Own quality performance across all clinical tiers, including call and documentation quality for RNs, providers, and PSS Engagers, plus organization-wide clinical outcomes.
Lead and develop a team of Quality Reviewers, setting standards, conducting calibrations, and coaching to ensure consistent, defensible scoring.
Build and analyze quality dashboards and datasets to identify trends, root causes, and improvement opportunities, presenting findings to executive leadership.
CareTalk Health is a fully remote, nationwide virtual medical practice partnering with Medicare Advantage plans to deliver Annual Wellness Visits and close care gaps. We are a growing, collaborative team focused on making virtual care simple, reliable, and human.
Conduct clinical audits for suspected fraud, waste, and abuse with high autonomy.
Document findings in formal reports, graphs, and audit logs, aligning with unit goals.
Develop and present FWA-related education to Oscar teams, ensuring compliance with regulations.
Oscar is a health insurance company built on a full stack technology platform, focused on serving members like a doctor in the family. Founded in 2012, it is a forward-thinking company that values diversity and innovation, with a culture of fostering belonging and support.
Develop, implement, and monitor outcome-based reporting systems for high-risk diagnoses, patient groups, and care processes.
Collaborate with interdisciplinary teams to prepare quality reports for clinical departments and regulatory bodies.
Apply performance improvement methods like Lean Six Sigma and Rapid Cycle PDSA to enhance patient care outcomes.
Cooper University Health Care is a leading healthcare provider committed to extraordinary care and clinical innovation. With a large team of professionals, it offers competitive benefits and opportunities for career growth.
Lead and support a remote clinical support team to ensure exceptional patient service and operational excellence.
Coach and mentor team members while overseeing performance, quality audits, and provider workflows.
Drive continuous improvement initiatives and maintain adherence to clinical and quality standards.
Ways2Well is redefining healthcare through regenerative and preventive medicine, offering data-driven personalized care. They operate as a remote clinical support team with a focus on high-impact healthcare and patient empowerment.
Oversee the Complex Clinical Bill Review team, managing production expectations, SLAs, client communication, and team performance.
Analyze and track internal business requirements, continuously evaluate functionality across programs, and perform requirements gathering to solve process issues.
Monitor team performance metrics, identify growth opportunities, and coordinate system enhancements including JIRA and UAT testing.
Machinify is a leading healthcare intelligence company providing an AI-powered platform for health plan clients. They are deployed by over 85 health plans, representing more than 270 million lives, with a culture of innovation and efficiency.
Survey ambulatory care organizations across the United States within the scope of Joint Commission's Ambulatory Programs.
Engage health care staff in interactive dialogues to assess compliance and identify opportunities for improving care quality.
Prepare management reports that link standards deficiencies with systems vulnerabilities and communicate findings to leadership.
The Joint Commission accredits and certifies health care organizations to improve patient safety and quality of care. It employs a nationwide team of surveyors who work remotely and travel extensively.
Conduct clinical audits and risk assessments to identify compliance gaps.
Manage multiple client engagements and deliver accurate project results.
Build strong client relationships and present findings to leadership.
Kodiak Solutions transforms healthcare through technology-driven solutions, specializing in finance, unclaimed property, and risk management. Their innovative platform streamlines operations, allowing providers to focus on patient care.
Review OASIS documentation and plan of care to ensure compliance with regulations and accuracy.
Evaluate patient visit frequency and utilization to align with clinical needs and provider orders.
Collaborate with coding partners and escalate documentation improvement opportunities to leadership.
Graham Healthcare Group designs business and technology solutions to drive better care and outcomes in home health and hospice. As a subsidiary of a publicly traded company, they've been improving care coordination for over 20 years, focusing on patient-centered home care.
Provide high-quality consulting services including clinical and regulatory compliance audits to long-term care facilities nationwide.
Manage assigned client facilities with emphasis on service quality, cost-effectiveness, and timely delivery of consulting visits.
Collaborate with teams and maintain effective communication with leadership about customer issues and industry regulations.
Assembly Health is a healthcare company providing clinical consulting services to long-term care facilities nationwide. The team is motivated, client-focused, and committed to excellence and integrity.
Perform medical necessity and level of care reviews using clinical judgment and guidelines.
Obtain member information via telephone and fax to assess condition and apply evidence-based criteria.
