Provide medical management and utilization management decisions within scope of authority, ensuring compliance with regulations and client expectations.
Conduct medical necessity reviews for rehabilitation services including physical therapy, occupational therapy, speech therapy, chiropractic, and acupuncture.
Support delegated appeals processes, quality assurance, and telehealth consultation while collaborating with senior medical directors and clinical teams.
Conduct medical necessity reviews for inpatient admissions and post-acute services using evidence-based guidelines.
Lead peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate care decisions.
Collaborate with utilization management and care management teams to ensure consistent, cost-effective care.
Our partner company provides utilization management services for Medicare Advantage members, focusing on evidence-based clinical decision-making. It operates with a collaborative, matrixed team and emphasizes regulatory compliance and patient-centered care.
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.
Set daily direction for your UM team, establishing priorities and reinforcing expectations.
Coach reviewers on criteria application, guiding consistent use of medical-necessity criteria.
Monitor workflow health daily, tracking intake volume and turnaround risk.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together. The team is on a mission to empower people to lead healthier lives.
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.
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.
Humana is a leading U.S. healthcare company providing insurance and healthcare services through its Humana insurance and CenterWell healthcare services. It is a large, publicly traded organization with a culture focused on the Humana Way, emphasizing collaboration, accountability, and improving member experiences.
Review and evaluate electronic medical records of emergency department admissions to screen for medical necessity using InterQual or MCG criteria.
Apply evidence-based clinical guidelines to assess and ensure proper utilization of healthcare resources.
Enter clinical review information into the system for transmission to insurance companies for authorization.
Netsmart provides advanced healthcare technology solutions for post-acute and human services clients, enabling better care through a comprehensive platform. We are a vision-driven team passionate about innovation, and we have been recognized as one of the best companies to work for.
Conduct approximately 20 telehealth visits per day with homebound Medicare patients.
Serve as the supervising and collaborating physician for a pod of nurse practitioners and physician assistants.
Review and sign care plans, conduct chart audits, and train care coordinators.
Ennoble Care provides mobile primary care, palliative care, and hospice services in multiple states, offering a continuum of care for patients with chronic conditions. They are a healthcare organization focused on home-based care, with a team that values their motto 'To Care is an Honor.'
Performs clinical evaluations on disability claims to substantiate medical necessity for absence.
Communicates with employees and providers to discuss clinical status and provides follow-up recommendations.
Acts as a clinical resource to claims examiners, ensuring accurate medical terminology and claim decisions.
Sedgwick is the world's leading risk and claims administration partner, helping clients navigate the unexpected with AI-enabled technology and expertise. With over 33,000 colleagues and 10,000 clients across 80 countries, they've been recognized as a Great Place to Work and offer a caring culture.
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.
Provide telephonic case management to proactively drive return to work.
Perform utilization review and coordinate care with providers and adjusters.
Evaluate treatment plans and partner with adjusters to achieve optimal outcomes.
AmTrust Financial Services is a fast-growing commercial insurance company providing comprehensive telephonic case management. They foster a diverse and inclusive culture with a focus on attracting and retaining the best talent.
Manage insurance authorizations for clients in PHP and IOP programs, including pre-certifications and concurrent reviews.
Verify benefits, obtain Single Case Agreements, and build medical necessity cases using ASAM, LOCUS, and CALOCUS criteria.
Maintain accurate authorization, denial, and SCA records and prepare appeals on denied authorizations.
AWA and PRC are dual behavioral health organizations operating PHP and IOP programs across South Florida. They exist to serve clients and families at their most critical moments.
Ensures prior authorization requests meet contractual requirements and are reviewed using evidence-based standards.
Performs concurrent or retrospective review of acute in-patient care services using established criteria.
Participates in Utilization Management Care Programs.
Central California Alliance for Health is a regional non-profit health plan providing accessible, quality health care guided by local innovation to members in five California counties. The organization employs over 500 dedicated employees in a respectful, diverse, professional, and fun culture.
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.
Manage UM nurse team performance, SLAs, and quality improvement.
Handle escalated UM cases and provider disputes 25% of time.
Partner with clients, medical directors, and IDTs to ensure consistent decision-making.
IntusCare builds an end-to-end ecosystem for Programs of All-Inclusive Care for the Elderly (PACE) to improve care, financial performance, and compliance. As a healthcare technology company, we empower teams to improve outcomes for dual-eligible seniors.
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.
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.
Manage the end-to-end credentialing process for assigned therapists, ensuring compliance with all requirements.
Review credentialing documents, complete primary source verifications, and maintain accurate records in multiple systems.
Partner with cross-functional teams to resolve issues and support timely onboarding.
Luna is revolutionizing the delivery of physical therapy by providing in-home care. The company is a start-up with a supportive leadership culture that offers opportunities for growth.
You will provide medical record reviews for second opinions without practicing acute care or prescribing medications.
You can work from home or anywhere with internet access on your own schedule.
You will be covered by top-rated medical malpractice coverage at a discount.
We provide comprehensive second medical opinions via a web-based platform. Our company size is not disclosed, but we offer a flexible, independent contractor culture.
Support member onboarding and care coordination in a remote healthcare environment.
Maintain accurate health records and assist with clinical and administrative tasks.
Collaborate with care teams to improve patient outcomes and operational workflows.
The partner company is a technology-driven healthcare organization focused on improving chronic disease outcomes. It operates with a collaborative global team and offers opportunities for professional growth.
Provide clinical guidance and support to a Virtual Nurse Practitioner in CA, ensuring high-quality patient care.
Ensure compliance with evidence-based clinical guidelines and protocols tailored to telemedicine.
Participate in case reviews, clinical audits, and quality improvement initiatives to maintain superior care standards.
Sprinter Health is an on-demand mobile health service that sends medical professionals to patients’ homes to perform blood draws, diagnostic and low acuity services, and wellness visits. We have a rapidly growing team of visionary leaders who are passionate about increasing access to care.