Review a variety of claim types including Radiology, Ambulance, Physical Therapy, and Surgical for medical necessity and coverage.
Document medical rationale for payment or denial decisions using Medicare guidelines and established criteria.
Educate internal and external staff on medical review, terminology, coverage determinations, and coding.
We transform 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 are built on integrity, collaboration, and excellence.
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established coverage guidelines.
Educate teams on medical review processes and support quality control activities.
Broadway Ventures is a veteran-owned small business delivering mission-critical support to federal health and defense customers. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it is built on integrity, collaboration, and excellence.
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.
Perform medical reviews and utilization management to determine medical necessity for services and appeals.
Evaluate medical records and document decisions using clinical guidelines and protocol sets.
Educate members, providers, and staff on coverage determinations, medical terminology, and coding procedures.
Palmetto GBA is a healthcare administrator and one of the nation's largest medical claims processors. As part of BlueCross BlueShield of South Carolina, we've served clients for 70+ years and offer training and tuition assistance.
Conduct comprehensive reviews of home health pre-claim review packages for Medicare compliance.
Document review outcomes with clinical rationale and meet a 7-business-day turnaround.
Maintain 98% accuracy and complete required training and quality assurance sessions.
Broadway Ventures is a consulting firm providing program management, technology, and innovative solutions to government and private sector clients. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it emphasizes integrity, collaboration, and excellence in its culture.
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.
Review and verify healthcare claims for accuracy, coding, eligibility, and coverage.
Approve or deny claims according to policy terms and regulations, and resolve discrepancies.
Process claims efficiently, meet performance targets, and maintain accurate records.
Blue Cross and Blue Shield of Kansas is a health insurance company providing coverage to Kansans. With over 80 years in the community, it fosters an inclusive, family-first culture and supports professional growth.
Coordinates utilization review and prior authorization requests, ensuring accurate entry into the UM platform.
Provides customer service to providers and members, confirming benefits and answering authorization questions.
Facilitates communication between reviewers, hospitals, and physicians to ensure timely decisions.
University of Utah Health Plans is a patient-focused organization that enhances health through patient care, research, and education. It is part of a nationally ranked academic medical center with five hospitals and eleven clinics, fostering a culture of collaboration and excellence.
Audit inpatient DRG, outpatient, and professional fee coding for accuracy and compliance.
Review up to 25 diagnoses and procedures per record, classify errors with references.
Deliver facility audit reports and lead training sessions for coding staff and clinicians.
Arrow ARC provides healthcare staffing and program support to Veterans Health Administration facilities across the U.S. It is a certified Service-Disabled, Veteran-Owned Small Business joint venture known for an agile, mission-focused, results-driven approach.
Conduct audits of medical records for compliance with federal coding regulations and guidelines.
Provide education and training to providers on CPT, ICD-10, and HCPCS codes.
Act as an internal expert to ensure coding compliance with state and federal regulations.
Privia Health is a technology-driven national physician enablement company collaborating with medical groups, health plans, and health systems. It aims to optimize physician practices and improve patient experiences through cloud-based technology and scalable operations.
Performs pre-admission, admission, and continued stay reviews using approved medical necessity criteria.
Coordinates patient care and communicates with physicians, patients, caregivers, and third-party payers.
Manages patient progression through the healthcare system and proactively works with payers to secure certification and minimize denials.
Ochsner Health is a leading not-for-profit healthcare provider in the Gulf South, with 46 hospitals and 370+ care centers. It employs more than 38,000 team members and has been recognized as a top workplace and the No. 1 hospital in Louisiana.
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.
Conduct independent coding audits of inpatient, outpatient, and professional fee services across multiple specialties.
Analyze sampled medical records to identify and substantiate coding, documentation, and compliance errors.
Provide targeted education and train-the-trainer sessions to strengthen coding practices.
This company provides medical coding auditing and validation services for Veterans Affairs medical centers, supporting healthcare data quality and compliance. It operates in a mission-driven environment focused on improving coding accuracy for veteran-serving facilities.
Review appeals of adverse benefit determinations within federal and state regulatory timeframes.
Apply medical policy, coding guidelines, and contractual requirements to assess coverage decisions.
Collaborate with medical divisions and respond to state insurance department inquiries regarding benefit complaints.
Arkansas Blue Cross and Blue Shield is a health insurance provider serving Arkansas. It is consistently ranked as one of the best places to work in Central Arkansas, with an inclusive culture and an average employee tenure of 10 years.
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.
Perform concurrent medical record reviews on nursing units to clarify patient documentation.
Prompt physicians to resolve missing, unclear, or conflicting documentation for appropriate reimbursement.
Provide education to patient care providers on clinical documentation standards and coding requirements.
Virginia Mason Franciscan Health provides a full spectrum of health care services across the Puget Sound region, with a legacy of compassionate care and innovation. With 10 hospitals and nearly 300 care sites, the organization is dedicated to healing the whole person through rigorous research, education, and collaboration.
Review and abstract professional medical records to ensure accurate code assignment.
Assign ICD-10-CM, CPT, HCPCS, and modifiers per national and payer-specific guidelines.
Maintain coding quality, compliance, and productivity standards while staying current on updates.
Sprinter Health reimagines access to care by bringing it directly to patients' homes via technology. It has supported 2M+ patients across 22 states, completed 130,000+ visits, raised over $125M, and maintains a 92 NPS.