Review and evaluate electronic medical records of emergency department admissions to screen for medical necessity using InterQual or MCG criteria.
Apply evidence-based clinical guidelines to assess and ensure proper utilization of healthcare resources.
Enter clinical review information into the system for transmission to insurance companies for authorization.
Netsmart provides advanced healthcare technology solutions for post-acute and human services clients, enabling better care through a comprehensive platform. We are a vision-driven team passionate about innovation, and we have been recognized as one of the best companies to work for.
Perform clinical reviews and conduct peer-to-peer discussions.
Participate in inter-rater reliability activities and clinical rounds.
Serve as a clinical resource and subject matter expert to clinical and non-clinical staff.
Devoted Health is a healthcare company that aims to improve the health and well-being of older Americans through a data and AI-driven care platform. The company values diversity, collaboration, and a supportive work environment, and is an equal opportunity employer.
Manage care for high-risk members by identifying needs and coordinating clinical, community, and in-network resources.
Perform utilization management reviews, ensure quality oversight, and support accreditation readiness.
Collaborate with multidisciplinary teams to analyze member outcomes and drive continuous improvement.
They are a health plan focused on improving outcomes for high-risk members through care coordination and quality initiatives. Their team values collaboration, clinical excellence, and mission-driven work to enhance community health.
Set daily direction for your UM team, establishing priorities and reinforcing expectations.
Coach reviewers on criteria application, guiding consistent use of medical-necessity criteria.
Monitor workflow health daily, tracking intake volume and turnaround risk.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. The team is on a mission to empower people to lead healthier lives.
Complete assigned medication utilization reviews and medical necessity appeals for commercial and governmental clients.
Provide peer-to-peer support to physicians and prescribers regarding clinical programs and utilization review decisions.
Actively participate in developing utilization management criteria and clinical policy revisions.
Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including pharmacy benefit management and health benefit management. They are rebuilding trust in healthcare in the U.S. and deploying infrastructure for better care, but no specific employee size or culture details are provided.
Provides medical interpretation and clinical review for appropriateness of services, including Home Care Solutions, Skilled Nursing Facility, Durable Medical Equipment, rehabilitation, and discharge planning.
Advises executives on functional strategies related to OneHome initiatives and clinical priorities, exercising independent judgment on complex issues.
Ensures compliance with CMS guidelines, Medicare/Medicaid requirements, and Humana policies while supporting quality, utilization management, and care coordination.
Humana is a leading U.S. healthcare company providing insurance and healthcare services through its Humana insurance and CenterWell healthcare services. It is a large, publicly traded organization with a culture focused on the Humana Way, emphasizing collaboration, accountability, and improving member experiences.
Conduct approximately 20 telehealth visits per day with homebound Medicare patients.
Serve as the supervising and collaborating physician for a pod of nurse practitioners and physician assistants.
Review and sign care plans, conduct chart audits, and train care coordinators.
Ennoble Care provides mobile primary care, palliative care, and hospice services in multiple states, offering a continuum of care for patients with chronic conditions. They are a healthcare organization focused on home-based care, with a team that values their motto 'To Care is an Honor.'
Applies approved utilization criteria to monitor appropriateness of admissions and continued stay reviews.
Communicates with third-party payers for initial and concurrent clinical review to ensure medical necessity.
Tracks length of stay and resource utilization to identify at-risk patients and supports appeals on denied cases.
University of Utah Health is a patient-focused healthcare organization dedicated to enhancing health and well-being through patient care, research, and education. It is a nationally ranked Level 1 Trauma Center with five hospitals and eleven clinics, fostering a culture of collaboration, excellence, and respect.
Review Home Health prior authorization requests using CMS guidelines and clinical judgment.
Lead and mentor the Home Health UM nursing team, ensuring quality and compliance.
Collaborate with cross-functional partners to optimize care and improve utilization.
Clover Health provides high-quality, affordable healthcare for America's seniors by combining data, technology, and preventive care. They are a mission-driven team with diverse expertise, focused on improving members' lives through innovation and empathy.
Perform medical claims audit reviews with a focus on the Home Health sector, applying medical review guidelines and documenting findings.
Collaborate with the audit team to identify vulnerabilities, generate audit letters, and support findings during appeals.
Maintain knowledge of coding systems (ICD-10, CPT-4, HCPCS) and regulatory changes to ensure high-quality, deadline-driven work.
Machinify is a leading healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients using an AI-powered platform. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, the company fosters a collaborative, fast-paced remote culture.
