Conduct medical necessity reviews and continued stay reviews using approved clinical criteria to support quality and financial outcomes.
Collaborate with liaisons, physicians, and revenue cycle teams to manage denials, appeals, and appropriate levels of care.
Maintain documentation, monitor utilization trends, and facilitate patient care planning across the care team.
Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They empower associates to challenge the status quo and put people first, fostering a collaborative and innovative culture.
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.
Oversee system-level utilization management activities across the organization.
Ensure compliance with medical necessity criteria such as InterQual and Milliman.
Manage professional staff and review processes to optimize patient care.
Piedmont Healthcare is a healthcare system providing comprehensive medical services. It is a large organization focused on utilization management and quality care.
Perform prospective, concurrent, and retrospective reviews of healthcare services to ensure medical necessity and appropriate level of care.
Contact medical and support personnel to recommend alternative treatment plans and coordinate care across the healthcare continuum.
Research and resolve issues related to benefits, eligibility, and appeals while delivering targeted education to providers.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, covering claims administration, payment integrity, and care management. The company is experiencing significant momentum and investing in employees who directly shape the future of healthcare technology.
Performs pre-admission, admission, and continued stay reviews using approved medical necessity criteria.
Coordinates patient care and communicates with physicians, patients, caregivers, and third-party payers.
Manages patient progression through the healthcare system and proactively works with payers to secure certification and minimize denials.
Ochsner Health is a leading not-for-profit healthcare provider in the Gulf South, with 46 hospitals and 370+ care centers. It employs more than 38,000 team members and has been recognized as a top workplace and the No. 1 hospital in Louisiana.
Oversee medical necessity reviews for home health, acute, post-acute, and outpatient services for Medicare Advantage populations.
Collaborate with treating physicians, nursing teams, and external agencies to promote evidence-based care and appropriate resource utilization.
Apply CMS regulations, coverage determinations, MCG criteria, and medical policies in a fully remote, part-time physician leadership role.
Jobgether is an AI-powered job matching platform that connects candidates with employers. It uses objective screening to share top-fitting applicants with hiring companies, emphasizing data privacy and human oversight throughout the recruitment process.
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.
Coordinates utilization review and prior authorization requests, ensuring accurate entry into the UM platform.
Provides customer service to providers and members, confirming benefits and answering authorization questions.
Facilitates communication between reviewers, hospitals, and physicians to ensure timely decisions.
University of Utah Health Plans is a patient-focused organization that enhances health through patient care, research, and education. It is part of a nationally ranked academic medical center with five hospitals and eleven clinics, fostering a culture of collaboration and excellence.
Manage and triage patient vital signs remotely, using motivational interviewing to drive positive health behavior changes.
Perform monthly wellness calls with patients, collaborating with care teams to set patient-centric goals.
Escalate urgent care needs appropriately and meet program engagement metrics in a remote MST-based role.
Vivo Care is building a future where care is continuous, personal, and connected, challenging the status quo in healthcare. We are a fast-growing startup where everyone has a voice, fostering a culture of inclusion, collaboration, and innovation.
Provide education and self-management support based on the patient's unique learning style, and coordinate care as an advocate and resource.
Conduct comprehensive assessments of medical, behavioral, pharmaceutical, and social needs, and collaborate with the care team to design care plans.
Support population health initiatives and measure quality outcomes to reduce unnecessary utilization and improve patient health.
Aledade PBC empowers independent primary care by creating value-based contracts and flipping the script on fee-for-service. Founded in 2014, it is the largest network of independent primary care in the country, with a remote-first, collaborative, and inclusive culture.
Lead clinical excellence managers across the Western U.S. to drive account management and customer success.
Partner with sales and cross-functional teams to support product adoption, expansion, and patient care standards.
Develop processes, training, and business planning to enhance customer satisfaction and strategic growth.
