Research and interpret payer policies in accordance with healthcare coding and regulatory requirements.
Identify common error areas that can be made into automated software logics that prevent overpayments.
Develop claims editing logics that promote payment accuracy and transparency across lines of business.
Rialtic is an enterprise software platform empowering health insurers and healthcare providers to run their most critical business functions. Founded in 2020 and backed by leading investors, they are tackling a $1 trillion problem to reduce costs, increase efficiency and improve quality of care.
Researching overpayments in instances where payors have paid more than the amount due, and fulfilling refund requests to our payors
Initiating and managing refunds once verified, and ensuring the appropriate steps are taken to return funds
Maintaining accurate records and keeping detailed documentation for transparency, audits, and process improvement
Grow Therapy aims to be the trusted partner for therapists growing their practice, and patients accessing high-quality care. They are a three-sided marketplace that empowers providers, augments insurance payors, and serves patients and have empowered more than ten thousand therapists and hundreds of thousands of clients across the country.
Perform comprehensive review and oversight of medical records for Risk Adjustment compliance keeping with CMS and departmental guidelines with a 95%+ accuracy rate
Collaborates with a variety of internal and external clients, including health care executives, physicians, provider office personnel, and payer representatives from various health plans to streamline and optimize accurate diagnosis code capture.
Reviews medical records and billing history to determine if specific disease conditions were correctly billed and documented.
Capital Blue Cross promises to go the extra mile for their team and community. Employees consistently vote them one of the “Best Places to Work in PA” and they recognize that work is a part of life, not separate from it, and foster a flexible environment.
Performs final reconciliation on clinic/provider visits, resolving documentation issues.
Reviews, abstracts, and codes multiple services and complex cases, assigning classifications.
Researches/resolves high volume accounts/claims and educates staff on guidelines.
University of Utah Health is a patient-focused organization with a mission to enhance the health and well-being of people through patient care, research, and education. They have five hospitals and eleven clinics and are known as a Level 1 Trauma Center, nationally ranked for academic research and patient experience.
Evaluate hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
Guide timely care determinations using CMS regulations and evidence-based practices while collaborating with care management teams and external providers.
Conduct timely medical necessity determinations for inpatient admissions and post-acute settings.
HJ Staffing is urgently seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. This physician leader will play a critical role in ensuring the clinical integrity of inpatient and post-acute care reviews, evaluating medical necessity to support optimal outcomes and regulatory compliance.
Interpret and apply CMS, Medicare, Medicaid, and AMA policies to define claims editing logic.
Analyze claims and edit performance data to confirm accuracy and prioritize enhancements.
Monitor regulatory updates and coding changes to keep edits current and compliant.
Machinify is a leading healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. They use an AI-powered platform with expertise across the payment continuum, serving over 85 health plans and 270 million lives.
Responsible for coding procedures and entering charges to comply with regulations and internal policies.
Coordinate with Practice Coordinator and Revenue Integrity to assure necessary documentation is present.
Participates in audits to evaluate code accuracy and develops methodologies to improve coding issues.
Northside Hospital is an award-winning and state-of-the-art healthcare provider that is continually growing. By constantly expanding the quality and reach of our care we hope to create even more opportunity for the best healthcare professionals in Atlanta and beyond.
Demonstrates knowledge of basic audit skills and adheres to Internal Audit Standards and UPH Internal Audit policies and methodologies.
UnityPoint Health is committed to their team members and has been recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row. They champion a culture of belonging where everyone feels valued and respected, and believe in equipping you with support and development opportunities to deliver an exceptional employment experience.
Codes and abstracts Inpatient records for data retrieval, analysis, reimbursement and research.
Codes diagnostic and procedure codes into a designated coding and abstracting system utilizing the 3M encoder, as appropriate.
Meets quality and productivity coding standards and demonstrates the ability to navigate an EMR.
CommonSpirit Health is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen both inside our hospitals and out in the community. With more than 700 care sites across the U.S., CommonSpirit is accessible to nearly one out of every four U.S. residents.
Auditing to ensure new provider and care center information is accurate.
Conducting Care Center audits based on the number of providers.
Identifying, monitoring, and managing denial management trends.
Privia Health is a technology-driven, national physician enablement company. They collaborate with medical groups, health plans, and health systems to optimize physician practices and improve patient experiences. Their platform is led by industry talent and cloud-based technology.
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 provides Specialty Revenue Cycle Management solutions for healthcare organizations. They leverage over 24 years of expertise and their E360 RCM ™ platform to improve financial sustainability for hospitals, health systems, and ambulatory surgery centers. EnableComp is a multi-year recipient of the Top Workplaces award recognized as Black Book's #1 Specialty Revenue Cycle Management Solution provider in 2024.