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.
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.
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.
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.
Communicate and provide education to members and providers on insurance plan benefits and digital health solutions.
Employ active listening & motivational interviewing skills, and can handle difficult calls tactfully, courteously, professionally and document accordingly that can build patient trust and engagement.
Accurately track and document work on a variety of internal software tools and platforms.
Evry Health is on a mission to bring humanity to health insurance. They are a high-technology health plan that expands benefits, increases access and transparency, and features a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL) with more than 3,000 corporate employees and 15,000 agents.
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.
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.
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.
Primarily responsible for making outbound calls to healthcare providers.
Accepting inbound calls from healthcare providers.
Answer questions about participation requirements, registration, assessment completion and scoring results.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With over 66,000 employees, we combine scale, expertise and execution to create meaningful, measurable impact.
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.
Responsible to secure outpatient accounts by performing insurance verification and obtaining benefit information.
Calculates patient estimates and obtains prior authorization before services are rendered.
Works with physicians, nurses, clinic managers, and financial advocates to resolve issues that arise during the prior authorizations process.
University of Utah Health is a patient-focused organization that enhances the health and well-being of people through patient care, research, and education. They have five hospitals and eleven clinics which provide excellence in comprehensive services, medical advancement, and overall patient outcomes.
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.
Oversee prior authorization technicians and administrative PA functions.
Analyze data and provide staffing, workflow, and system enhancement recommendations.
Investigate/resolve escalated issues from clients and providers.
Judi Health is an enterprise health technology company providing a suite of solutions for employers and health plans. They have a comprehensive Enterprise Health Platform that consolidates all claim administration-related workflows in one scalable, secure platform.
Monitor compliance with assigned responsibilities and coordinate with patient financial services.
Conduct initial and continued clinical authorization reviews.
Jobgether uses an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly. They identify the top-fitting candidates, and this shortlist is then shared directly with the hiring company.
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.
Rapidly assess and prioritize patients' healthcare needs and direct them to the appropriate level of care.
Conduct patient interviews, evaluate symptoms, perform initial assessments, and apply critical thinking to determine urgency and disposition.
Provide advice, educate, and coordinate care, while managing priorities effectively under pressure to ensure timely and appropriate patient attention.
Virginia Mason Franciscan Health provides exceptional healthcare. They have a comprehensive network of 10 hospitals and nearly 300 care sites across the greater Puget Sound region.
Take incoming requests for appeals ensuring customer service and maximizing productivity.
Work with appeals team for multiple lines of business ensuring appeal submission for review.
Maintain quality standards, remain current on updated processes, and follow SOPs and HIPAA guidelines.
Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans. They have full-service health benefit management solutions to employers, TPAs, and health plans.