Performs utilization review to determine medical necessity criteria compliance and facilitates resolution of escalated cases.
Collaborates with clients and physician reviewers, ensuring adherence to all HIPAA, state, federal, and regulatory standards like URAC & NCQA.
Utilizes various computer systems to manage cases, engages in provider communication, and participates in quality management programs while prioritizing independent work.
WNS, part of Capgemini, is an AI-powered leader in intelligent operations and transformation, serving over 700 clients across industries like Healthcare and Financial Services. It is a large global company with over 66,000 employees, combining deep domain expertise with AI platforms to create lasting business value.
Review patient charts and documentation against defined coverage criteria.
Work with internal AI software that enables review productivity and apply structured processes to determine documentation sufficiency.
Produce clear, standardized written summaries of review outcomes and meet daily throughput and quality targets.
Verse Medical is building the modern software infrastructure to make hospital-quality care accessible everywhere. They're a well-funded Series C company, backed by notable investors, on a mission to heal a fragmented system by connecting providers, payors, and patients.
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.
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.
Review and process appeals submitted by members and providers, ensuring timely and accurate resolution.
Evaluate cases, determine next steps, and manage multiple priorities while meeting strict turnaround times.
Review clinical and medical records, summarize findings for Medical Director review, and operate within turnaround times as short as 24–72 hours.
BlueCross BlueShield of Tennessee has been helping Tennesseans find their own unique paths to good health since 1945. At BCBST, they empower their employees to thrive both independently and collaboratively, creating a collective impact on the lives of their members.
Analyze "trigger reports" to identify potential financial exposure early in the claims process.
Gather clinical information to evaluate liability and make recommendations to stakeholders.
Provide cost containment by managing Stop Loss claims and negotiating prices for medical services.
Ullico is the only labor-owned insurance and investment company and has been a partner of the labor movement for over 95 years. The company provides insurance products for members, leaders, and employers, as well as investments.
Provide independent medical documentation review and functional capacity analysis to support RA determinations under the Rehabilitation Act of 1973 and aligned with EEOC.
No patient care, no medical exams, record based review only (paper file review).
Ability to clearly communicate medical findings in written form for non-clinical review.
AdNet/AccountNet, Inc. is an 8(a), WOSB, and WBE-owned management consulting firm founded in 1990. We blend the best people with the ongoing demands of the workplace by providing high-quality staffing and executive search services.
Supervise day-to-day operations of assigned Utilization Management staff.
Provide full people management for assigned Utilization Management teams, including hiring and performance management.
Drive team performance against key metrics, including engagement, productivity, and quality scores.
Personify Health has created a personalized health platform, bringing health plan administration, wellbeing solutions, and care navigation together. Their data-driven solutions aim to reduce costs while improving health outcomes, empowering people to lead healthier lives.
Conduct objective medical case reviews for the Department of Veterans Affairs using standardized assessment criteria.
Evaluate the timeliness and appropriateness of care to identify quality improvement opportunities and assess medical decision-making.
Provide expert medical opinions by analyzing complex clinical scenarios from an impartial, evidence-based perspective.
Broadway Ventures is a service-disabled veteran-owned small business that provides expert program management, technology, and consulting solutions to government and private sector clients. With a focus on integrity and collaboration, the firm is a certified 8(a) and HUBZone contractor dedicated to operational success and growth.
Coordinate care and collaborate with multiple disciplinary team members to improve the quality of care and clinical outcomes.
Conduct thorough assessments to determine unmet needs and develop individualized care plans.
Promote quality cost-effective outcomes with the goal of improved care coordination.
Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services. They strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships.
Manages medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.
Utilizes clinical background to address the clinical denials, as well as write sound, compelling factual arguments for appealing denials.
Responsible for maintaining a detailed knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria, as well as filing compliant appeals.
Shriners Children’s respects, supports, and values each other. They are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact and were named as the 2025 best mid-sized employer by Forbes.
Conduct objective medical case reviews using standardized assessment criteria.
Evaluate the timeliness and appropriateness of care provided.
Identify quality improvement opportunities.
Broadway Ventures transforms challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. It is an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB).
Management and oversight of a quality team conducting quality assurance activities.
Responsible for the successful execution of the Quality Improvement Program in accordance with CMS requirements.
Plans, organizes, and directs activities of Clinical Quality, including planning, training, and staff development.
HealthEdge is committed to workforce diversity and actively encourages all qualified persons to seek employment. They provide effective and efficient solutions to complex business problems.