Manage UM nurse team performance, SLAs, and quality improvement.
Handle escalated UM cases and provider disputes 25% of time.
Partner with clients, medical directors, and IDTs to ensure consistent decision-making.
IntusCare builds an end-to-end ecosystem for Programs of All-Inclusive Care for the Elderly (PACE) to improve care, financial performance, and compliance. As a healthcare technology company, we empower teams to improve outcomes for dual-eligible seniors.
Provide clinical guidance and support to a Virtual Nurse Practitioner in CA, ensuring high-quality patient care.
Ensure compliance with evidence-based clinical guidelines and protocols tailored to telemedicine.
Participate in case reviews, clinical audits, and quality improvement initiatives to maintain superior care standards.
Sprinter Health is an on-demand mobile health service that sends medical professionals to patients’ homes to perform blood draws, diagnostic and low acuity services, and wellness visits. We have a rapidly growing team of visionary leaders who are passionate about increasing access to care.
Serve as primary physician reviewer for Utilization Management (UM) cases, advising other reviewers and attending daily calls with health plan teams.
Establish 2-3 cases per day for up to 6 markets, ensuring attendance on health plan calls and weekly meetings.
Participate in Process and Quality improvement in delegated Utilization Management, utilizing excellent analytical and deductive reasoning skills.
ChenMed is a family-owned, physician-led primary care provider focused on improving healthcare for moderate-to-low-income seniors. The company is rapidly expanding, with a culture of innovation, kindness, and making a difference.
Provide clinical leadership and medical oversight for audit programs involving governmental and commercial payer claims.
Evaluate medical necessity, level of care, coding accuracy, and documentation sufficiency using payer policies and clinical standards.
Support audit methodologies, clinical validation frameworks, and quality assurance to ensure regulatory alignment and defensibility.
Machinify is a leading healthcare intelligence company delivering value, transparency, and efficiency to health plan clients. Deployed by over 85 health plans representing more than 270 million lives, they bring an AI-powered platform alongside best-in-class expertise.
Ensures prior authorization requests meet contractual requirements and are reviewed using evidence-based standards.
Performs concurrent or retrospective review of acute in-patient care services using established criteria.
Participates in Utilization Management Care Programs.
Central California Alliance for Health is a regional non-profit health plan providing accessible, quality health care guided by local innovation to members in five California counties. The organization employs over 500 dedicated employees in a respectful, diverse, professional, and fun culture.
Own first-level reviews of pre-certification requests for medical appropriateness and necessity.
Drive post-service reviews and manage the appeals process for non-certified services.
Coordinate smooth discharges and redirect care in-network to keep patients on track.
Personify Health created the first personalized health platform, bringing health plan administration, wellbeing solutions, and care navigation together in one place. Their team serves employers, health plans, and health systems with a mission to empower people to lead healthier lives.
Performs clinical evaluations on disability claims to substantiate medical necessity for absence.
Communicates with employees and providers to discuss clinical status and provides follow-up recommendations.
Acts as a clinical resource to claims examiners, ensuring accurate medical terminology and claim decisions.
Sedgwick is the world's leading risk and claims administration partner, helping clients navigate the unexpected with AI-enabled technology and expertise. With over 33,000 colleagues and 10,000 clients across 80 countries, they've been recognized as a Great Place to Work and offer a caring culture.
Supervise daily operations of clinical compliance auditors and specialists.
Assist in developing coordinated team processes and managing UM and PHM plan adherence.
Serve as clinical services liaison to senior management and ensure timely documentation.
Guidehealth is a data-powered healthcare company focused on operational excellence and value-based care. They emphasize empathy, AI, and collaboration, with a remote-first culture.
Support clinicians with patient coordination tasks including pharmacy communication, referrals, and scheduling.
Provide empathetic, patient-centered communication and document tasks accurately in the electronic health record.
Ensure compliance with HIPAA and confidentiality standards while participating in team huddles and quality initiatives.
Curai is a healthcare company that harnesses artificial intelligence and clinical expertise to make high-quality primary care more affordable, accessible, and effective. They are a mission-driven, remote team committed to diversity and inclusion.
Review patient records and clinical documentation to determine eligibility accurately.
Communicate with patients, clinicians, and providers to ensure a smooth onboarding process.
Maintain records in EMR systems and manage multiple cases simultaneously.
Our partner is a healthcare organization focused on improving patient access to specialized services. They operate with a remote, patient-focused team committed to efficient and compassionate care delivery.