Source Job

• Processes acute and post-acute inpatient medical or behavioral health and select intensive outpatient higher level of care requests through review of the submitted request and applicable clinical records
• Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination, and with Care Management staff on discharge planning and transition of care activities.
• Identifies and refers members with complex needs to the appropriate population health and/or care management program.

Capital Blue Cross promises to go the extra mile for our team and our community. Our employees consistently vote us one of the “Best Places to Work in PA, and we foster a flexible environment where your health and wellbeing are prioritized.

• Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes.
• Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process.
• Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.

Virtua Health strives to connect individuals to the care they need, building a healthier community in South Jersey. They are a Magnet-recognized health system with over 14,000 colleagues, including over 2,850 doctors, physician assistants, and nurse practitioners.

The Cardiovascular Program Specialist (CVPS) will provide expert clinical support, education, and training to physicians, nurses, and hospital staff on the use of DaVinci cardiac surgery, devices and therapies. This role partners closely with the sales team, specifically the Cardiovascular Sales Manager (CVSM) to ensure safe and effective product adoption while driving positive patient outcomes. This role is part of a small team of strategic sales professionals across the country who are focused on developing cardiac surgeons, and all those associated with cardiac programs.

At Intuitive, we are united behind our mission: we believe that minimally invasive care is life-enhancing care.

• Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity.
• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers.
• Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times.

Judi Health offers full-service health benefit management solutions to employers, TPAs, and health plans, and Judi® the industry’s leading proprietary Enterprise Health Platform (EHP). Together with our clients, they’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve.

• 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 offers specialty revenue cycle management solutions for healthcare organizations, leveraging industry expertise and its E360 RCM intelligent automation platform. EnableComp has received the Top Workplaces award multiple times and was recognized as Black Book's #1 Specialty Revenue Cycle Management Solution provider in 2024 and is among the top one percent of companies to make the Inc. 5000 list of the fastest-growing private companies in the United States for the last eleven years.