Supervise day-to-day operations of clinical compliance auditors and specialists, serving as a liaison to senior management.
Coordinate orientation, training, and performance monitoring for clinical compliance auditors to promote professional growth.
Oversee development of UM and PHM agenda, audit guidelines, and ensure adherence to denial processes and compliance requirements.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence, aiming to make healthcare affordable and improve patient health. It is a physician-led, remote-first organization that leverages AI and predictive analytics to empower partners in delivering high-quality, value-based care.
Perform utilization review including precertification and concurrent reviews using medical necessity criteria.
Collaborate with medical directors and providers on complex cases and integrate AI tools into workflow.
Initiate referrals to disease management programs and participate in quality improvement initiatives.
Guidehealth is a data-powered healthcare company that uses AI and predictive analytics to improve healthcare affordability and patient outcomes. It is a physician-led organization with a culture of accountability, learning, innovation, and empathy.
Build meaningful relationships with patients and families to understand their goals and barriers.
Create personalized care plans addressing medical, behavioral, and social needs.
Coordinate care across providers and settings, ensuring safety, quality, and continuity.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to making great healthcare affordable and improving patient health. As a physician-led organization with a high degree of agility, it employs a remote team and fosters a collaborative, mission-driven culture focused on continuous learning.
Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies.
Collaborates with client personnel to resolve customer concerns and facilitates resolution of escalated cases.
Maintains written documentation per HealthHelp’s policy and ensures compliance with HIPAA, state, and federal regulations.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With three global headquarters, operations in 13 countries, 65 delivery centers, and more than 66,000 employees, WNS combines scale, expertise, and execution to create meaningful, measurable impact.
Review Home Health prior authorization requests for medical necessity using CMS regulations and Clover clinical guidelines.
Perform initial and concurrent clinical reviews, ensuring appropriate care in the least restrictive setting.
Collaborate with providers and internal teams to support timely decision-making and positive member outcomes.
Clover Health is a healthcare company that uses data and technology to provide affordable, high-quality insurance plans for seniors. The company fosters a remote-first culture with a diverse and mission-driven team focused on improving member outcomes.
Provide telephonic triage assessments and health education using nursing protocols and algorithms.
Utilize critical thinking and communication skills to manage diverse patient populations.
Work a flexible schedule that includes evenings and weekend shifts from your home office.
Carenet Health provides telephonic clinical assessments, health education, and utilization management services to patients and members. They are a growing organization with a collaborative national team of Registered Nurses, offering work-from-home options and a supportive culture.
Review patient records and healthcare documentation to ensure compliance with regulatory standards.
Evaluate accuracy and completeness of clinical documentation, including OASIS guidelines and coding.
Collaborate with interdisciplinary teams to enhance patient outcomes through quality improvement initiatives.
Jobgether is a job platform that uses AI-powered matching to connect candidates with hiring companies. They partner with various employers to manage recruitment processes.
Provide clinical and operational leadership to support timely, evidence-based coverage determinations in Utilization Management.
Coach reviewers on consistent application of medical-necessity criteria, medical policy, and benefit plan language.
Monitor daily workflow health, coordinate coverage plans, and communicate barriers and risks to the UM Manager.
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. The company serves employers, health plans, and health systems with data-driven solutions and is on a mission to empower people to lead healthier lives.
Support quality, safety, and compliance by identifying documentation and workflow improvements.
Process physician orders within the EMR and ensure verbal orders meet documentation requirements.
Manage end-of-episode documentation, including discharge reports and OASIS visits.
Adaptive Home Health is an AI-native physical care platform transforming US healthcare, starting with home health. The company combines a world-class AI team with healthcare veterans to build a new type of healthcare company that delivers care at the speed of an AI company.
Shape and govern multi-state licensure and regulatory compliance for non-clinical home care operations.
Define strategy, operating model, and governance framework for compliant state expansion and ongoing readiness.
Translate complex state regulations into actionable operational requirements supporting scalable service delivery.
This partner company is a high-impact healthcare organization focused on improving care delivery and outcomes. It operates in a fast-scaling, mission-driven environment with a remote-first work culture.
Must have at least 5 years' RN experience with current licensure, a bachelor's degree or equivalent, and at least 1 year of leadership with direct reports.
