Conduct Skilled Nursing Facility medical claims audit reviews applying medical review guidelines.
Document findings and generate articulation letters for audit results.
Collaborate with audit team and clients to improve medical policies and workflows.
Machinify is a leading healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. Deployed by over 85 health plans representing more than 270 million lives, the company uses an AI-powered platform and best-in-class expertise to reimagine healthcare.
Survey ambulatory care organizations across the United States within the scope of Joint Commission's Ambulatory Programs.
Engage health care staff in interactive dialogues to assess compliance and identify opportunities for improving care quality.
Prepare management reports that link standards deficiencies with systems vulnerabilities and communicate findings to leadership.
The Joint Commission accredits and certifies health care organizations to improve patient safety and quality of care. It employs a nationwide team of surveyors who work remotely and travel extensively.
Conduct detailed assessments and coordinate individualized care plans with healthcare teams.
Educate patients and families on disease processes, treatment options, and self-care strategies.
Advocate for patients' needs within the healthcare system, ensuring timely access to services.
Empowers individuals facing health challenges by providing compassionate, expert-guided care advocacy services. Dedicated to ensuring personalized support and seamless care coordination.
Manage care for high-risk members by identifying needs and coordinating clinical, community, and in-network resources.
Perform utilization management reviews, ensure quality oversight, and support accreditation readiness.
Collaborate with multidisciplinary teams to analyze member outcomes and drive continuous improvement.
They are a health plan focused on improving outcomes for high-risk members through care coordination and quality initiatives. Their team values collaboration, clinical excellence, and mission-driven work to enhance community health.
Strategically assess, plan, and facilitate comprehensive care across the continuum for high-risk patients.
Collaborate with physicians, nursing, insurers, and post-acute providers to ensure timely transitions.
Work remotely from California, using provided equipment, with potential weekend/holiday coverage.
Dignity Health Management Services provides integrated managed care administrative and clinical services to medical groups, hospitals, and health plans. It is part of CommonSpirit Health, one of the largest nonprofit health systems in the US, with a focus on coordinated patient care and community health.
Review OASIS documentation and plan of care to ensure compliance with regulations and accuracy.
Evaluate patient visit frequency and utilization to align with clinical needs and provider orders.
Collaborate with coding partners and escalate documentation improvement opportunities to leadership.
Graham Healthcare Group designs business and technology solutions to drive better care and outcomes in home health and hospice. As a subsidiary of a publicly traded company, they've been improving care coordination for over 20 years, focusing on patient-centered home care.
Oversee the Complex Clinical Bill Review team, managing production expectations, SLAs, client communication, and team performance.
Analyze and track internal business requirements, continuously evaluate functionality across programs, and perform requirements gathering to solve process issues.
Monitor team performance metrics, identify growth opportunities, and coordinate system enhancements including JIRA and UAT testing.
Machinify is a leading healthcare intelligence company providing an AI-powered platform for health plan clients. They are deployed by over 85 health plans, representing more than 270 million lives, with a culture of innovation and efficiency.
Review medical history with patients in preparation for prescriber review.
Provide patient counseling on medication use, safety, and side effects.
Collaborate with the Customer Experience team and medical network to coordinate care.
Remedy (formerly Thirty Madison) revolutionizes healthcare accessibility by providing remote care and support. The company is building a diverse and inclusive workplace as part of a larger organization.
Review medically complex claims, pre-authorization requests, appeals, and fraud and 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, we empower clients with tailored solutions, operating with integrity and collaboration.
Lead and support a remote clinical support team to ensure exceptional patient service and operational excellence.
Coach and mentor team members while overseeing performance, quality audits, and provider workflows.
Drive continuous improvement initiatives and maintain adherence to clinical and quality standards.
Ways2Well is redefining healthcare through regenerative and preventive medicine, offering data-driven personalized care. They operate as a remote clinical support team with a focus on high-impact healthcare and patient empowerment.
Coordinate and provide care that is timely, effective, and member-centric while following HMO processes.
Manage case assignments including outreach, documentation, monitoring for case progression, and case closure.
Assist members in reaching wellness by addressing barriers, social determinants, and psychosocial issues.
Guidehealth is a data-powered healthcare company dedicated to making great healthcare affordable and improving patient outcomes. It is a physician-led, performance-driven organization with a culture of empathy, accountability, and continuous learning.
Conduct telephonic clinical assessments and health education using nursing process and protocols.
Utilize critical thinking to triage, make care recommendations, and document patient interactions.
Work a schedule including evenings and weekends, with full-time flexibility and remote setup.
Carenet Health provides clinical services and health education to patients through innovative telephonic channels. They are a growing organization with a collaborative team of registered nurses across the United States.
Serve as the dedicated point of contact for clinicians from hire to go-live, orienting them to culture and workflows.
Train clinicians on Synapse and site-specific processes through live sessions and create training materials.
Own institutional knowledge for each hospital site and lead remedial education when gaps arise.
Sevaro is a physician-founded virtual specialty care company providing teleneurology and multispecialty virtual care through its Synapse AI platform. They foster a collaborative, mission-driven culture focused on patient outcomes and operational excellence.
Review medical records to develop concise clinical reviews supporting authorization and reimbursement.
Facilitate communication with payors to ensure appropriate utilization management decisions.
Collaborate with interdisciplinary team to prevent denials and optimize patient care.
West Virginia University Health System is West Virginia’s largest health system, providing comprehensive healthcare services. With over 35,000 employees and 25 hospitals, it is the state's largest employer and offers a collaborative, patient-centered culture.
Performing timely utilization review of healthcare services using approved medical necessity criteria.
Collaborating with medical directors, providers, and internal teams for compliant review processes.
Ensuring accurate documentation and communication of determinations within regulatory timeframes.
Guidehealth is a data-powered, performance-driven healthcare company focused on making healthcare affordable and improving patient health. It is a physician-led organization using AI and predictive analytics, with a culture of accountability, growth, innovation, and empathy.
Perform clinical reviews for medical necessity, level of care, and authorization compliance.
Prepare and submit high-quality appeals related to DRG downgrades and clinical validation denials.
Apply payer-specific guidelines and document review findings accurately in designated systems.
CorroHealth helps clients exceed their financial health goals through scalable revenue cycle solutions and clinical expertise. The company builds long-term careers by investing in team members' professional development and personal growth.
Analyze health plan reports and clinical data to identify members eligible for case management.
Conduct comprehensive telephonic and virtual assessments to evaluate medical, behavioral, and social needs.
Develop, implement, and monitor individualized care plans with measurable goals and interventions.
Duly Health and Care is a physician-led medical group offering a connected network of primary and specialty care, surgery centers, imaging, lab, and therapy services. They foster a collaborative culture centered on putting patients first and supporting team growth.
Review Home Health prior authorization requests using CMS guidelines and clinical judgment.
Lead and mentor the Home Health UM nursing team, ensuring quality and compliance.
Collaborate with cross-functional partners to optimize care and improve utilization.
Clover Health provides high-quality, affordable healthcare for America's seniors by combining data, technology, and preventive care. They are a mission-driven team with diverse expertise, focused on improving members' lives through innovation and empathy.
Lead the application of the Clinical Quality Management Regime across Delivery Partners, ensuring compliance with contractual quality standards.
Use quality intelligence and performance data to assess effectiveness of controls and identify emerging risks.
Provide hands-on clinical quality expertise to diagnose performance issues and support corrective actions.
Ingeus is a leading human services provider that helps people, businesses, and communities thrive through employment, skills, and health & wellbeing services. It is a trusted partner to government and industry, committed to creating positive social impact, and fosters an inclusive culture treating everyone with dignity.