Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes.
Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process.
Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
Virtua Health strives to connect individuals to the care they need, building a healthier community in South Jersey. They are a Magnet-recognized health system with over 14,000 colleagues, including over 2,850 doctors, physician assistants, and nurse practitioners.
Processes acute and post-acute inpatient medical or behavioral health and select intensive outpatient higher level of care requests through review of the submitted request and applicable clinical records
Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination, and with Care Management staff on discharge planning and transition of care activities.
Identifies and refers members with complex needs to the appropriate population health and/or care management program.
Capital Blue Cross promises to go the extra mile for our team and our community. Our employees consistently vote us one of the “Best Places to Work in PA, and we foster a flexible environment where your health and wellbeing are prioritized.
Responsible for working insurance A/R and assisting patients with billing or insurance related issues.
Resolves denied claims, handles claims appeals, posts payments, and processes insurance and patient refunds.
Communicates with patients and clinicians regarding billing matters and reviews patient eligibility and benefits.
Blackbird Health is a clinician-founded and operated organization that provides virtual and in-person mental health services for children and young adults in Pennsylvania, Virginia, and New Jersey. They aim to change mental health care for children for the better and foster an inclusive and collaborative work environment.
Responsible for submitting medical billing claims and appealing denied claims.
Obtain referrals and verify healthcare service eligibility.
Follow up on missed payments and resolve financial discrepancies.
CRMS by DocGo leads the proactive healthcare revolution with an innovative care delivery platform. They disrupt the traditional healthcare system by providing high quality, affordable care with a team of over 5,000 certified health professionals.
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.
Manages client denials and concerns through analytic review of clinical documentation.
Delivers final determination based on skillsets and partnerships with Humana parties.
Investigates and resolves member and practitioner issues via phone or face to face to support quality goals.
Humana Inc. is committed to putting health first for teammates, customers, and the company. Through Humana insurance services and CenterWell healthcare services, they strive to make it easier for millions to achieve their best health, delivering needed care and service.
Prepare and submit credentialing and enrollment packets.
Maintain accurate provider files and track expirations.
Provide assistance to the billing team during staff absences.
Modena Health and Modena Allergy & Asthma are leading medical practices specializing in allergy, asthma, and immunology care, with clinics across Southern California and Arizona and plans for national expansion. They are physician-led and technology-enabled, committed to transforming allergy care while advancing clinical research and expanding access to cutting-edge medicine.
Support clinical staff by gathering data to complete the medical necessity review process.
Create and send letters to providers and/or members to communicate information.
Collaborate with care management teams and stakeholders to provide optimal service.
Wellmark is a mutual insurance company owned by policy holders across Iowa and South Dakota, and they’ve built their reputation on over 80 years’ worth of trust. They are motivated by the well-being of their members, putting them first and committing to sustainability and innovation.
Support patients through the denial and appeal process.
Coordinate with healthcare providers and insurance companies.
Ensure seamless access to our innovative DME device.
Noctrix Health is redefining the treatment of chronic neurological disorders with clinically validated therapeutic wearables. Their team is dedicated to delivering prescription-grade therapy with an outstanding user experience and has pioneered the world’s first drug-free wearable therapy.
Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
Guide timely care determinations using CMS regulations and evidence-based practices.
Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
HJ Staffing is seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. The company has not provided any information about its size/employees and culture but is likely a medium to large medical or staffing company.
Investigate and resolve insurance claim denials with speed and accuracy.
Partner with payers to resolve issues and secure timely reimbursement.
Provide top-tier phone support to patients, insurance companies, and internal teams.
IVX Health is a national provider of infusion and injection therapy for individuals managing complex chronic conditions like rheumatoid arthritis, Crohn’s disease, and multiple sclerosis. They foster a culture of respect, empowerment, and shared purpose, living out their values every day.
Obtains authorizations from Insurance companies for scheduled tests/procedures.
Interprets patient medical records and reviews cases with the insurance nurse reviewer.
Accurately enters information into multiple computer programs and insurance websites.
CoxHealth is a leading healthcare system serving 25 counties across southwest Missouri and northern Arkansas. With six hospitals, 5 ERs, and over 80 clinics, CoxHealth has earned honors for workplace excellence and employs over 14,000 employees.
Appeal denied claims through Redetermination, Reconsideration, or Administrative Law Judge processes, following laws.
Proactively investigate patient charts by reading documents and conduct computer-based research.
Solventum is a new healthcare company with a history of tackling major challenges to improve lives and support healthcare professionals. They focus on innovative solutions at the intersection of health, material, and data science and are guided by empathy and clinical intelligence.
Execute payer enrollment applications from credentialing approval through payer confirmation.
Coordinate CAQH profile maintenance and attestations in alignment with Medallion workflows and payer requirements.
Track enrollment status, follow up with payers, and escalate delays or issues to the Payer Enrollment Manager.
Spring Health aims to eliminate barriers to mental health by delivering the right care at the right time through their clinically validated technology, Precision Mental Healthcare. They partner with over 450 companies and are valued at $3.3 billion.
Review and refine AI-generated clinical summaries and indicators related to medical necessity.
Collaborate with Product and Data Science teams to define and validate clinical logic.
Translate clinical knowledge into prompts and guidelines for large language models.
SmarterDx builds clinical AI that is transforming how hospitals translate care into payment. Founded by physicians in 2020, their platform connects clinical context with revenue intelligence, helping health systems recover millions in missed revenue, improve quality scores, and appeal every denial.
Conduct timely and accurate eligibility checks and benefit investigations through payer portals and phone outreach to ensure claims are submitted correctly from the start
Enter and monitor DME claims across multiple platforms, troubleshoot billing issues, and proactively follow up to reduce denials and accelerate reimbursement
Analyze explanation of benefits (EOBs) for errors, missing payments, or misapplied patient responsibility, then determine and execute the correct resolution path
Babylist is the leading registry, e-commerce, and content platform for growing families helping parents feel confident, connected, and cared for at every step. It has over $1 billion in annual GMV, and more than $500 million in 2024 revenue and is reshaping the $320 billion baby product industry.
Serve as a patient advocate and navigator, guiding patients and caregivers through the healthcare system.
Complete emergency room and hospital follow-up calls, offering education on alternative access points to reduce avoidable ED visits.
Facilitate medication education and adherence support, including alignment with standing orders, protocols, and chronic disease management goals.
Praxis Health is a family of medical groups providing high-quality healthcare throughout the state of Oregon. They foster a supportive and collaborative workplace where every team member is valued and empowered to succeed with community-based clinics.
Performing physician-level utilization management reviews for behavioral health services across all applicable levels of care.
Conducting peer-to-peer consultations with treating psychiatrists and other behavioral health providers.
Serving as a consultative clinical resource to behavioral health utilization management nurses, care managers, and operational leaders.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and AI, they leverage remotely-embedded Healthguides™ and a centralized Managed Service Organization.
Responsible for economic credentialing and provider enrollment with contracted managed care and governmental plans.
Communicating provider participation information to internal and external customers.
Ensures compliance with regulatory agencies and maintains a working knowledge of statues and laws.
The West Virginia University Health System is West Virginia’s largest health system and the state’s largest employer. They have more than 3,400 licensed beds, 4,600 providers, 35,000 employees, and $7 billion in total operating revenues.
Showcase customer service and data entry skills as part of the healthcare team.
Involved in claims adjudication and/or provider credentialing.
Support customers by phone, email and chat.
Sutherland helps customers globally achieve greater agility and transform automated customer experiences. As a digital transformation company they have been in business for over 35 years and are Great Place to Work certified with nearly 40,000 employees.