Conduct prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services.
Collaborate with Medical Directors to draft denial language and ensure consistent use of standardized UM criteria.
Support the UM Team with benefit interpretation and participate in LEAN activities to achieve department goals.
IEHP is a health plan committed to healing and inspiring the human spirit. They offer a supportive culture with career advancement opportunities, wellness programs, and a state-of-the-art fitness center.
Work independently to make clinical decisions on routine patient care matters at your license level.
Provide patient-focused care and guidance on the phone or online, accurately assessing needs and directing to appropriate care.
Communicate with clients and team members, monitor performance metrics, and document all interactions via management software.
Carenet Health provides telehealth and virtual care clinical triage, health education, and other services to diverse populations of patients and health plan members. As one of America's fastest-growing private companies, it partners with over 250 premier health plans and health systems, with compassion-focused teams guiding people via phone, video, and chat.
Perform prospective, concurrent, and retrospective utilization review to ensure medical necessity and appropriate level of care.
Research and respond to appeals, coordinate discharge planning, and analyze care patterns.
Collaborate with providers and internal teams to resolve benefit and eligibility issues.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, helping them modernize operations and compete effectively. The company is expanding and investing in its people, offering opportunities to shape the future of healthcare technology.
Conduct clinical reviews of inpatient admissions and continued stays using approved medical necessity criteria.
Collaborate with physicians, care managers, and payer teams to resolve utilization concerns and prevent denials.
Support quality improvement initiatives, maintain accurate documentation, and communicate review outcomes effectively.
This role is with a partner company focused on healthcare utilization management, helping hospitals improve patient outcomes and ensure appropriate resource use. The team operates as a distributed remote group supporting care coordination, revenue integrity, and clinical compliance.
Perform clinical reviews to evaluate medical necessity, level of care, and benefit coverage for members.
Apply internal policies, MCG, and NCCN guidelines to deliver timely and compliant utilization management decisions.
Escalate complex cases and build audit-ready documentation for Medical Director review.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. Their mission-driven culture empowers diverse perspectives to drive real impact on people's health.
Manage case assignments with extensive patient outreach via telephone, documentation, and monitoring for progression and closure.
Coordinate and provide timely, equitable, and member-centric care while following HMO processes.
Assist members in reaching wellness by addressing barriers, social determinants, and psychosocial issues.
Guidehealth is a physician-led, value-based care healthcare company that improves health outcomes by making care more accessible and connected. They are a remote-first organization with a focus on compassionate human support and innovative technology.
You perform complex medication reconciliations and identify clinical red flags to prevent ER visits and readmissions.
You deliver high-touch engagement for high-risk patients through post-discharge follow-up and care coordination.
You collaborate with practices and document interventions across multiple EHRs to ensure care gaps are closed.
Aledade PBC is a public benefit corporation that empowers independent primary care by creating value-based contracts. Founded in 2014, we are the largest network of independent primary care in the country, with a remote-first culture that is collaborative and inclusive.
Conduct comprehensive telephonic assessments and develop individualized care plans for patients with chronic conditions.
Use Motivational Interviewing to promote self-management and coordinate care with interdisciplinary teams.
Monitor biometric data and IVR trends to identify clinical risks and prevent hospitalizations.
The company provides telephonic nurse care management services for patients with chronic conditions, using technology-enabled care delivery. It has a mission-driven, collaborative culture focused on innovation and patient impact, with a fully remote team.
Conduct nursing assessments and enroll patients in chronic care management programs.
Develop individualized care plans and coordinate transitions to improve outcomes.
Collaborate with providers and teams to support value-based care delivery.
Jobgether is an AI-powered job platform that matches candidates with hiring companies. It focuses on objective, efficient recruitment and partners with healthcare organizations.
Lead, coach, and onboard Utilization Management nurses while managing daily workloads and escalations.
Ensure reviews and determinations are timely, accurate, and compliant with CMS and Clover policies.
Collaborate with Medical Directors and cross-functional teams to improve workflows and member outcomes.
