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 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 (SDVOSB), they empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth.
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 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 (SDVOSB), they empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth.
Evaluate hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
Guide timely care determinations using CMS regulations and evidence-based practices while collaborating with care management teams and external providers.
Conduct timely medical necessity determinations for inpatient admissions and post-acute settings.
HJ Staffing is urgently seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. This physician leader will play a critical role in ensuring the clinical integrity of inpatient and post-acute care reviews, evaluating medical necessity to support optimal outcomes and regulatory compliance.
Assigns ICD-10 and CPT Codes and performs charge reconciliation.
Cooper University Health Care is committed to providing extraordinary health care. They are continuously discovering clinical innovations. Cooper offers career growth through professional development and is the employer of choice in South Jersey.
Review documentation to assign appropriate CPT, HCPCS, and ICD-10 diagnosis codes
Resolve edits in WQs (charge review, claim edit, and follow up) and review denials for possible corrected claims or appeals
Work with clinic supervisors and/or providers to resolve coding issues and questions, following applicable payer rules and guidelines
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 our hospitals and out in the community.
Perform in-depth medical claim reviews using UB-04 and itemized statements.
Verify itemized charge accuracy based on policy and industry standards.
Validate system denials and suggest system enhancements for efficiency.
Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. They bring together an AI-powered platform, are deployed by over 85 health plans, and represent more than 270 million lives.
Ensuring the accuracy, integrity, and quality of coding practices within the HIM department.
Conducting thorough reviews of clinical documentation, coding, and billing processes to ensure compliance.
Educating and training coding staff on best practices and updates in coding guidelines.
Cooper University Health Care is committed to providing extraordinary health care. They focus on clinical innovations and access to facilities, equipment, technologies and research protocols, and offer competitive rates, compensation programs, benefits, and career growth.
Demonstrates knowledge of basic audit skills and adheres to Internal Audit Standards and UPH Internal Audit policies and methodologies.
UnityPoint Health is committed to their team members and has been recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row. They champion a culture of belonging where everyone feels valued and respected, and believe in equipping you with support and development opportunities to deliver an exceptional employment experience.
Performs Current Procedural Terminology (CPT) and International Classification of Diseases, volume 10 (ICD10) coding through abstraction of the medical record.
Trains physicians and other staff regarding documentation, billing and coding, and performs various administrative and clerical duties to support the roles core function.
Acts as a key collaborator with Providers and Clinical areas to ensure the medical record accurately reflects the patient's service.
At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. As an integral part of their team, you'll have the opportunity to join their quest for better health care, no matter where you work within the Northwestern Medicine system.
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 provides Specialty Revenue Cycle Management solutions for healthcare organizations. They leverage over 24 years of expertise and their E360 RCM ™ platform to improve financial sustainability for hospitals, health systems, and ambulatory surgery centers. EnableComp is a multi-year recipient of the Top Workplaces award recognized as Black Book's #1 Specialty Revenue Cycle Management Solution provider in 2024.
Utilizes technical coding expertise to assign appropriate ICD-10-CM and CPT-4 codes to outpatient visit types.
Reviews the medical record thoroughly, utilizing all available documentation to code appropriate diagnoses and procedures
Interprets health record documentation using knowledge of anatomy, physiology, clinical disease process, pharmacology, and medical terminology to report appropriate diagnoses and/or procedures.
Northwestern Medicine is committed to a patient-first approach, setting them apart as a leader in healthcare. They pride themselves on providing competitive benefits, from tuition reimbursement and loan forgiveness to 401(k) matching and lifecycle benefits, aiming to care for their employees.
Maintain a working knowledge and understanding of DMEOPS CPT and ICD-10 codes.
Utilize the company billing and collections system to identify and resolve any claims that have been unpaid, short paid and/or denied.
Review EOB's and other correspondence from insurance companies for correct reimbursement according to rules and regulations and contract terms.
Hanger, Inc. is the world's premier provider of orthotic and prosthetic (O&P) services and products, offering the most advanced O&P solutions, clinically differentiated programs and unsurpassed customer service. They have 160 years of clinical excellence and innovation, and its vision is to lead the orthotic and prosthetic markets by providing superior patient care, outcomes, services and value.
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.
Complete timely review of healthcare services using appropriate medical criteria to support determinations.
Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make great healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages Healthguides™ and a Managed Service Organization to build stronger connections with patients and providers.
Performs the final reconciliation on clinic or provider visits.
Reviews, abstracts, and codes multiple or sub specialty services and complex or unusual cases, and assigns appropriate coding classifications.
Interacts with coding staff, business office, providers, hospital staff, clinic managers, and other clinical personnel on billing related issues.
University of Utah Health is a patient-focused organization that enhances the health and well-being of people through patient care, research, and education. They are a Level 1 Trauma Center and are nationally ranked and recognized for their academic research and quality standards.
Accurately translate patients’ medical records into standardized codes for diagnoses and treatments.
Ensure compliance with legal, regulatory, and organizational standards.
Ensure claims are processed correctly and on time with efficient management of records.
Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. As an affiliate of Dignity Health, they work hand-in-hand with physicians and providers throughout California to provide comprehensive health care services.
Audit patient medical records using clinical, coding, and payer guidelines to ensure accurate reimbursement.
Provide clear, evidence-based rationale for code recommendations or reconsiderations to providers or payers.
Collaborate with team leaders to ensure thorough review of DRG denials.
Machinify is a healthcare intelligence company delivering value, transparency, and efficiency to health plan clients. They deploy a configurable, AI-powered platform and best-in-class expertise, serving over 85 health plans representing more than 270 million lives.
Organizes and prioritizes assigned work to ensure completion within the assigned time frame.
Reviews charts and medical records, assigning ICD and CPT code combinations to each data element.
Audits for documentation opportunities and queries clinical staff to fill in any gaps.
Riverside Health System's mission is to care for others as we would care for those we love. We extend that sense of caring to every patient, resident and customer, as well as to each member of our team, offering care at all stages of life, in hundreds of locations.
Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs.
Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals.
Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance.
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. They serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes and have a mission to empower people to lead healthier lives.
Coordinate and support the hospital’s Utilization Review and Case Management program.
Review patient charts and clinical documentation to verify medical necessity.
Monitor patient progress and coordinate care management strategies.
NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. With hospitals in Indiana, Michigan, Texas, and Arizona, they’re expanding access to their unique model of care across the United States.