Evaluate hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
Guide timely care determinations using CMS regulations and evidence-based practices while collaborating with care management teams and external providers.
Conduct timely medical necessity determinations for inpatient admissions and post-acute settings.
Review daily inpatient and observation admissions to determine appropriate status.
Collaborate with physicians, case management, and insurance partners.
Utilize electronic medical records to support documentation, review, and reporting.
Logan Health aims to deliver quality, compassionate care for all, reimagining health care through connection, service and innovation. They value kindness, collaboration, trust, and strive for excellence in a supportive, mission-driven nursing culture.
Assists in development and maintenance of an efficient UM program to meet the needs of health plan members commensurate with company values.
Perform clinical reviews (i.e., part A, B, appeals, quality of care) and conduct peer to peer discussions.
Provide appropriate mentoring and leadership to clinical teams as well as develop relationships to support growth and fiscal responsibility.
Devoted Health is dedicated to improving the health and well-being of older Americans by providing all-in-one healthcare solutions. Founded in 2017, they've rapidly expanded across the United States, fostering a diverse and collaborative work environment where employees are valued for their unique perspectives.
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.
Serve as the Medicare coverage determinations and redeterminations subject matter expert.
Create and uphold robust policies and procedures for coverage determinations and redeterminations in accordance with CMS guidelines.
Recruit, onboard, train, and manage Medicare PA and Appeals pharmacists and technicians.
Judi Health provides a comprehensive suite of solutions for employers and health plans. Together with our clients, they’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve.