Processes acute and post-acute inpatient medical and select intensive outpatient higher level of care requests through clinical review.
Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies to requests.
Collaborates with UM department staff and Medical Directors to make a final determination, and with Care Management staff on discharge planning.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. At Capital, employees work alongside a caring team of supportive colleagues and are encouraged to volunteer in their community.
Analyze, define, and document business requirements on assigned work streams.
Translate clinical and operational needs into clear and actionable business requirements for Product, Engineering and Service Operations teams.
Partner with clinical, operations, product, technology, and analytics teams to align on solution design and delivery.
Transcarent is a health and care platform, bringing medical, pharmacy, and point solutions together. They empower health consumers with more choice, access to higher-quality care, and lower costs for 21 million members, serving over 1,700 employers and health plans.
Analyze data to assist in the design of Value Based Programs.
Develop analytic and/or report requirements that support informed decisions regarding strategy initiatives.
Help identify, research, and resolve operational and other business issues relating to value-based programs and initiatives.
Capital Blue Cross is committed to the health and well-being of its members and communities. They have been voted as one of the “Best Places to Work in PA” and foster a flexible environment where employees are encouraged to volunteer and grow professionally.
Elicit, document, and validate business and functional requirements from clinical and operational stakeholders
Write detailed user stories, acceptance criteria, and process flow diagrams for engineering
Serve as a liaison between clinical SMEs, product managers, and development teams throughout delivery
Oddball believes that the best products are built when companies understand and value the things they are working on. They value learning and growth and the ability to make a big impact at a small company.
Participate in provider case reviews to identify trends and deficits.
Coach providers and participate in client meetings to support expectations.
Contribute to workflow design, QA improvements, and risk management.
Amwell transforms healthcare with technology and people. They aim to provide convenient, affordable, and effective care, serving large healthcare organizations in the U.S. and worldwide.
Responsible for planning and executing quality and oversight activities to ensure operational compliance.
Responsible for internal and external case audits for Capital and our delegated UM vendors.
Responsible for educating staff on findings, and the audit tool ensuring a consistent approach.
Capital Blue Cross promises to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”
Develop functional test scripts and facilitate testing sessions for system integration.
Articulate technical designs to developers, ensuring interface specifications are understood.
Maintain Epic Bridges interfaces for reliable integration and data exchange.
Lucile Packard Children’s Hospital Stanford combines advanced technologies and breakthrough discoveries with family-centered care. They provide their caregivers with continuing education and state-of-the-art facilities.
Support clinical operations: Help build and maintain the workflows that get patients and therapists onto the platform smoothly and quickly.
Track key operational metrics: Monitor and report on the metrics that matter most — retention, NPS, clinical outcomes, and billing performance.
Contribute to care coordination and product feedback loops: Work with clinical and product teams to translate frontline data into insights.
Sailor Health aims to solve the mental health crisis among older adults by connecting them to therapists and AI-powered care agents covered by Medicare. They are growing quickly and partnered with Medicare to offer psychotherapy to hundreds of patients, backed by founders of large healthcare companies.
Analyze and support non-clinical workflows across CM, CDM, and UM programs.
Translate operational and clinical requirements into process maps, SOPs, and job aids.
Support workflow automation and system optimization initiatives.
Personify Health created a personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. They serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes.
Define and champion a bold vision for our internal clinical tooling platform.
Partner with Product, Engineering, and Clinical leadership to define the 6-12 month product roadmap.
Design modular components and frameworks that empower clinical leadership to rapidly experiment with new care protocols.
Included Health delivers integrated virtual care and navigation and is on a mission to raise the standard of healthcare for everyone. They break down barriers to provide high-quality care for every person in every community. They are an Equal Opportunity Employer.
Conduct quality audits of inpatient clinical determinations to ensure alignment with clinical guidelines and quality standards
Analyze QA findings and translate insights into actionable recommendations for operational leaders and cross-functional partners
Provide coaching and feedback to improve clinical decision accuracy, guideline adherence, and overall team performance
Cohere Health delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. They work with over 660,000 providers and are backed by leading investors such as Deerfield Management. The coherenauts who succeed there are empathetic teammates who are candid, kind, caring, and embody their core values and principles. Cohere is deeply invested in ensuring that they have a supportive, growth-oriented environment that works for everyone.
Provide clinical leadership and subject-matter expertise to support the analysis, configuration, and administration of complex medical policy content within claims processing systems.
Ensure the accurate implementation of medical policies, review criteria, and authorization requirements, while maintaining the integrity of system infrastructure and serving as a key liaison between business and technical teams.
Research and analyze system and business issues, develop high-level requirements, test and implement solutions, and audit and document outcomes.
Wellmark is a mutual insurance company owned by policy holders across Iowa and South Dakota, built on over 80 years of trust and motivated by member well-being, not profits. They are committed to providing best-in-class service, sustainability, and innovation.
Review and analyze data to assess validity of data and clinical risk.
Act as a strategic partner to underwriting by applying evidence-based criteria and sound clinical judgment to evaluate complex clinical and claims data.
Develop, maintain, and manage strong relationships with internal and external clients, Third-Party Administrators (TPAs), and vendors.
Crum & Forster’s Accident & Health division offers specialty insurance and reinsurance products. They focus on product development, creative distribution methods, client service and support and recorded $741M in gross premium written at year-end 2023.
Provide clinical expertise during complex sales cycles, addressing clinical objections.
Collaborate with internal measurement and data teams to develop end-to-end analytics models.
Develop compelling case studies and sales collateral that highlight data-driven clinical impact.
DrFirst empowers providers and patients to achieve better health through intelligent medication management. They improve healthcare workflows and help patients start and stay on therapy with end-to-end solutions. They have over 420,000 prescribers, 71,000 pharmacies, 270 EHRs and health information systems, and over 2,000 hospitals in the U.S.
Support the MPG Manager – MES in advancing Medicaid Enterprise Systems modernization initiatives.
Serve as a Business Analyst and MES Subject Matter Expert, supporting requirements gathering, analysis, and documentation.
Assist in the development of core MES deliverables and artifacts, including requirements and analysis documentation.
BerryDunn helps businesses, nonprofits, and government agencies throughout the US and its territories solve their greatest challenges. They are a client-centered, people-first professional services firm with a mission to empower the meaningful growth of their people, clients, and communities.
Provides direction and support for on-going program development.
Aligns multiple departments and staff to foster interdepartmental collaboration across the full continuum of care.
Develops program goals and objectives to ensure efficient and cost effective operations consistent with the program's mission and standards.
University of Utah Health is focused on enhancing the health and well-being of people through patient care, research, and education. As a Level 1 Trauma Center, they are nationally ranked and recognized for their academic research, quality standards and overall 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.
Bridge the gap between business needs and IT solutions, by understanding and translating requirements into functional specifications.
Collaborate with stakeholders, gather and analyze business requirements, identify improvement opportunities, and document specifications.
Facilitate communication and support testing, demonstrating exceptional analytical, problem-solving, and communication skills.
CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually.
Responsible for the design, build, testing, validation, maintenance and ongoing support of Epic Radiant.
Works across interdisciplinary workgroups to accomplish set goals as a team.
Functions as business partner with service lines, departments, individuals, and coworkers.
Emory Healthcare is a healthcare system that provides comprehensive medical services. They are committed to providing reasonable accommodations to qualified individuals with disabilities and offer a supportive environment.