Own first-level reviews of pre-certification requests for medical appropriateness and necessity.
Drive post-service reviews and manage the appeals process for non-certified services.
Coordinate smooth discharges and redirect care in-network to keep patients on track.
Personify Health created the first personalized health platform, bringing health plan administration, wellbeing solutions, and care navigation together in one place. Their team serves employers, health plans, and health systems with a mission to empower people to lead healthier lives.
Perform clinical reviews and conduct peer-to-peer discussions.
Participate in inter-rater reliability activities and clinical rounds.
Serve as a clinical resource and subject matter expert to clinical and non-clinical staff.
Devoted Health is a healthcare company that aims to improve the health and well-being of older Americans through a data and AI-driven care platform. The company values diversity, collaboration, and a supportive work environment, and is an equal opportunity employer.
Perform utilization review including precertification and concurrent reviews using medical necessity criteria.
Collaborate with medical directors and providers on complex cases and integrate AI tools into workflow.
Initiate referrals to disease management programs and participate in quality improvement initiatives.
Guidehealth is a data-powered healthcare company that uses AI and predictive analytics to improve healthcare affordability and patient outcomes. It is a physician-led organization with a culture of accountability, learning, innovation, and empathy.
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.
Develop and coordinate individualized treatment plans and discharge services for patients.
Perform medical record reviews to assess admission appropriateness and ensure compliance with standards.
Support denials management and appeals for insurance claims to ensure quality care.
Northwestern Medicine is a healthcare system focused on patient-first care. We offer a supportive workplace with competitive benefits and a culture of growth.
Review Home Health prior authorization requests for medical necessity using CMS regulations and Clover clinical guidelines.
Perform initial and concurrent clinical reviews, ensuring appropriate care in the least restrictive setting.
Collaborate with providers and internal teams to support timely decision-making and positive member outcomes.
Clover Health is a healthcare company that uses data and technology to provide affordable, high-quality insurance plans for seniors. The company fosters a remote-first culture with a diverse and mission-driven team focused on improving member outcomes.
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.
Provide telephonic case management and utilization review for assigned consumers.
Develop, implement, and monitor individualized care plans to ensure quality and cost-effective outcomes.
Collaborate with healthcare providers, payors, and internal teams to coordinate care.
Cottingham & Butler helps clients through life's toughest moments by providing insurance and benefits solutions. The company fosters a culture of continuous improvement, seeking to hire, train, and grow the best professionals in the industry.
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.
Serve as primary physician reviewer for Utilization Management (UM) cases, advising other reviewers and attending daily calls with health plan teams.
Establish 2-3 cases per day for up to 6 markets, ensuring attendance on health plan calls and weekly meetings.
Participate in Process and Quality improvement in delegated Utilization Management, utilizing excellent analytical and deductive reasoning skills.
ChenMed is a family-owned, physician-led primary care provider focused on improving healthcare for moderate-to-low-income seniors. The company is rapidly expanding, with a culture of innovation, kindness, and making a difference.
Provide telephonic case management to proactively drive return to work.
Perform utilization review and coordinate care with providers and adjusters.
Evaluate treatment plans and partner with adjusters to achieve optimal outcomes.
AmTrust Financial Services is a fast-growing commercial insurance company providing comprehensive telephonic case management. They foster a diverse and inclusive culture with a focus on attracting and retaining the best talent.
Manage UM nurse team performance, SLAs, and quality improvement.
Handle escalated UM cases and provider disputes 25% of time.
Partner with clients, medical directors, and IDTs to ensure consistent decision-making.
IntusCare builds an end-to-end ecosystem for Programs of All-Inclusive Care for the Elderly (PACE) to improve care, financial performance, and compliance. As a healthcare technology company, we empower teams to improve outcomes for dual-eligible seniors.
Prepare prior authorization requests by validating prescriber and member information and ensuring appropriate clinical guidelines.
Make outbound calls to providers to obtain additional clinical information for pharmacist review.
Review and analyze pharmacy claims data for proactive outreach and intervention.
Judi Health is an enterprise health technology company offering pharmacy benefit management and health benefit solutions for employers and health plans. They are a startup focused on rebuilding trust in healthcare in the U.S.
Perform prospective, concurrent, and retrospective utilization reviews for behavioral health services across multiple care settings.
Assess medical necessity and coordinate care with providers, members, and internal teams to ensure appropriate access and treatment.
Support discharge planning, benefit utilization, and regulatory compliance while improving overall care quality.
This company provides high-quality behavioral health coordination and utilization management services to improve member outcomes. They foster a supportive, collaborative environment focused on professional growth and clinical excellence.
Assess, plan, implement, and coordinate comprehensive care plans to meet individual health needs and ensure cost-effective healthcare delivery.
Serve as a liaison facilitating collaboration among patients, families, physicians, and providers to promote quality of care.
Provide specialized education on disease-specific conditions and remain current with medical trends and procedures.
Arkansas Blue Cross and Blue Shield is a health insurance company providing healthcare coverage and services. They are consistently ranked as a top workplace in Central Arkansas with an inclusive culture and average employee tenure of 10 years.