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.
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.
Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
Apply payer-specific guidelines and internal policies to support clear, defensible clinical narratives.
Meet assigned turnaround times and document findings accurately in designated systems.
CorroHealth helps clients exceed their financial health goals through scalable reimbursement solutions and clinical expertise, leveraging technology and analytics. The company builds long-term careers by investing in professional development and personal growth, fostering a culture of accountability and success.
Represent Included Health at industry events, showcasing expertise in clinical navigation and virtual care.
Develop and deliver engaging educational sessions on general health and well-being.
Collaborate with the sales team to highlight the value of clinical services during client meetings.
Included Health is an integrated virtual care and navigation company on a mission to raise the standard of healthcare for everyone. They break down barriers to provide high-quality care for every person and offer care guidance, advocacy, and access to personalized care.
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.
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.
Provide call-based care to members in Perry Health's Remote Patient Monitoring (RPM) program.
Evaluate medical history and data to determine member eligibility for the clinical program.
Collaborate with the broader care team to reinforce clinical goals and SMART goal progression.
Perry Health is rethinking chronic care through a fully remote, continuous care model. They provide expert diabetes education and clinical management for Medicare patients, delivered by a comprehensive team. They value diversity and aim to create an environment where team members can thrive.
Respond to questions from primary care clinicians on a HIPAA-compliant platform.
Ensure recommendations are educational, cost-effective, and evidence-based.
Participate in product interviews and voluntary projects.
RubiconMD is a web-based electronic consultation platform connecting primary care clinicians with medical specialists. They aim to improve patient care and reduce unnecessary referrals by providing same-day insights from a network of specialists.
Serve as the lead clinical liaison for partner providers across multiple regions.
Partner with PRMs on clinic visits and ongoing relationship management to strengthen long-term program engagement.
Translate field insights into actionable intelligence for clinical, product, and engineering teams, directly informing service improvements and care model refinement.
Cadence is a clinical AI company that delivers continuous, proactive care for older adults with chronic conditions. They pair patients with a dedicated clinical team and integrate deeply into health system EMRs and workflows.
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.
Oversee prior authorization technicians and administrative PA functions.
Analyze data and provide staffing, workflow, and system enhancement recommendations.
Investigate/resolve escalated issues from clients and providers.
Judi Health is an enterprise health technology company providing a suite of solutions for employers and health plans. They have a comprehensive Enterprise Health Platform that consolidates all claim administration-related workflows in one scalable, secure platform.
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.
Analyze denied insurance claims and apply clinical reasoning to determine appeal merit.
Draft persuasive, medically sound appeal letters to recover denied revenue.
Collaborate with legal team to ensure appeals are compelling and complete.
Ternium specializes in resolving complex healthcare insurance claim denials and delays for hospitals. They have a dedicated, mission-driven team and value diversity and inclusion.
Provide supervisory oversight for Physician Assistants in a primary care setting.
Serve in a collaborative, non‑clinical capacity focused on supervision and compliance.
Maintain availability and responsiveness to supervised providers.
Optima Medical is an Arizona-based medical group with 30 locations and over 130 medical providers, caring for more than 200,000 patients statewide. We aim to improve the quality of life throughout Arizona by helping communities live better and longer through personalized healthcare.
Review and validate all assigned OASIS assessments for accuracy, completeness, and internal consistency.
Code and sequence diagnoses per ICD-10 and CMS guidelines to ensure optimal reimbursement.
Provide clear, actionable feedback to field clinicians with a focus on education and process improvement.
Adaptive Home Health builds a higher-acuity, patient-centered home health model across Michigan. The company operates in a tech-forward environment with strong operational support.
Conduct video-based appointments for non-emergency issues, treating patients in internal medicine and related areas such as urgent care, gynecology, and obesity care.
Design personalized treatment plans supported by current clinical guidelines and record encounters using efficient EHR tools for accurate follow-up and prescriptions.
Collaborate remotely with other clinicians to deliver coordinated, high-quality care and stay updated on telehealth standards and evolving best practices.
DrHouse is building a new model of virtual healthcare that is fast, accessible, and centered on both patient and provider experience. They are a rapidly expanding digital health company with a diverse, mission-driven community of clinicians committed to equitable healthcare access.
Deliver high-quality virtual urgent and primary care to patients of all ages, conducting examinations, evaluations, and treatment plans.
Maintain accurate patient records, order and interpret diagnostic tests, and collaborate with provider and support teams.
Provide scheduling flexibility including evenings, weekends, and holiday shifts, with a minimum of 32 hours per week.
Included Health delivers integrated virtual care and navigation, aiming to raise the standard of healthcare for everyone by breaking down barriers to provide high-quality care across acute, chronic, behavioral, and physical needs. The company operates as a new kind of healthcare company offering personalized virtual and in-person care, with a focus on inclusivity and community impact.
Provide executive oversight of all clinical programs, including Behavioral Health and EAP services, establishing strategic direction and quality frameworks.
Lead and supervise AVP-level clinical leaders, ensuring accountability and cross-functional alignment across clinical operations.
Develop clinical strategies, policies, and procedures, oversee utilization management, and drive quality improvement initiatives.
Uprise Health transforms the delivery and accessibility of mental and behavioral healthcare, bringing whole person care to individuals worldwide. The company values compassion, integrity, collaboration, velocity, and advocacy, and seeks to foster a culture of care and support.
Direct and oversee operations of the Enhanced Care Management program, including CalAIM performance and staff supervision.
Refine program policies, manage P&L, and develop KPIs to align performance with business objectives.
Collaborate cross-functionally with other departments and represent the organization externally.
Vynca provides comprehensive care for more quality days at home for individuals with complex needs. It is a close-knit community guided by core values of Excellence, Compassion, Curiosity, and Integrity, fostering a transformative movement.
Coordinate end-to-end provider credentialing and re-credentialing processes with commercial and government payers.
Support payer contracting activities, including data collection, application submission, and follow-up.
Maintain accurate provider credentialing files in accordance with regulatory and accreditation standards.
Sunrise Group builds the future of sleep health by combining breakthrough technology with expert care. Backed by more than $50M, their team of 100+ clinicians, engineers, and operators across the US and Europe is dedicated to making high-quality sleep care accessible to everyone.