Review patient medical records to determine why claims are denied and prepare compelling appeal arguments using clinical evidence and regulatory guidelines.
Search for supporting evidence and analyze insurance denial trends to provide feedback to hospitals and executive leadership.
Ensure compliance with HIPAA regulations and demonstrate excellent written communication skills in crafting appeal letters and hearing testimony.
Implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center.
Functions within the multidisciplinary team to secure complex pre-authorizations and prevent/appeal clinical denials.
Utilizes clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided.
The Ohio State University is a top-20 public university with one of America’s leading academic health centers. They are a team of dedicated colleagues with access to boundless resources.
Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
Review inpatient and outpatient medical records to support appeal submissions and apply payer-specific guidelines.
Document review findings accurately and meet assigned turnaround times while maintaining quality standards.
CorroHealth helps clients exceed their financial health goals by providing scalable solutions and clinical expertise across the reimbursement cycle. The company fosters a supportive culture that invests in professional development and personal growth.
Supports and facilitates the design, development and implementation of Utilization Management data collection methodologies.
Displays and analyzes data to identify trends and works collaboratively to develop a plan of action.
Northside Hospital is an award-winning, state-of-the-art healthcare provider that is continually growing in Atlanta and beyond. As a large healthcare organization, they offer opportunities for healthcare professionals to join a team focused on expanding quality and reach of care.
Conduct medical claim reviews using clinical information and established criteria to determine medical necessity and appropriate reimbursement.
Educate internal and external staff on medical reviews, coding procedures, and coverage determinations.
Participate in quality control activities and provide guidance to LPN team members.
Palmetto GBA is a healthcare service administrator and one of the nation's largest providers of high-volume medical claims and transaction processing. The company offers a diverse workforce, training programs for leadership, tuition assistance, and financial incentives.
Manage high-value medical claims, denials, and appeals to ensure accurate and timely reimbursement.
Analyze unpaid/underpaid claims, investigate billing errors, and communicate with insurance payors via portals, phone, and email.
Maintain detailed documentation, process updates, and collaborate with internal teams to resolve complex accounts receivable issues.
Our partner operates within the healthcare revenue cycle, ensuring accurate reimbursement for medical services. They are a collaborative team focused on improving financial outcomes and maintaining compliance with healthcare regulations.
Lead deep-dive analyses of clinical and technical denials to uncover root causes affecting hospital reimbursement and operational efficiency.
Partner with hospital leadership and revenue cycle teams to present findings and support operational transformation initiatives.
Design and deliver training and documentation to improve denial prevention practices across teams and departments.
Our partner is a healthcare services organization operating in revenue cycle management and analytics. It is a growing company with strong client relationships and a focus on operational transformation.
Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies.
Collaborates with client personnel to resolve customer concerns and facilitates resolution of escalated cases.
Maintains written documentation per HealthHelp’s policy and ensures compliance with HIPAA, state, and federal regulations.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With three global headquarters, operations in 13 countries, 65 delivery centers, and more than 66,000 employees, WNS combines scale, expertise, and execution to create meaningful, measurable impact.
Review and evaluate medical record documentation for completeness, accuracy, and compliance.
Collaborate with physicians, nurses, and coding professionals to ensure appropriate clinical documentation.
Identify opportunities for documentation improvement to support coding accuracy, reimbursement, and clinical outcomes.
We improve the quality and accuracy of clinical documentation through expert CDI consulting. Our collaborative, mission-driven team offers opportunities for continuous learning and professional growth.
Facilitate improvement in provider-based clinical documentation accuracy to reflect patient acuity and severity.
Conduct concurrent record reviews and formulate compliant documentation queries to improve accuracy.
Educate clinicians and facility management on documentation opportunities and coding reimbursement issues.
Banner Health is a large nonprofit health care system with hospitals, clinics, and research centers across multiple states. They focus on skilled and compassionate care using advanced technology to improve patient outcomes.
Identify, research, process, and resolve customer inquiries regarding health insurance benefits, claims, and eligibility.
Analyze medical records and apply medical necessity criteria to determine the appropriateness of benefit requests.
Maintain accurate records, meet quality and timeliness standards, and coordinate with internal departments and external organizations.
Blue Cross Blue Shield of Arizona provides health insurance products and services to individuals, families, and businesses, aiming to inspire health and make it easy. The company has been recognized as a Healthiest Employer and has transformed healthcare for over 80 years with teams in Phoenix, Tucson, Chandler, and Flagstaff.
Perform medical necessity reviews of clinical documentation to determine appropriateness of inpatient and outpatient services.
