Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
Apply payer-specific guidelines and internal policies to support clear, defensible clinical narratives.
Meet assigned turnaround times and document findings accurately in designated systems.
CorroHealth helps clients exceed their financial health goals through scalable reimbursement solutions and clinical expertise, leveraging technology and analytics. The company builds long-term careers by investing in professional development and personal growth, fostering a culture of accountability and success.
Conduct clinical reviews of medical records to determine medical necessity and payer compliance.
Evaluate denial cases including appeals, audits, and no-authorization determinations.
Develop evidence-based clinical rationales aligned with payer and regulatory guidelines.
This partner company provides clinical review and healthcare reimbursement support services. The team is remote and operates in a fast-paced, performance-driven environment.
Review and analyze insurance denials using EOBs, payer correspondence, and claims data to determine appropriate resolution strategies.
Differentiate between clinical and technical denials and identify required next steps for appeals or reprocessing.
Prepare and submit appeals using supporting documentation such as medical records, appeal letters, and clinical justification when necessary.
Jobgether is an AI-powered job matching platform that connects candidates with hiring companies. They use automated technology to review applications and share top-fitting candidates directly with employers, ensuring a fair and efficient hiring process.
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.
Investigate and resolve insurance claim denials, handling 50 to 100 denials daily with speed and accuracy.
Partner with payers to secure timely reimbursement and interpret LCD/NCD requirements for CPT/HCPCS-related denials.
Provide top-tier phone support to patients, insurance companies, and internal teams while using payer portals and clearinghouses.
IVX Health is a national provider of infusion and injection therapy for individuals managing complex chronic conditions like rheumatoid arthritis, Crohn’s disease, and multiple sclerosis. We foster a culture of respect, empowerment, and shared purpose, with a team committed to patient-centered outcomes and values such as Be Kind and Do What’s Right.
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.
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.
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.
Performs activities related to insurance company notifications and obtaining certifications/authorizations related to Utilization Review.
Communicates clinical information and updates to insurance companies as requested or required to justify medical necessity.
Liaises with third-party payers regarding UR requirements and assists with complex authorization needs impacting patient transition planning.
Phoebe Putney Health System is southwest Georgia’s preferred career choice for professionals who want to improve the community’s health by joining a respected, cutting-edge team. They are one of the area’s premier employers, offering a close-knit culture, outstanding benefits and many ways to develop your career.
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.
Responsible for the review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms.
Follows established policies and procedures to pay, pend for additional information, or deny claims.
Accountable to meet and maintain established department production and quality standards.
Evry Health is on a mission to bring humanity to health insurance by expanding benefits, increasing access and transparency, and featuring 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.
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.
Pulling, sorting, and analyzing data to determine member eligibility for the Population Health management Program.
Coordinating and providing care that is timely, effective, equitable, safe, and member-centric while following HMO processes.
Managing case assignments which includes outreach, documentation, monitoring for case progression, and case closure.
Guidehealth is a data-powered healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine. Guidehealth is a growing and innovative organization and employees are expected to adapt to evolving business needs.