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.
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 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.
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.
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.
Own first-level reviews of pre-certification requests for medical appropriateness and necessity.
Drive post-service reviews and manage the appeals process for non-certified services.
Coordinate smooth discharges and redirect care in-network to keep patients on track.
Personify Health created the first personalized health platform, bringing health plan administration, wellbeing solutions, and care navigation together in one place. Their team serves employers, health plans, and health systems with a mission to empower people to lead healthier lives.
Develop and coordinate individualized treatment plans and discharge services for patients.
Perform medical record reviews to assess admission appropriateness and ensure compliance with standards.
Support denials management and appeals for insurance claims to ensure quality care.
Northwestern Medicine is a healthcare system focused on patient-first care. We offer a supportive workplace with competitive benefits and a culture of growth.
Conduct Skilled Nursing Facility medical claims audit reviews applying medical review guidelines.
Document findings and generate articulation letters for audit results.
Collaborate with audit team and clients to improve medical policies and workflows.
Machinify is a leading healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. Deployed by over 85 health plans representing more than 270 million lives, the company uses an AI-powered platform and best-in-class expertise to reimagine healthcare.
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.
Our partner is a healthcare organization that provides physician-led clinical oversight across utilization management, medical necessity review, quality management, and virtual healthcare support. The company operates with a collaborative team of senior medical leadership and clinical staff, offering a remote work environment and part-time opportunities.
Review Home Health prior authorization requests using CMS guidelines and clinical judgment.
Lead and mentor the Home Health UM nursing team, ensuring quality and compliance.
Collaborate with cross-functional partners to optimize care and improve utilization.
Clover Health provides high-quality, affordable healthcare for America's seniors by combining data, technology, and preventive care. They are a mission-driven team with diverse expertise, focused on improving members' lives through innovation and empathy.
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.
Conduct utilization review to determine medical necessity of admission and continued stay using established criteria.
Collaborate with payers to secure authorization and work with multidisciplinary teams to reduce length of stay and readmissions.
Provide clinical data for denial management, appeal letter writing, and trend identification to improve processes.
OHSU is Oregon's only public academic health center, providing patient care, groundbreaking research, and training health professionals. As Portland's largest employer, we offer diverse opportunities in a system of hospitals and clinics, committed to building an anti-racist, multicultural institution.
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.
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 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.
Perform prospective, concurrent, and retrospective utilization reviews for behavioral health services across multiple care settings.
Assess medical necessity and coordinate care with providers, members, and internal teams to ensure appropriate access and treatment.
Support discharge planning, benefit utilization, and regulatory compliance while improving overall care quality.
This company provides high-quality behavioral health coordination and utilization management services to improve member outcomes. They foster a supportive, collaborative environment focused on professional growth and clinical excellence.
Conduct telephonic clinical assessments and health education using nursing process and protocols.
Utilize critical thinking to triage, make care recommendations, and document patient interactions.
Work a schedule including evenings and weekends, with full-time flexibility and remote setup.
Carenet Health provides clinical services and health education to patients through innovative telephonic channels. They are a growing organization with a collaborative team of registered nurses across the United States.
Triage and provide clinical support for incoming patient communications.
Conduct phone assessments of clinical symptoms to determine the best path of care.
Assist in the development of processes and systems for urgent care and virtual triage.
Galileo is a team-based medical practice providing high-touch, data-driven, multi-specialty care across the United States. They are a team of healthcare and technology innovators focused on improving care quality and affordability for all.
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.