Conduct clinical reviews of inpatient admissions and continued stays using approved medical necessity criteria.
Collaborate with physicians, care managers, and payer teams to resolve utilization concerns and prevent denials.
Support quality improvement initiatives, maintain accurate documentation, and communicate review outcomes effectively.
This role is with a partner company focused on healthcare utilization management, helping hospitals improve patient outcomes and ensure appropriate resource use. The team operates as a distributed remote group supporting care coordination, revenue integrity, and clinical compliance.
Perform prospective, concurrent, and retrospective utilization review to ensure medical necessity and appropriate level of care.
Research and respond to appeals, coordinate discharge planning, and analyze care patterns.
Collaborate with providers and internal teams to resolve benefit and eligibility issues.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, helping them modernize operations and compete effectively. The company is expanding and investing in its people, offering opportunities to shape the future of healthcare technology.
Perform clinical reviews to evaluate medical necessity, level of care, and benefit coverage for members.
Apply internal policies, MCG, and NCCN guidelines to deliver timely and compliant utilization management decisions.
Escalate complex cases and build audit-ready documentation for Medical Director review.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. Their mission-driven culture empowers diverse perspectives to drive real impact on people's health.
Conduct clinical and billing reviews of claims, itemized bills, and UB-04 forms to ensure accuracy.
Perform utilization reviews to assess medical necessity and validate charges against policies.
Mentor reviewers, meet productivity targets, and maintain active RN licensure with CEUs.
Our partner is a healthcare services company that conducts medical claims and utilization reviews to ensure accurate billing and appropriate care. They offer a collaborative, quality-focused remote environment with opportunities for professional development.
Review, investigate, and appeal denied hospital insurance claims using clinical documentation and payer policies.
Develop evidence-based appeal letters addressing medical necessity, level-of-care, and charge discrepancies.
Collaborate with nursing, revenue integrity, and financial teams to resolve denials and prevent future rejections.
This partner company is a healthcare system that provides hospital services and focuses on revenue integrity. It supports fully remote work and values clinical expertise, collaboration, and financial sustainability.
Conduct comprehensive telephonic assessments and develop individualized care plans for patients with chronic conditions.
Use Motivational Interviewing to promote self-management and coordinate care with interdisciplinary teams.
Monitor biometric data and IVR trends to identify clinical risks and prevent hospitalizations.
The company provides telephonic nurse care management services for patients with chronic conditions, using technology-enabled care delivery. It has a mission-driven, collaborative culture focused on innovation and patient impact, with a fully remote team.
Coordinate interdisciplinary care plans and serve as a liaison between patients, providers, and insurance partners.
Provide telephonic nursing triage, health guidance, and on-call support according to agency protocols.
Manage lab results, referrals, prescription refills, and patient follow-up to ensure continuity of care.
Planned Parenthood of the Pacific Southwest provides sexual and reproductive healthcare across 20 health centers in Southern California. The organization fosters a collaborative, mission-driven culture with over 100 years of advocacy.
Lead, coach, and onboard Utilization Management nurses while managing daily workloads and escalations.
Ensure reviews and determinations are timely, accurate, and compliant with CMS and Clover policies.
Collaborate with Medical Directors and cross-functional teams to improve workflows and member outcomes.
Clover Health provides data-driven healthcare plans for seniors, using the Clover Assistant to support physician decisions. The company is a mission-driven team of diverse experts focused on improving members' quality of life.
Conduct nursing assessments and enroll patients in chronic care management programs.
Develop individualized care plans and coordinate transitions to improve outcomes.
Collaborate with providers and teams to support value-based care delivery.
Jobgether is an AI-powered job platform that matches candidates with hiring companies. It focuses on objective, efficient recruitment and partners with healthcare organizations.
Evaluate outpatient referrals and inpatient admissions for medical appropriateness.
Perform peer-to-peer discussions with providers and support utilization management processes.
Mentor UM nurses and contribute to clinical guideline development.
