Assess referred concurrent denials and determine next steps for resolution.
Review medical record documentation to support denial management strategies.
Advocate for patients to ensure coverage and reimbursement.
They are currently looking for a Utilization Management Coordinator. By enhancing operational efficiencies and implementing educational initiatives, this role significantly impacts the financial and quality outcomes of healthcare delivery.
Review admissions and service requests for medical necessity and reimbursement compliance.
Provide case management and consultation for complex cases and coordinate discharge planning.
Oversee compliance with federally mandated and third-party payer utilization management rules.
UAB St. Vincent's is a trusted healthcare provider serving Alabama for over 125 years, offering comprehensive care across five hospitals and clinics. The organization employs over 4,800 people and fosters a collaborative culture rooted in compassion, service, respect, and teamwork.
Conducts medical necessity reviews to determine appropriate patient class designation.
Performs timely reviews using InterQual Criteria and clinical nursing judgement.
Communicates with the provider team regarding patient class designation and medical necessity.
Emory Healthcare fuels professional journeys with benefits, resources, mentorship, and leadership programs. They offer a supportive environment for career growth.
Performs concurrent inpatient utilization review using InterQual criteria to determine if requests meet medical necessity criteria.
Engages in clinical collaboration with physicians, hospitalists, and care teams to obtain clinical information.
Maintains knowledge of regulations, accreditation requirements, and payer-specific guidelines.
WNS Healthhelp, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. They bring together deep domain excellence with AI-powered platforms and analytics to help businesses innovate, scale, adapt and build resilience. With more than 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact.
Reviewing cases, educating patients on appropriate care.
Managing health care costs for the dependents of our Nation’s Active Duty and eligible retirees.
Working remotely Monday through Friday, 8 hours per day.
Spectrum Healthcare Resources (SHR) delivers systems and processes designed to meet the unique needs of Military and VA Health Systems. They provide physician and clinical staffing and management services to United States Military Treatment Facilities and VA clinics.
Assess, plan, coordinate, and monitor patient care.
Develop, implement, and monitor individualized care plans.
Coordinate care across providers, facilities, and community resources.
Limitlessli specializes in recruiting, hiring, and managing high-caliber remote staff for dynamic and growing healthcare facilities. They connect clients with highly qualified professionals, offering tailored services to meet unique business needs, leveraging an extensive global network.
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.
Evaluates certification requests by reviewing the group specific requirements.
Triage the call to determine if a Utilization Review Nurse is needed to complete the call.
Cottingham & Butler sells a promise to help their clients through life’s toughest moments. Their culture is guided by the theme of “better every day” constantly pushing themselves to be better than yesterday.
Provide first level review for all outpatient and ancillary pre-certification requests.
Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care.
Complete documentation for all reviews in Eldorado/Episodes and maintain confidentiality.
Personify Health created a personalized health platform bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. Their team is on a mission to empower people to lead healthier lives.
Responsible for the coordination of services for members meeting established criteria, emphasizing education/self-management and promoting quality care and cost-effective outcomes.\n- Uses a collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor progress, and evaluate Member status.\n- Addresses medical, psychosocial, clinical needs, and behavioral health needs including members with mental health and substance use disorder needs, providing counseling and referrals to community/local/state programs.
Capital Blue Cross is committed to providing excellent service to both its team and the community. Employees have consistently voted it as one of the “Best Places to Work in PA”, which indicates a positive and supportive company culture.
Conduct in-depth telephonic assessments to understand patient needs.
Develop individualized care plans and guide patients through treatment goals.
Document clearly and accurately in the EHR and care-management systems.
Guidehealth is a data-powered healthcare company. They aim to make healthcare affordable and improve patient health with AI and predictive analytics. They operate with agility, encouraging cross-training and development to ensure employees thrive.
Conduct assessments, establish care goals, and deliver telephonic coaching and education to support clients in managing chronic conditions.
Perform first‑level Utilization Review for inpatient and outpatient services based on plan guidelines.
Document all condition management activities, track client progress, and report outcomes, savings, and quality improvements.
Cottingham & Butler sells a promise to help their clients through life’s toughest moments and aim to hire, train, and grow the best professionals in the industry. Their culture is guided by the theme of “better every day” constantly pushing themselves to be better than yesterday.
Perform comprehensive medical record and claims review to make payment determinations for Medicare Durable Medical Equipment.
Conduct in-depth claims analysis utilizing ICD-10-CM, AMA-CPT, and HCPCS Level II coding principles.
Make clinical judgment decisions based on clinical experience when applicable.
Empower AI provides AI tools for government to elevate workforce potential. They have three decades of experience solving complex challenges in Health, Defense, and Civilian missions and are headquartered in Reston, VA.
Coordinate and implement medical case management to facilitate case closure.
Assess appropriate utilization of medical treatment and services.
Review medical records and assess data to ensure appropriate case management process.
Berkley Medical Management Solutions (BMMS) provides managed-care service for W.R. Berkley Corporation, focusing on injured worker’s return to work. BMMS was started in 2014 and combines clinical practices, return-to-work strategies, and software for workers’ compensation cases.
Lead utilization management strategy and medical policy development, incorporating regulatory and clinical guideline updates.
Provide medical oversight and expertise to ensure the delivery of cost-effective, quality healthcare services to plan members.
Promote positive relations with the medical community and integrate clinical quality into program development and staff education.
Evry Health is the major medical division of Globe Life, a technology-enabled health plan focused on expanding benefits and increasing transparency. It is part of Globe Life, a large insurance company with over 3,000 corporate employees and a long-standing A (Excellent) rating from A.M. Best.
Managing the overall care management of patient panel by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations.
Establishing trusting and empathetic relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey.
Serving as an advocate and community liaison for patients to ensure proper and timely resources and support while navigating the health care system and maintaining compliance with the primary care team’s/nephrologist’s treatment plan.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. They are committed to improving patient outcomes and improving quality of life.
Conduct targeted patient outreach to close care gaps and ensure timely care transitions.
Deliver high-touch engagement for high-risk patients to prevent readmissions through follow-up.
Collaborate with Practices to support interventions such as Transitional Care Management.
Aledade empowers independent primary care practices, helping them deliver better care and thrive in value-based care. Founded in 2014, they are the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.
Serves as a patient advocate and navigator, guiding patients and caregivers through the healthcare system.
Completes emergency room and hospital follow-up calls, offering education on alternative access points to reduce avoidable ED visits.
Facilitates 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 are a company of small groups and clinics, of nimble micro-cultures that can quickly adapt to industry changes, as well as patient needs.
The RN Case Manager serves as a trusted clinical partner to patients, families, providers, and interdisciplinary teams, guiding individuals through complex health journeys with compassion, clinical excellence, and purpose.
The RN Case Manager is responsible for assessment, care planning, coordination, monitoring, and evaluation of services for a defined population, including members with chronic, complex, and high-risk conditions.
Working closely with primary care providers, patient navigators, and other care team members, the Care Manager – Registered Nurse ensures safe, effective, equitable, and patient-centered care within a value-based care model.
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. This growing organization operates with agility, encouraging cross-training, development, and learning across all areas of the business.