Responsible for overseeing RN denials management specialists, pre-bill utilization reviews, payer calls, workflow optimization, and collaboration with internal RCM teams.
Blends clinical expertise with revenue cycle management to protect the organization's bottom line, decrease A/R, and ensure compliance.
Banner Health is one of the largest nonprofit health care systems in the country, providing hospital services, primary care, research, and physician practices across multiple states. With 31 facilities and a focus on innovation, they recently earned Great Place To Work certification, reflecting their investment in employee happiness and fulfillment.
Ensure acute hospital admissions have appropriate level of care and meet medical necessity.
Monitor patient progress in plan of care for continued stay.
Provide clinical information to payer to authorize acute hospital stay and continued services.
Piedmont Healthcare is a healthcare organization focused on patient outcomes. It offers a supportive culture with diverse teams, schedule flexibility, and comprehensive benefits, fostering employee growth and well-being.
Provide clinical assessment and nursing triage to diverse patients across the health continuum.
Assist in directing patients to the most appropriate level of care via telephonic health information.
Work in collaboration with Telehealth providers for virtual care visits and follow-up calls.
We bring hospitals and healers together in the pursuit of clinical effectiveness. With a portfolio of over 8 million patients, 7500 providers, and 400 healthcare facilities, we are a leader in clinical practice management with a culture of belonging and empowerment.
Provides visionary leadership and strategic direction for care coordination and service delivery teams.
Drives transformational initiatives to scale operations, enhance quality, and improve patient outcomes.
Uses data analytics and key performance indicators to monitor program effectiveness and guide evidence-based decision-making.
WellSky is a technology company that provides software, analytics, and services for intelligent, coordinated care across health and community care. The company fosters a culture of independent thinking, collaboration, and innovation, with a focus on improving outcomes and lowering costs.
Perform daily audits on client data for completeness and accuracy of coding using clinical knowledge.
Respond to provider appeals and meet client turnaround time and KPI goals.
Utilize coding validation training to become familiar with claims payment policies and regulations.
Cotiviti is a healthcare analytics company that uses data-driven solutions to improve payment accuracy and quality in healthcare. The company offers a competitive benefits package and fosters a collaborative, fast-paced work environment.
Provide telephonic case management and utilization review for assigned consumers.
Develop, implement, and monitor individualized care plans to ensure quality and cost-effective outcomes.
Collaborate with healthcare providers, payors, and internal teams to coordinate care.
Cottingham & Butler helps clients through life's toughest moments by providing insurance and benefits solutions. The company fosters a culture of continuous improvement, seeking to hire, train, and grow the best professionals in the industry.
Lead, coach, and develop a team of Engagement Specialists through regular feedback and performance management.
Conduct compassionate outreach to patients, explain services, and guide them through onboarding with accurate EHR documentation.
Oversee daily operations, optimize PRM workflows, and collaborate with clinical teams for seamless care transitions.
The employer is a mission-driven healthcare organization dedicated to improving access to behavioral health support for individuals navigating complex medical journeys. It is a fast-growing, startup-like company with a collaborative culture focused on continuous learning and innovation.
Manage provider and clinic compliance relationships, including onboarding and edge case resolution for approximately 3,500 clinics.
Lead investigations into prescribing pattern anomalies and credential lapses, producing written summaries and communicating outcomes.
Build and deliver compliance training for the sales team and develop provider-facing educational materials.
Strive Pharmacy is a personalized compounding pharmacy focused on individualized care and genuine partnership with patients and providers. The company is growing and seeks people who share their conviction for a more human approach to healthcare.
Manage patient physiological markers and provide clinical triage.
Conduct wellness calls and collaborate with care teams to set health goals.
Drive patient engagement and ensure adherence to RPM program standards.
Vivo Care is building a platform to make healthcare continuous, personal, and truly connected. It is a fast-growing startup with a culture of inclusion, collaboration, and innovation.
Lead and develop a team of Patient Success Advocates, providing coaching and performance management.
Monitor team metrics like volume, response times, and patient satisfaction to drive improvements.
Serve as escalation point for complex patient interactions and collaborate cross-functionally.
Cadence is a clinical AI company that automates the treatment of chronic disease. It partners with 20+ leading health systems, serves over 100,000 patients, and has been recognized by TIME and LinkedIn as a top startup.