Perform clinical reviews for medical necessity, level of care, and authorization compliance.
Prepare and submit high-quality appeals related to DRG downgrades and clinical validation denials.
Apply payer-specific guidelines and document review findings accurately in designated systems.
CorroHealth helps clients exceed their financial health goals through scalable revenue cycle solutions and clinical expertise. The company builds long-term careers by investing in team members' professional development and personal growth.
Review and analyze Medicare claims sampled by the Department of Justice to determine correct coding and payment based on coverage and utilization.
Conduct in-depth claims analysis to detect fraudulent or abusive billing practices using ICD-10, CPT-4, and CMS guidelines.
Complete summary reports and communicate findings internally while maintaining confidentiality and compliance with DOJ and CMS regulations.
Empower AI provides AI-powered solutions for federal government agencies, helping them transform their workforce and operations. Headquartered in Reston, Va., the company has three decades of experience in Health, Defense, and Civilian missions and is recognized as a 2024 Military Friendly Employer.
Review medically complex claims, pre-authorization requests, appeals, and fraud and abuse referrals.
Assess payment determinations using clinical information and established guidelines.
Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
Broadway Ventures transforms challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, we empower clients with tailored solutions, operating with integrity and collaboration.
Review medical records to develop concise clinical reviews supporting authorization and reimbursement.
Facilitate communication with payors to ensure appropriate utilization management decisions.
Collaborate with interdisciplinary team to prevent denials and optimize patient care.
West Virginia University Health System is West Virginia’s largest health system, providing comprehensive healthcare services. With over 35,000 employees and 25 hospitals, it is the state's largest employer and offers a collaborative, patient-centered culture.
Conduct complex medical review of Medicare claims for Inpatient Rehabilitation Facility services.
Perform pre-claim review determinations and evaluate Additional Documentation Request responses.
Communicate determinations to providers and meet production-driven turnaround requirements.
Broadway Ventures is a small business that provides program management, technology, and consulting solutions to government and private sector clients. As a Service-Disabled Veteran-Owned Small Business, they emphasize integrity, collaboration, and excellence.
Review, analyze, and complete pre- and post-payment claim audits and appeals in accordance with client policies, CMS guidelines, and healthcare industry standards.
Apply clinical judgment to evaluate documentation and determine the appropriateness and accuracy of claims.
Analyze healthcare claims, reimbursement information, and supporting documentation to identify discrepancies and potential payment issues.
Our partner company focuses on ensuring healthcare claims are reviewed accurately, consistently, and in accordance with applicable policies and industry standards. It is a collaborative, fast-paced, and evolving environment with opportunities for professional development and career advancement.
Provide high-quality consulting services including clinical and regulatory compliance audits to long-term care facilities nationwide.
Manage assigned client facilities with emphasis on service quality, cost-effectiveness, and timely delivery of consulting visits.
Collaborate with teams and maintain effective communication with leadership about customer issues and industry regulations.
Assembly Health is a healthcare company providing clinical consulting services to long-term care facilities nationwide. The team is motivated, client-focused, and committed to excellence and integrity.
Validate accuracy of CPT, HCPCS, revenue codes, and billed line-item charges on outpatient and inpatient facility claims.
Review medical records and supporting documentation to confirm appropriate billing and apply CMS guidance, coding guidelines, and MUE/NCCI edits.
Prepare appeal responses using applicable coding guidance and assist with new concept development and claim selection criteria.
Trend Health Partners is a tech-enabled payment integrity company that facilitates collaboration between payers and providers to reduce waste and improve access to healthcare. It is a dynamic growing organization with a collaborative and innovative work environment.
Conduct utilization review to determine medical necessity of admission and continued stay using established criteria.
Collaborate with payers to secure authorization and work with multidisciplinary teams to reduce length of stay and readmissions.
Provide clinical data for denial management, appeal letter writing, and trend identification to improve processes.
OHSU is Oregon's only public academic health center, providing patient care, groundbreaking research, and training health professionals. As Portland's largest employer, we offer diverse opportunities in a system of hospitals and clinics, committed to building an anti-racist, multicultural institution.
Performing timely utilization review of healthcare services using approved medical necessity criteria.
Collaborating with medical directors, providers, and internal teams for compliant review processes.
Ensuring accurate documentation and communication of determinations within regulatory timeframes.
Guidehealth is a data-powered, performance-driven healthcare company focused on making healthcare affordable and improving patient health. It is a physician-led organization using AI and predictive analytics, with a culture of accountability, growth, innovation, and empathy.
Conducts redetermination reviews in compliance with Medicare rules.
Responds to appeals and writes professional correspondence.
Researches claims issues and submits educational referrals.
Broadway Ventures transforms challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As a small business focused on government and private sector clients, they foster integrity, collaboration, and excellence.