Outset is a trailblazing medical device company revolutionizing dialysis with the Tablo Hemodialysis System. Our culture revolves around moving farther, faster, together, with every person mattering in our mission to transform patient care.
Provide patient-centered care navigation and telephonic clinical outreach to patients with chronic conditions.
Collaborate with PCPs, NPs, and care teams to coordinate treatment and support safe transitions home.
Serve as a key resource for patients, caregivers, and community agencies, implementing interventions that improve outcomes.
Vytalize Health is a healthcare company focused on value-based care for patients with chronic or serious conditions. It is a rapidly growing organization with an entrepreneurial, patient-forward culture, and you will play a key role in building a market leader.
Acts as a patient advocate coordinating transitions to the next level of care per regulations and agency policies.
Collaborates with MJHC and inpatient facilities to evaluate inpatients for transitional planning and home health services.
Uses telephonic outreach with discharge planners and case managers for Elderplan's SNP.
Elderplan and HomeFirst are Medicare and Medicaid managed care health plans under MJHS, offering personalized care to help people remain independent. MJHS fosters a collaborative culture focused on excellence, respect, work-life balance, and career development.
Perform quality audits on clinical documentation across clinical departments.
Collaborate with leadership to develop corrective action plans and provide 1:1 coaching.
Support organizational readiness for NCQA and other regulatory audits.
Oscar is the first health insurance company built around a full stack technology platform, focusing on serving members with a concierge-level experience. It started in 2012 and is an Equal Opportunity Employer cultivating an authentic, inclusive environment.
Provide high-quality, person-centered care management to high-risk members.
Coordinate care across medical, behavioral, and social services using evidence-based approaches.
Engage members through motivational interviewing and develop individualized care plans.
IEHP is a not-for-profit health plan serving members in Southern California's Inland Empire. It fosters a team culture focused on healing and inspiring the human spirit, offering competitive benefits and professional development.
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established coverage guidelines.
Educate teams on medical review processes and support quality control activities.
Broadway Ventures is a veteran-owned small business delivering mission-critical support to federal health and defense customers. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it is built on integrity, collaboration, and excellence.
Perform medical reviews and utilization management to determine medical necessity for services and appeals.
Evaluate medical records and document decisions using clinical guidelines and protocol sets.
Educate members, providers, and staff on coverage determinations, medical terminology, and coding procedures.
Palmetto GBA is a healthcare administrator and one of the nation's largest medical claims processors. As part of BlueCross BlueShield of South Carolina, we've served clients for 70+ years and offer training and tuition assistance.
Lead external customer audits and utilization management oversight activities as a subject matter expert.
Analyze complex UM data, investigate findings, and prepare evidence-based responses for regulators and accreditation organizations.
Collaborate with operational, technical, and client-facing teams to drive compliance and process improvements.
This company is a healthcare organization specializing in utilization management and regulatory compliance. It operates with a remote team across the United States, fostering a collaborative and improvement-driven culture.
Provide strategic and operational leadership for assigned onsite health centers, ensuring alignment with client and organizational goals.
Oversee occupational health services including injury prevention, return-to-work programs, and workers' compensation management.
Mentor nursing leaders and collaborate with interdisciplinary teams to drive clinical quality, compliance, and workforce health outcomes.
Concentra is the nation's leading occupational health care company, with more than 40 years of experience providing employer-sponsored workplace health services. Its culture emphasizes service mentality, attention to detail, and proactive care for America's workforce.
Hire and manage a team of Oscar colleagues with direct responsibility for performance management, growth, and development.
Monitor operational KPIs, conduct root-cause analysis, and construct action plans to drive team performance.
Serve as a central communicator by leading team huddles and connecting colleagues to Oscar's mission, vision, and values.
Oscar is a health insurance company built around a full stack technology platform and a relentless focus on serving members. They started in 2012 to create a kind of health insurance company that behaves like a doctor in the family, fostering an inclusive culture where people can be their most authentic selves.