Develop relationships with medical providers and health plans to confirm adherence to policies and guidelines.
Stay updated on technology changes, regulatory issues, and medical practices through ongoing training.
Trend Health Partners is a tech-enabled payment integrity company that facilitates collaboration between payers and providers to reduce waste and improve healthcare access. It promotes a collaborative and innovative work environment as a dynamic, growing organization.
Review, evaluate, appeal, and follow up on denied and underpaid claims using proprietary software.
Use payment documentation and contract information to ensure correct reimbursement.
Research and submit complex underpayment appeals to payers for timely claim resolution.
EnableComp provides Specialty Revenue Cycle Management solutions for healthcare organizations using proprietary automation. The company has been recognized as a top workplace and among the fastest-growing private companies in the US for eleven years.
Perform daily audits on client data for completeness and accuracy of coding using clinical knowledge.
Respond to provider appeals and meet client turnaround time and KPI goals.
Utilize coding validation training to become familiar with claims payment policies and regulations.
Cotiviti is a healthcare analytics company that uses data-driven solutions to improve payment accuracy and quality in healthcare. The company offers a competitive benefits package and fosters a collaborative, fast-paced work environment.
Serve as a facilitator between the patient and the company, ensuring a seamless experience.
Handle patient complaints and identify the appropriate response and strategy to solve issues quickly.
Keep records of patient interactions, process accounts, and file documents.
Homera Health has built large and fast-growing D2C telemedicine brands, expanding into new markets with virtual healthcare experiences. We are a diverse, global team hiring talent across product design, engineering, digital marketing, and operations.
Conduct medical risk assessments by analyzing clinical data, case management notes, and treatment plans to evaluate underwriting outcomes and financial exposure.
Partner strategically with underwriting teams to prioritize requests, apply evidence-based criteria, and advise on complex claims to influence underwriting decisions.
Manage relationships with internal clients, TPAs, and vendors, ensuring data integrity, accurate reporting, and clear communication of risk conclusions.
Crum & Forster provides property & casualty, accident & health, specialty and standard commercial lines insurance solutions. With 3,000 employees and a financial strength rating of A+ by AM Best, the company is consistently recognized as a great place to work, earning multiple workplace and wellness awards.
Review and process prior authorizations for biologics, oncology, and specialty therapies with timely and accurate completion.
Manage clinical documentation, submit and track authorization requests, and resolve issues with insurance providers.
Communicate effectively with patients, clinical staff, and insurance representatives to ensure compliance and workflow efficiency.
IVX Health is a national provider of infusion and injection therapy for individuals managing chronic conditions like Rheumatoid Arthritis, Crohn's Disease, and Multiple Sclerosis. They are a rapidly growing company focused on patient comfort and employee empowerment, with core values of kindness, integrity, and continuous improvement.
Support implementation and operation of the Compliance Program, including conflict of interest, compliance hotline, and regulatory reviews.
Serve as liaison for compliance questions and incidents, and recommend corrective actions and education opportunities.
Work with all levels to ensure internal controls provide accurate, complete, and compliant processes.
Cooper University Health Care is a healthcare organization dedicated to providing extraordinary health care and fostering clinical innovation. It offers competitive compensation, comprehensive benefits, and opportunities for professional growth.
Ensure acute hospital admissions have appropriate level of care and meet medical necessity.
Monitor patient progress in plan of care for continued stay.
Provide clinical information to payer to authorize acute hospital stay and continued services.
Piedmont Healthcare is a healthcare organization focused on patient outcomes. It offers a supportive culture with diverse teams, schedule flexibility, and comprehensive benefits, fostering employee growth and well-being.
Manage provider credentialing and enrollment processes to ensure compliance with NCQA, URAC, Joint Commission, CMS, and state regulations.
Oversee a team of specialists, monitor KPIs like "Days to Enroll," and resolve complex application rejections to protect cash flow.
Collaborate with Compliance, Billing, Legal, and Clinical teams to troubleshoot credentialing-related claim denials and maintain database accuracy.
Sleep Doctor is a trusted sleep health company helping millions get better rest through clinical expertise and consumer-first experiences. They foster a collaborative, growth-oriented culture where every team member contributes to bold solutions.
Process hospital privilege applications for clinicians and communicate with medical staff offices for status updates.
Maintain credentialing database, document all communications, and conduct follow-up on application status.
Respond to inquiries, escalate issues, and develop relationships with medical staff offices.
Pediatrix Medical Group is one of the nation's largest providers of prenatal, neonatal, and pediatric services. They are an innovative company focused on a team approach to improve patient lives, offering diverse opportunities and a commitment to clinical excellence.