execution of the Quality Improvement Program in accordance with CMS requirements.
Plans, organizes, and directs activities of Clinical Quality, including planning, training, and staff development.
HealthEdge is committed to workforce diversity and actively encourages all qualified persons to seek employment. They provide effective and efficient solutions to complex business problems.
Manage relationships for clients with varying levels of complexity and take ownership of resolving client issues.
Lead regular client meetings, maintain action logs, and manage project plans for moderate to complex projects.
Analyze client benefits strategy and suggest improvements, identifying opportunities for increased member participation.
HealthEquity's mission is to save and improve lives by empowering healthcare consumers. We are passionate about providing solutions that allow American families to connect health and wealth, and we value our employees.