Review all assigned OASIS assessments for accuracy, completeness, and consistency.
Validate diagnosis coding and sequencing per CMS guidelines.
Identify and correct errors impacting reimbursement, quality measures, or compliance.
They are responsible for coding, reviewing, validating, and correcting OASIS assessments to ensure clinical accuracy, regulatory compliance, and optimal reimbursement. This is an adaptive, remote-friendly role designed to scale with agency census and workflow needs.
Responsible for ensuring that the Value Hub adheres to regulatory standards, contract requirements, and internal quality benchmarks.
Analyzing compliance data, preparing detailed reports, and working closely with various departments to maintain and improve compliance and quality standards.
Supporting the understanding of local regulatory requirements, completion of local audits, participation in quality committees, and supporting health plan needs and interactions to ensure consistent implementation of contractual obligations.
CommonSpirit Health has more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services. They are committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside their hospitals and out in the community.
Be responsible for department quality audit process related to service standards, adherence to procedural, regulatory and financial requirements.
Review the referral of, submit, monitor and track all subrogation referrals receive by the Claim department and forwarded to external vendors.
Handle overpayment, check void and refunds, including maintenance of the overpayment log.
Berkley Accident and Health is a risk management company that designs innovative solutions to address the unique challenges of each client. With its entrepreneurial culture and a strong emphasis on analytics, they can help employers better manage their risk.
Manage telephone, electronic, and face-to-face interactions professionally and efficiently.
Effectively present and discuss products and services to customers with integrity and accuracy.
Focus on customer retention by resolving concerns and enhancing the member experience.
Capital Blue Cross is committed to going the extra mile for their team and community. They are a caring team of supportive colleagues where your health and wellbeing are prioritized.
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.
Lead the oversight of all delegated activities to ensure compliance with CMS, and NCQA requirements.
Serve as the subject matter expert in interpreting compliance and regulatory requirements.
Direct pre-delegation audits, annual audits, required reporting and ongoing oversight of delegates.
Hackensack Meridian Health helps patients live better, healthier lives, and helps team members succeed. They have a culture rooted in connection and collaboration, and employees are considered team members. They are advancing their mission to transform healthcare and serve as a leader of positive change.
Performs routine and complex audits on phone calls and claims adjudication.
Researches claim processing problems and errors to determine their origin and appropriate resolution.
Provides prompt customer service to members, providers, billing departments, and other insurance companies regarding claims.
University of Utah Health is an integrated academic healthcare system with five hospitals, community health centers, and a health plan. It is nationally ranked and recognized for academic research, quality standards and overall patient experience with over 1,600 providers.
Serve as a subject matter expert and coach to QA staff and leaders across multiple states, promoting consistent quality practices and continuous improvement.
Facilitate regular meetings with state QA leaders to review performance goals, challenges, and improvement opportunities.
Analyze QA metrics, KPI dashboards, and audit findings to identify trends and areas for operational improvement.
Dungarvin is dedicated to enhance the quality of life for people with intellectual and developmental disabilities, including those with mental health, behavioral, or complex medical needs. Dungarvin has services nationwide, and is united by a shared commitment to making a real difference.
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.
Lead end-to-end investigations into compliance and ethics.
Translate complex regulations into practical guidance.
Identify systemic risks and ensure robust remediation.
Rula is dedicated to treating the whole person and aims to create a world where mental health is embraced as an integral part of one's overall well-being. They are a remote-first company that is dedicated to having a culture of inclusion that will support their employees.
Manage multiple channel interactions professionally and efficiently.
Effectively present products/services to providers with integrity, understanding, and accuracy.
Focus on provider retention through first call resolution and maintain positive relationships.
Capital Blue Cross promises to go the extra mile for its team and community. Employees consistently vote it one of the “Best Places to Work in PA”, valuing professional/personal growth by investing heavily in training and continuing education.
Ensure the highest level of quality in customer support interactions and internal processes.
Contribute to improving customer satisfaction, agent performance, and operational efficiency.
Monitor and provide feedback to improve customer and patient satisfaction.
Privia Health is a technology-driven, national physician enablement company. They collaborate with medical groups, health plans, and health systems to optimize physician practices and improve patient experiences.
Assists in the maintenance of structures and processes which support improvement and patient safety.
Uses clinical knowledge in formal and informal consultation with individual staff, clinicians and managers, to address clinical quality and safety concerns.
Participates in clinical adverse event task groups.
Dartmouth Health is a nationally recognized Academic Medical Center set in the White Mountains of New Hampshire, stretching over New Hampshire and Vermont. They offer a rigorous, research-focused environment and are anchored by the academic Dartmouth Hitchcock Medical Center in Lebanon, NH.
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.
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.
Applies systems analysis skills and inductive reasoning skills to determine health care organizations' degree of compliance.
Engages health care organization staff in interactive dialogues on standards-based issues.
Prepares management reports that clearly link individual standards deficiencies with potential systems vulnerabilities.
They are seeking an Acute Care Registered Nurse with Leadership experience in quality, accreditation and/or regulations. They offer comprehensive benefits for their employees for full-time and part-time positions.
Perform in-depth quality audits on customer support calls and email cases.
Ensure accuracy of information and professionalism in customer interactions.
Propose documentation updates to enhance the Customer Service Representative (CSR) experience.
Evry Health aims to bring humanity to health insurance with high-technology health plans that expand benefits, increase access and transparency, and feature a personalized, human approach. They are the major medical division of Globe Life (NYSE:GL), which has 16.8 million policies in force, more than 3,000 corporate employees and 15,000 agents.
Conduct operational, compliance, financial and investigative audits.
Review audit work papers and communicate the results of projects.
Identify audit issues and recommend improved internal controls.
Humana Inc. is committed to putting health first – for our teammates, our customers and our company. Through Humana insurance services and CenterWell healthcare services, they make it easier for the millions of people they serve to achieve their best health.
Work in a partially remote environment, collaborating with team members virtually each day.
Serve as a Subject Matter Expert (SME) on quality improvement measures, customer needs, and payer‑specific quality initiatives across commercial and government programs.
Conduct proactive patient outreach to identify and close quality gaps—educating patients, scheduling screenings, supporting treatment plan adherence, and improving outcomes.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers.
Responsible for coordination of services for members, emphasizing education/self-management and quality care. \n- Assesses member needs, reviews service options, develops and implements care plans, and coordinates resources. \n- Manages a caseload of moderate-high risk members with complex medical/behavioral/psychosocial needs.
Capital Blue Cross is committed to improving the health and well-being of our members and the communities in which they live. They offer flexibility, prioritize health and well-being, and encourage employees to volunteer in their community.