Complete timely review of healthcare services using appropriate medical criteria to support determinations.
Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make great healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages Healthguides™ and a Managed Service Organization to build stronger connections with patients and providers.
Oversee the RN Reviewer team including one RN Team Lead
Manage the daily timeliness report and ensure all cases meet expected turnaround times
Monitor the nurse productivity reports daily and provide feedback to the nurses, managing performance to ensure consistency
Cohere Health's clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. They work with over 660,000 providers and handle over 12 million prior authorization requests annually.
Responsible for coordination of services for members, emphasizing education/self-management and quality care. \n- Assesses member needs, reviews service options, develops and implements care plans, and coordinates resources. \n- Manages a caseload of moderate-high risk members with complex medical/behavioral/psychosocial needs.
Capital Blue Cross is committed to improving the health and well-being of our members and the communities in which they live. They offer flexibility, prioritize health and well-being, and encourage employees to volunteer in their community.
Participate in provider case reviews to identify trends and deficits.
Coach providers and participate in client meetings to support expectations.
Contribute to workflow design, QA improvements, and risk management.
Amwell transforms healthcare with technology and people. They aim to provide convenient, affordable, and effective care, serving large healthcare organizations in the U.S. and worldwide.
Provide case management to members including medical, social, psychological, physical, and spiritual needs.
Develop, implement, and monitor the care plan in conjunction with the PCP, caregivers, and other team members.
Help meet the member's needs.
Elderplan and HomeFirst are Medicare and Medicaid managed care health plans that are expanding services in response to patients' needs. At MJHS, they are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services.
Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel.
Provides guidance and counseling to coordinators and Clinical Supervisors to assist them in continually improving all aspects of home health care services.
Assists the Executive Director in the preparation and administration of the organization's budget.
Mission Healthcare, located in seven states, is the largest home health and hospice company in the western United States. They provide services that meet the needs of patients and families across the healthcare continuum and believe their people deserve care delivered with Compassion, Accountability, Respect, Excellence and Service.
Managing the care of patient panel by leveraging experience and knowledge.
Establishing relationships with patients and families to provide support.
Serving as an advocate and community liaison for patients.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach. We are committed to improving patient outcomes and quality of life by delaying disease progression and shifting care to the home.
Coordinate and support the hospital’s Utilization Review and Case Management program.
Review patient charts and clinical documentation to verify medical necessity.
Monitor patient progress and coordinate care management strategies.
NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. With hospitals in Indiana, Michigan, Texas, and Arizona, they’re expanding access to their unique model of care across the United States.
You will be responsible for using your assessment and communication skills to engage with patients in need of clinical support to determine and prioritize their needs.
Conduct timely telephonic clinical outreach to identified patients.
Collaborate with PCPs, NPs, and other members of the healthcare team to coordinate care for patients and actively help keep them stable at home.
Vytalize Health is building a market leader in value-based healthcare. They are a rapidly growing organization that embraces the power of AI and encourages innovative, responsible use of emerging technologies in their work.
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.
HealthCheck360 focuses on reducing medical costs while increasing employee engagement and productivity. They accomplish this by providing onsite biometric screenings, engaging participants through technology and programming, educating the participant with risk-specific targeted communications, and supporting positive behavior change through Health Coaching and Condition Management programs.
Review daily inpatient and observation admissions across the system.
Evaluate physician documentation and patient data to determine admission status.
Collaborate with interdisciplinary teams for authorizations and medical necessity reviews.
Jobgether is a company that uses AI to help candidates get hired. They use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements.
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.
Deliver coordinated, patient-centered virtual Care Management by telephone or video that improves members' health outcomes.
Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general.
Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family.
Included Health is a healthcare company that delivers integrated virtual care and navigation, aiming to raise the standard of healthcare for everyone. They break down barriers to provide high-quality care for every person, offering care guidance, advocacy, and access to personalized virtual and in-person care.
Provides quality driven telephonic clinical assessments, health education, and utilization management services.
Provides assessments to individuals using telecommunications in accordance with computer-based algorithms, protocols, and guidelines.
Uses clinical knowledge to assess, disposition, make recommendations for care, provide education and health information.
Carenet Health values the expertise and dedication of their team members. They are committed to offering an appealing compensation package and creating an inclusive environment for all employees.
Reviews pre-admissions for correct classification and admission order.
Performs Utilization Review for each patient on their assigned daily census using established medical necessity guidelines.
Communicates with payers regarding authorization and medical necessity, utilizing excellent negotiating skills.
Oregon Health & Science University values a diverse and culturally competent workforce. They are an equal opportunity, affirmative action organization that does not discriminate against applicants.
Processes acute and post-acute inpatient medical and select intensive outpatient higher level of care requests through clinical review.
Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies to requests.
Collaborates with UM department staff and Medical Directors to make a final determination, and with Care Management staff on discharge planning.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. At Capital, employees work alongside a caring team of supportive colleagues and are encouraged to volunteer in their community.
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, 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 provide high-technology health plans that expand benefits, increase access and transparency, and feature a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL), which has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents.
Provide exceptional care, disease management and health education to patients
Support goal setting for individual patients asynchronously to help them better manage their chronic conditions
Create personalized action plans with guidelines to reduce or eliminate unwanted behaviors
Salvo is focused on chronic gut health and metabolic conditions from IBS to obesity, assigning patients a care team and providing app-based care seven days a week. Salvo is backed by leading health care investors from innovators; they offer a culture that drives constant innovation and is marked by relentless curiosity and a sense of empathy.