Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members.
Guide timely care determinations using CMS regulations and evidence-based practices.
Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
HJ Staffing is seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. The company has not provided any information about its size/employees and culture but is likely a medium to large medical or staffing company.
Conduct coverage reviews based on member plan benefits and policies.
Document clinical review findings, actions, and outcomes.
Communicate and collaborate with providers for benefit determinations.
Capital Blue Cross promises to go the extra mile for their team and community. They foster a flexible environment where health and wellbeing are prioritized and employees consistently vote it as one of the "Best Places to Work in PA."
Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
Provide medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.
Centene is committed to helping people live healthier lives. They provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well. Centene values diversity and is an equal opportunity employer.
Review and refine AI-generated clinical summaries and indicators related to medical necessity.
Collaborate with Product and Data Science teams to define and validate clinical logic.
Translate clinical knowledge into prompts and guidelines for large language models.
SmarterDx builds clinical AI that is transforming how hospitals translate care into payment. Founded by physicians in 2020, their platform connects clinical context with revenue intelligence, helping health systems recover millions in missed revenue, improve quality scores, and appeal every denial.
Review medically complex claims, pre-authorization requests, appeals, and fraud/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 (SDVOSB), they empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth.
Performing physician-level utilization management reviews for behavioral health services across all applicable levels of care.
Conducting peer-to-peer consultations with treating psychiatrists and other behavioral health providers.
Serving as a consultative clinical resource to behavioral health utilization management nurses, care managers, and operational leaders.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine for providers. Driven by empathy and AI, they leverage remotely-embedded Healthguides™ and a centralized Managed Service Organization.