Provides medical interpretation and clinical review for appropriateness of services, including Home Care Solutions, Skilled Nursing Facility, Durable Medical Equipment, rehabilitation, and discharge planning.
Advises executives on functional strategies related to OneHome initiatives and clinical priorities, exercising independent judgment on complex issues.
Ensures compliance with CMS guidelines, Medicare/Medicaid requirements, and Humana policies while supporting quality, utilization management, and care coordination.
Provide clinical leadership and medical oversight for audit programs involving governmental and commercial payer claims.
Evaluate medical necessity, level of care, coding accuracy, and documentation sufficiency using payer policies and clinical standards.
Support audit methodologies, clinical validation frameworks, and quality assurance to ensure regulatory alignment and defensibility.
Machinify is a leading healthcare intelligence company delivering value, transparency, and efficiency to health plan clients. Deployed by over 85 health plans representing more than 270 million lives, they bring an AI-powered platform alongside best-in-class expertise.
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.
Lead medical work across sponsor-direct trials, including encoding new trials, iterating screening rules with engineering, and supervising a small medical contractor team.
Perform hands-on EMR review and clinical reasoning while setting strategic medical direction and contributing to customer and business conversations.
Partner with engineering to refine automated EMR screening, defining clinical logic for patient exclusion and human review, and contribute to product and trial design.
HealthMatch is on a mission to advance medicine by connecting patients with clinical trials. With over 2 million patients in our database and a growing trial portfolio, we are closing the gap in trial recruitment through technology and patient engagement.
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.
Lead clinical performance and drive quality outcomes across assigned ACOs, aligning with national strategy on value-based care initiatives.
Serve as a national clinical champion, influencing best practices and workflows for hypertension and risk management among partner practices.
Act as a thought partner to market leadership, contributing to growth and policy initiatives while representing the clinical voice in strategic workgroups.
Aledade is a public benefit corporation that empowers independent primary care practices to thrive in value-based care. Founded in 2014, we are the largest network of independent primary care in the country, with a collaborative, inclusive, and remote-first culture.
Serve as both a practicing clinician and clinical leader, managing Clinical Leads and driving clinical quality and performance.
Chair the Credentialing Committee, act as a collaborating/supervising physician for nurse practitioners, and participate in direct patient care with a 1-in-2 on-call schedule.
Collaborate across Operations, Product, Engineering, Legal, and Compliance to support safe and effective AI integration into clinical care.
Curai Health is an AI-enabled, fully virtual medical group making high-quality, asynchronous primary care accessible at scale. They are a mission-driven team of talented colleagues committed to living their values and driving meaningful impact in healthcare.
Complete assigned medication utilization reviews and medical necessity appeals for commercial and governmental clients.
Provide peer-to-peer support to physicians and prescribers regarding clinical programs and utilization review decisions.
Actively participate in developing utilization management criteria and clinical policy revisions.
Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including pharmacy benefit management and health benefit management. They are rebuilding trust in healthcare in the U.S. and deploying infrastructure for better care, but no specific employee size or culture details are provided.
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.
Serve as lead clinician and engagement manager for complex care clients, collaborating with PhD scientists and care coordinators.
Utilize clinical expertise to assess key issues, identify top experts, and guide patients to optimized care plans.
Build strong client relationships and coordinate with external providers and internal teams to deliver personalized care.
Private Health Management guides patients and families through the chaos and complexity of serious medical care as an independent advocate. The company is a remote organization with team members across the United States, focused on delivering personalized, measurably better outcomes.
Lead clinical programming and quality initiatives, including Stars/HEDIS strategy and risk coding documentation improvement.
Collaborate with Product, Engineering, and Analytics to design AI-enabled clinical tools and workflows.
Drive data-driven outcomes by monitoring metrics and identifying opportunities for intervention and improvement.
Chamber Cardio rebuilds the cardiology system by partnering with independent cardiologists to improve population health through technology, data, and operational tools. They are a mission-driven organization focused on innovation and empathy, blending clinical expertise with modern operating platforms.
Provides visionary leadership and strategic direction for care coordination and service delivery teams.
Drives transformational initiatives to scale operations, enhance quality, and improve patient outcomes.
Uses data analytics and key performance indicators to monitor program effectiveness and guide evidence-based decision-making.
WellSky is a technology company that provides software, analytics, and services for intelligent, coordinated care across health and community care. The company fosters a culture of independent thinking, collaboration, and innovation, with a focus on improving outcomes and lowering costs.
Provide strategic leadership and operational oversight for care management functions across the assigned region.
Ensure alignment with systemwide standards and regulatory requirements for hospital Care Management.
Collaborate with leadership to formulate strategies that drive organizational objectives and patient-centered outcomes.
CommonSpirit Health is a nonprofit Catholic healthcare organization delivering integrated health services through a network of hospitals, clinics, and care sites across 24 states. With over 157,000 employees and 25,000 physicians, it is one of the largest nonprofit healthcare systems, committed to creating a more just and equitable healthcare delivery system.
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.
Provide clinical and operational leadership for maternal and pediatric complex care programs.
Manage a team of clinicians to ensure high-quality, scalable support and performance.
Collaborate cross-functionally to shape population health strategy and improve outcomes.
Included Health is a digital healthcare company delivering integrated virtual care and navigation. The company has a remote-first culture and focuses on high-quality care for all.
Applies approved utilization criteria to monitor appropriateness of admissions and continued stay reviews.
Communicates with third-party payers for initial and concurrent clinical review to ensure medical necessity.
Tracks length of stay and resource utilization to identify at-risk patients and supports appeals on denied cases.
University of Utah Health is a patient-focused healthcare organization dedicated to enhancing health and well-being through patient care, research, and education. It is a nationally ranked Level 1 Trauma Center with five hospitals and eleven clinics, fostering a culture of collaboration, excellence, and respect.
Assist clinicians with gathering medical information for patients in between visits using various electronic health record systems.
Report medical concerns monthly such as falls, medications, behavioral issues, and hospitalizations.
Complete PCM interventions each month for approximately 15 patients per day.
MTC Care is the nation's leading telemedicine provider of behavioral health care to skilled nursing and assisted living facilities. They are an equal opportunity employer committed to fostering an inclusive workplace.