Clover Health provides data-driven healthcare plans for seniors, using the Clover Assistant to support physician decisions. The company is a mission-driven team of diverse experts focused on improving members' quality of life.
Manage a portfolio of clients, providing education, advocacy, and care coordination.
Conduct clinical intakes via email or phone to assess needs and guide next steps.
Collaborate with internal teams and support triage for new patients.
Private Health Management guides patients and families through serious medical care as an independent advocate. A remote company with employees across the US, it focuses on better outcomes through expert coordination and compassionate support.
Assess patients' immediate and long-term needs through evaluation of social and medical history.
Develop and continuously evaluate individualized plans of care in collaboration with the interdisciplinary team.
Act as a patient advocate, coordinating resources, ensuring compliance, and negotiating cost-effective quality care.
Independent Health provides innovative health care products and benefits designed to engage consumers in their health and well-being. The company serves nearly 400,000 members and fosters a culture of growth, innovation, and collaboration.
Review, investigate, and appeal denied hospital insurance claims using clinical documentation and payer policies.
Develop evidence-based appeal letters addressing medical necessity, level-of-care, and charge discrepancies.
Collaborate with nursing, revenue integrity, and financial teams to resolve denials and prevent future rejections.
This partner company is a healthcare system that provides hospital services and focuses on revenue integrity. It supports fully remote work and values clinical expertise, collaboration, and financial sustainability.
Handle over 100 calls per day and schedule appointments for office, lab, and nurse visits.
Take detailed messages based on provider protocols and multitask across multiple offices.
Use independent judgment to prioritize urgent versus routine matters.
Silver Cross Hospital is a healthcare organization committed to providing exceptional patient care and community services. They foster a culture of excellence and offer a comprehensive benefits package to support their employees.
Conduct telephonic nursing assessments and triage using clinical protocols.
Provide health education and care recommendations to patients.
Collaborate with remote RNs to meet quality and performance metrics.
Carenet Health delivers telephonic clinical assessments, health education, and utilization management services. They are a growing, collaborative company with a nationwide remote team of registered nurses.
Clarity Pediatrics is a virtual clinic reimagining pediatric chronic care, starting with ADHD and expanding to obesity and overweight management. It is a fast-growing startup with a remote-friendly culture and a leadership team committed to clinical excellence.
Coordinate interdisciplinary care plans and serve as a liaison between patients, providers, and insurance partners.
Provide telephonic nursing triage, health guidance, and on-call support according to agency protocols.
Manage lab results, referrals, prescription refills, and patient follow-up to ensure continuity of care.
Planned Parenthood of the Pacific Southwest provides sexual and reproductive healthcare across 20 health centers in Southern California. The organization fosters a collaborative, mission-driven culture with over 100 years of advocacy.
Conduct timely post-discharge outreach and assessments for high-risk patients.
Coordinate telephonic care, medication reconciliation, and patient education.
Connect patients with community resources and collaborate with care teams.
UnityPoint Health is a healthcare system delivering coordinated care and services across clinics and hospitals. Recognized as a top workplace in healthcare, it fosters a culture of belonging and team member support.
Provide direct patient care using the nursing process, from assessment to evaluation.
Collaborate with the care team to monitor patients, adjust care plans, and ensure safety.
Maintain EHR documentation, administer treatments, and delegate to support staff.
Advocate Health is a top nonprofit, integrated health system in the US, formed from Advocate Aurora and Atrium Health. It serves 6 million patients and employs 155,000 teammates across 69 hospitals, with a culture focused on equitable care and innovation.
Build relationships with patients and caregivers through in-person re-engagement in southern New Jersey.
Support re-enrollment, onboarding, app setup, and telephonic outreach to reconnect families to care.
Partner with interdisciplinary teams and local resources to address barriers to care and social needs.
Imagine Pediatrics is a tech-enabled, pediatrician-led medical group reimagining care for children with special health care needs. It provides 24/7 virtual-first and in-home medical, behavioral, and social care, with a culture centered on compassion and creativity.