Perform concurrent inpatient utilization review using InterQual criteria to determine medical necessity.
Engage in clinical collaboration with physicians and care teams to support appropriate level-of-care decisions.
Maintain documentation, comply with regulations, and ensure quality customer service.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations serving over 700 clients across 10 industries. With over 66,000 employees across 13 countries and 65 delivery centers, the company combines scale and expertise to create meaningful impact.
Perform concurrent and retrospective reviews on all facility and appropriate home health services.
Monitor level and quality of care and proactively manage acutely and chronically ill patients.
Act as liaison to Plan Medical Director and coordinate interdisciplinary approach.
Curana Health is a national leader in value-based care for senior living communities and skilled nursing facilities. Founded in 2021, they serve 200,000+ seniors in 1,500+ communities across 32 states with a team of over 1,000 clinicians.
Performs activities related to insurance company notifications and obtaining certifications/authorizations related to Utilization Review.
Communicates clinical information and updates to insurance companies as requested or required to justify medical necessity.
Liaises with third-party payers regarding UR requirements and assists with complex authorization needs impacting patient transition planning.
Phoebe Putney Health System is southwest Georgia’s preferred career choice for professionals who want to improve the community’s health by joining a respected, cutting-edge team. They are one of the area’s premier employers, offering a close-knit culture, outstanding benefits and many ways to develop your career.
Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
Apply payer-specific guidelines and internal policies to support clear, defensible clinical narratives.
Meet assigned turnaround times and document findings accurately in designated systems.
CorroHealth helps clients exceed their financial health goals through scalable reimbursement solutions and clinical expertise, leveraging technology and analytics. The company builds long-term careers by investing in professional development and personal growth, fostering a culture of accountability and success.
Provide clinical review and correspondence for utilization management, including medical necessity reviews and member communications.
Collaborate with Medical Directors to ensure evidence-based decisions that meet NCQA and CMS standards.
Maintain productivity and quality while working 100% remotely in a fast-paced environment.
Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With over 250 employees, the company fosters a supportive, growth-oriented environment and has been named to the Inc. 5000 list and a Top 5 LinkedIn Startup.
Conduct clinical reviews of medical records to determine medical necessity and payer compliance.
Evaluate denial cases including appeals, audits, and no-authorization determinations.
Develop evidence-based clinical rationales aligned with payer and regulatory guidelines.
This partner company provides clinical review and healthcare reimbursement support services. The team is remote and operates in a fast-paced, performance-driven environment.
Evaluates member health metrics and professional resources to inform UM/CM initiatives and programs.
Refers members and providers to G.E.H.A resources and programs, as indicated, maximizing their health plan benefits.
Monitors and evaluates program effectiveness, tracks relevant metrics, and reports outcomes.
Government Employees Health Association (G.E.H.A) is a nonprofit member association providing health and dental benefits to millions of federal employees and retirees since 1937. G.E.H.A is headquartered in Lee's Summit, Missouri, offering hybrid and work-from-home options for many roles.
Analyze denied insurance claims and apply clinical reasoning to determine appeal merit.
Draft persuasive, medically sound appeal letters to recover denied revenue.
Collaborate with legal team to ensure appeals are compelling and complete.
Ternium specializes in resolving complex healthcare insurance claim denials and delays for hospitals. They have a dedicated, mission-driven team and value diversity and inclusion.
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 delivers tailored solutions that drive operational success, sustainability, and growth for government and private sector clients. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), they empower clients with expert program management, cutting-edge technology, and innovative consulting solutions.
Nurse conducts clinical review of cases not meeting criteria by performing clinical intake.
Adjudicates (closes), requests additional clinical information or escalates to Medical Directors.
Active PRC and USRN License required with 2 years Bedside Experience.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact.
Review clinical documentation and treatment trajectory to ensure care meets medical necessity standards.
Synthesize clinical documentation, medical record information, and outcomes data to make recommendations on next steps in care.
Partner cross-functionally to support high-quality, clinically appropriate care across the network.
Rula is dedicated to treating the whole person and aims to create a world where mental health is no longer stigmatized. They are a remote-first company committed to providing quality, evidence-based, and compassionate care, empowering individuals to take charge of their mental health.
Support payer audits and medical record reviews, ensuring timely submission of documentation.
Manage medical review requests and appeals associated with CMS contractors and regulatory agencies.
Review clinical documentation using audit checklists and partner with teams to gather required records.
VitalCaring is a provider of home health and hospice services founded in 2021. They are a growing company focused on quality and compliance, with a mission to deliver exceptional patient care.
Pulling, sorting, and analyzing data to determine member eligibility for the Population Health management Program.
Coordinating and providing care that is timely, effective, equitable, safe, and member-centric while following HMO processes.
Managing case assignments which includes outreach, documentation, monitoring for case progression, and case closure.
Guidehealth is a data-powered healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine. Guidehealth is a growing and innovative organization and employees are expected to adapt to evolving business needs.
Provides clinical oversight and medical necessity reviews for home health, DME, and related services using evidence-based guidelines.
Conducts peer to peer consultations and adverse determinations when clinical criteria are not met to support quality outcomes.
Collaborates with health plan leadership, participates in committees, and achieves SLA metrics for client performance guarantees.
CareCentrix provides clinical oversight and utilization management for home health, DME, home infusion therapy, and sleep medicine services. The company has an award-winning culture that values care, integrity, excellence, and innovation, operating with a drug-free workplace and equal opportunity commitment.