Provide clinical review and correspondence for utilization management, including medical necessity reviews and member communications.
Collaborate with Medical Directors to ensure evidence-based decisions that meet NCQA and CMS standards.
Maintain productivity and quality while working 100% remotely in a fast-paced environment.
Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With over 250 employees, the company fosters a supportive, growth-oriented environment and has been named to the Inc. 5000 list and a Top 5 LinkedIn Startup.
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.
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.
Pulling, sorting, and analyzing data to determine member eligibility for the Population Health management Program.
Coordinating and providing care that is timely, effective, equitable, safe, and member-centric while following HMO processes.
Managing case assignments which includes outreach, documentation, monitoring for case progression, and case closure.
Guidehealth is a data-powered healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine. Guidehealth is a growing and innovative organization and employees are expected to adapt to evolving business needs.
Performs activities related to insurance company notifications and obtaining certifications/authorizations related to Utilization Review.
Communicates clinical information and updates to insurance companies as requested or required to justify medical necessity.
Liaises with third-party payers regarding UR requirements and assists with complex authorization needs impacting patient transition planning.
Phoebe Putney Health System is southwest Georgia’s preferred career choice for professionals who want to improve the community’s health by joining a respected, cutting-edge team. They are one of the area’s premier employers, offering a close-knit culture, outstanding benefits and many ways to develop your career.
Collaborate with physicians, APPs, and interdisciplinary team members to manage a patient panel and address specialized needs post-hospitalization.
Perform assessments and develop comprehensive care plans based on individual patient values, goals, and preferences.
Coordinate patient care delivery with clinicians, network providers, contracted vendors, and community-based services.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic approach. The company provides interdisciplinary clinical resources and analytical tools to improve patient outcomes, operating with a team that values innovation and comprehensive care.
Communicate and provide education to members and providers on insurance plan benefits and digital health solutions.
Employ active listening & motivational interviewing skills, and can handle difficult calls tactfully, courteously, professionally and document accordingly that can build patient trust and engagement.
Accurately track and document work on a variety of internal software tools and platforms.
Evry Health is on a mission to bring humanity to health insurance. They are a high-technology health plan that expands benefits, increases access and transparency, and features a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL) with more than 3,000 corporate employees and 15,000 agents.
Nurse conducts clinical review of cases not meeting criteria by performing clinical intake.
Adjudicates (closes), requests additional clinical information or escalates to Medical Directors.
Active PRC and USRN License required with 2 years Bedside Experience.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact.
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.
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.
Provide exceptional care, disease management and health education to patients.
Support goal setting for individual patients asynchronously to help them better manage their chronic conditions.
Create personalized action plans with guidelines to reduce or eliminate unwanted behaviors.
Salvo Health is a new approach to help millions of Americans facing chronic health conditions, centered on chronic gut health and metabolic conditions from IBS to obesity. They bring multidisciplinary virtual care to patients at community specialty care practices. Salvo offers a competitive salary and health benefits, a remote work environment, flexible time-off, a larger sense of mission, and professional development and entrepreneurial opportunities.
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.
Coordinate care and collaborate with multiple disciplinary team members to improve the quality of care and clinical outcomes.
Conduct thorough assessments to determine unmet needs and develop individualized care plans.
Promote quality cost-effective outcomes with the goal of improved care coordination.
Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services. They strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships.
Provides clinical oversight and medical necessity reviews for home health, DME, and related services using evidence-based guidelines.
Conducts peer to peer consultations and adverse determinations when clinical criteria are not met to support quality outcomes.
Collaborates with health plan leadership, participates in committees, and achieves SLA metrics for client performance guarantees.
CareCentrix provides clinical oversight and utilization management for home health, DME, home infusion therapy, and sleep medicine services. The company has an award-winning culture that values care, integrity, excellence, and innovation, operating with a drug-free workplace and equal opportunity commitment.
Monitor and interpret patient vitals, assessments, and alerts within Welby Health’s platform.
Develop, implement, and adjust individualized care plans that address both clinical and social needs.
Deliver patient education and coaching via telephone and secure messaging.
Welby Health is committed to transforming the way complex conditions are managed. They aim to advance patient outcomes by integrating efficient care coordination, data-driven insights, and enhanced communication across the care continuum. Welby Health is headquartered in San Diego.
Ensures that transitional needs and barriers are resolved in a timely manner to meet regulatory timeframes.
Interacts directly with providers and their staff to obtain clinical information, and with members or their advocates to understand transition needs.
Reviews information and makes recommendations to the collaborative team based on analysis of clinical material.
Mass General Brigham Health Plan is at the forefront of transformation with one of the world’s leading integrated healthcare systems. They provide members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.
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.
Conducting virtual assessments, diagnoses, and evidence-based treatment for patients.
Managing and coordinating care for chronic conditions.
Providing preventive care, wellness counseling, and health education.
Curai Health aims to transform healthcare using AI and clinical expertise to make care more affordable and accessible. They are a mission-driven team committed to collaboration and driving meaningful impact in healthcare.
Supports clinical safety, accuracy, and oversight of integrated AI tools by reviewing AI-assisted outputs and surfacing risks.
Applies nursing judgment to review charts, calls, messages, and other member interactions to assess quality, safety, and member experience.
Assists with data collection and basic analysis for quality and safety work, and participates in cross-functional improvement efforts.
Included Health is a healthcare company delivering integrated virtual care and navigation. They are on a mission to raise the standard of healthcare for everyone, and offer members care guidance, advocacy, and access to personalized virtual and in-person care.