Clover Health is reinventing health insurance by combining data with human empathy to keep members healthier. It is a mission-driven company focused on providing high-quality, affordable healthcare for America's seniors.
Manage patient messages through the telehealth platform and address routine clinical questions within your nursing scope.
Escalate complex medical concerns, coordinate with providers, and ensure timely follow-ups.
Maintain accurate documentation, follow HIPAA protocols, and work independently in a fast-paced remote environment.
LumiMeds is a fast-growing U.S.-based telehealth startup focused on weight management and long-term metabolic health. It is an early-stage, remote-first company with a globally distributed team that values clarity, accountability, and initiative.
Conduct telephonic nursing assessments and triage using clinical protocols.
Provide health education and care recommendations to patients.
Collaborate with remote RNs to meet quality and performance metrics.
Carenet Health delivers telephonic clinical assessments, health education, and utilization management services. They are a growing, collaborative company with a nationwide remote team of registered nurses.
Audit medical summaries, timelines and record classifications against source records.
Write clinical review guidelines and gold-standard examples for research and engineering teams.
Flag clinically significant omissions, causation issues and prior-history findings.
Brighterway builds AI-native claims software and administration for casualty claims, starting with workers' compensation medical-legal review. The team is small, technical, and close to customers, with everyone shipping and talking directly to users.
Work independently to make clinical decisions on routine patient care matters at your license level.
Provide patient-focused care and guidance on the phone or online, accurately assessing needs and directing to appropriate care.
Communicate with clients and team members, monitor performance metrics, and document all interactions via management software.
Carenet Health provides telehealth and virtual care clinical triage, health education, and other services to diverse populations of patients and health plan members. As one of America's fastest-growing private companies, it partners with over 250 premier health plans and health systems, with compassion-focused teams guiding people via phone, video, and chat.
Assess patients' immediate and long-term needs through evaluation of social and medical history.
Develop and continuously evaluate individualized plans of care in collaboration with the interdisciplinary team.
Act as a patient advocate, coordinating resources, ensuring compliance, and negotiating cost-effective quality care.
Independent Health provides innovative health care products and benefits designed to engage consumers in their health and well-being. The company serves nearly 400,000 members and fosters a culture of growth, innovation, and collaboration.
Evaluate AI-generated clinical interactions for accuracy, safety, and appropriateness.
Annotate and score AI responses against evidence-based protocols and structured rubrics.
Provide detailed written feedback and participate in calibration sessions to enhance AI reliability.
The company focuses on improving AI-powered clinical solutions by leveraging clinical expertise. It is an early-stage partner organization offering flexible, remote contract opportunities for healthcare professionals.
You ensure prior authorization requests are completed in a manner that meets contractual requirements using evidence-based standards.
You participate in the Utilization Management (UM) Care Programs.
You evaluate medical records and health care data to interpret and apply policies and regulations.
Central California Alliance for Health is an award-winning regional Medi-Cal managed care plan that provides health insurance for children, adults, seniors and people with disabilities in Mariposa, Merced, San Benito and Santa Cruz counties. We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation.
Analyze and summarize medical records, highlighting relevant clinical findings for attorneys.
Prepare medical chronologies and long-term care assessments to support case evaluations.
Provide objective, evidence-based medical insights and coordinate with expert witnesses.
The partner company provides specialized legal nurse consulting services to attorneys, analyzing medical records and supporting injury-related cases. This role offers flexible, part-time contract work in a fully remote environment.
Lead UM decisions, clinical oversight, and complex case reviews for medical necessity.
Conduct peer-to-peer payer reviews to support authorizations and overturn denials.
Educate providers on documentation, identify gaps, and support audit response.
Council Capital is a healthcare-focused private equity firm based in Nashville, TN, managing over $350M in committed capital. We invest in lower middle market healthcare companies and support founders through our Council Model of operators, investors, and value creation experts.
Clarity Pediatrics is a virtual clinic reimagining pediatric chronic care, starting with ADHD and expanding to obesity and overweight management. It is a fast-growing startup with a remote-friendly culture and a leadership team committed to clinical excellence.