Meet decision-making SLAs and refer members for further care engagement when needed.
Oscar Health is a technology-driven health insurance company focused on simplifying healthcare for its members. We are a mission-driven organization with a diverse team, committed to innovation and equity in healthcare.
Perform clinical medical record review and abstraction to support healthcare quality and compliance.
Apply established review criteria consistently and document findings clearly and objectively.
Work independently to complete accurate reviews within project deadlines while managing multiple priorities.
Health Services Advisory Group (HSAG) is transforming the delivery of healthcare in the United States. They are a growing team dedicated to improving healthcare quality, with a focus on community and collaboration.
Review and analyze Medicare claims sampled by the Department of Justice to determine correct coding and payment based on coverage and utilization.
Conduct in-depth claims analysis to detect fraudulent or abusive billing practices using ICD-10, CPT-4, and CMS guidelines.
Complete summary reports and communicate findings internally while maintaining confidentiality and compliance with DOJ and CMS regulations.
Empower AI provides AI-powered solutions for federal government agencies, helping them transform their workforce and operations. Headquartered in Reston, Va., the company has three decades of experience in Health, Defense, and Civilian missions and is recognized as a 2024 Military Friendly Employer.
Performing timely utilization review of healthcare services using approved medical necessity criteria.
Collaborating with medical directors, providers, and internal teams for compliant review processes.
Ensuring accurate documentation and communication of determinations within regulatory timeframes.
Guidehealth is a data-powered, performance-driven healthcare company focused on making healthcare affordable and improving patient health. It is a physician-led organization using AI and predictive analytics, with a culture of accountability, growth, innovation, and empathy.
Conduct complex medical review of Medicare claims for Inpatient Rehabilitation Facility services.
Perform pre-claim review determinations and evaluate Additional Documentation Request responses.
Communicate determinations to providers and meet production-driven turnaround requirements.
Broadway Ventures is a small business that provides program management, technology, and consulting solutions to government and private sector clients. As a Service-Disabled Veteran-Owned Small Business, they emphasize integrity, collaboration, and excellence.
Conducts appeals reviews of new evidence disputing medical review audit findings.
Documents and reports appeals results accurately, upholding or overturning determinations.
Serves as a subject matter expert, supporting training and process improvements.
Machinify is a healthcare intelligence company offering an AI-powered platform for health plan payment and clinical review. It serves over 85 health plans and over 270 million lives, with a culture of innovation and continuous improvement.
Review patient charts and verify eligibility for cardio-kidney-metabolic (CKM) conditions, releasing standing lab orders under the Regional ACCESS Director's authority.
Manage daily order queues with high clinical accuracy to maintain strict turnaround targets and prevent enrollment delays.
Act as a subject matter expert on lab ordering processes, identify friction, and partner with stakeholders to optimize workflows.
Aledade is a public benefit corporation that empowers independent primary care practices to thrive in value-based care. Founded in 2014, they have become the largest network of independent primary care in the country, with a culture that is collaborative, inclusive, and remote-first.
Lead clinical testing and validation of AI-enabled healthcare solutions.
Coordinate clinical testers and ensure consistency in testing and documentation.
Translate clinical findings into actionable recommendations for Product and Engineering teams.
OutcomesAI is a healthcare technology company building an AI-enabled nursing platform to augment clinical teams and automate workflows. They aim to create the world's first AI + nurse hybrid workforce, though the company size is not specified.
Support clinical process improvement initiatives and monitor performance to client SLAs.
Conduct root cause analyses and develop remediation plans for process variations.
Collaborate with product and analytics teams to optimize letters and template tracking.
Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans and providers to optimize care quality and reduce costs. The company has been named to the Inc. 5000 list and ranked a Top 5 LinkedIn Startup, backed by leading investors, with a culture that values empathy and collaboration.
Apply specialized clinical knowledge to categorize, code, and summarize patient data from medical records with high accuracy.
Manage multiple concurrent tasks, prioritize deadlines, and propose solutions to obstacles in a timely manner.
Navigate electronic medical records and registry tools, contributing to team best practices and process improvements.
Q-Centrix delivers data abstraction solutions for hospital partners to improve patient outcomes and advance research. They have a supportive, remote-first culture recognized as a Great Place to Work multiple years in a row.