Review and process appeals submitted by members and providers, ensuring timely and accurate resolution.
Evaluate cases, determine next steps, and manage multiple priorities while meeting strict turnaround times.
Review clinical and medical records, summarize findings for Medical Director review, and operate within turnaround times as short as 24–72 hours.
BlueCross BlueShield of Tennessee has been helping Tennesseans find their own unique paths to good health since 1945. At BCBST, they empower their employees to thrive both independently and collaboratively, creating a collective impact on the lives of their members.
Oversee prior authorization technicians and administrative PA functions.
Analyze data and provide staffing, workflow, and system enhancement recommendations.
Investigate/resolve escalated issues from clients and providers.
Judi Health is an enterprise health technology company providing a suite of solutions for employers and health plans. They have a comprehensive Enterprise Health Platform that consolidates all claim administration-related workflows in one scalable, secure platform.
Performs advanced level work related to denial management.
Processes and follows up on all appeal types, at an expert level, to all payers.
Takes actionable steps to resolve open claims, including refiling or appealing claims, or resolving manual tasks.
US Anesthesia Partners is a company that provides anesthesia services. They provide equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, gender identity, sexual orientation, pregnancy, status as a parent, national origin, age, or disability.
Manages medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.
Utilizes clinical background to address the clinical denials, as well as write sound, compelling factual arguments for appealing denials.
Responsible for maintaining a detailed knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria, as well as filing compliant appeals.
Shriners Children’s respects, supports, and values each other. They are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact and were named as the 2025 best mid-sized employer by Forbes.
Supervise day-to-day operations of assigned Utilization Management staff.
Provide full people management for assigned Utilization Management teams, including hiring and performance management.
Drive team performance against key metrics, including engagement, productivity, and quality scores.
Personify Health has created a personalized health platform, bringing health plan administration, wellbeing solutions, and care navigation together. Their data-driven solutions aim to reduce costs while improving health outcomes, empowering people to lead healthier lives.
Conduct high-volume calls with patients, providers, and pharmacies using established protocols.
Collaborate with patients to remove barriers to medication adherence and escalate clinical barriers to a pharmacist.
Accurately document all interactions, outcomes, and identified barriers in appropriate systems.
Aledade empowers independent primary care practices to deliver better care and thrive in value-based care. Founded in 2014, they've become the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.
Resolve aged claims and appeals via payer portals & outbound phone calls.
Identify non-payment trends and escalate groups of claims to the Dispute Resolution teams.
Propose solutions and collaborate cross-functionally with the Denials Management Steering Committee.
CareDx, Inc. is a precision medicine solutions company focused on healthcare solutions for transplant patients. They offer products, testing services, and digital healthcare solutions. They are the leading provider of genomics-based information for transplant patients.
Deliver an outstanding customer experience by supporting inquiries across phone, email, text, and chat.
Manage high-complexity insurance workflows and inbound support requests to collect documentation.
Partner with clinical, scheduling, and operations teams to ensure accurate treatment plan alignment and continuity of care.
Expressable is a virtual speech therapy practice that aims to transform care delivery and expand access to high-quality services. Since 2019, they serve thousands of clients with a focus on parent-focused intervention and an e-learning platform with home-based learning modules.
Supports outbound calls and data/benefit analysis related to various clinical pharmacy programs.
Performs advanced administrative/operational/member support duties.
Initiates and responds professionally to a high volume of calls in a timely and efficient manner.
Capital Blue Cross promises to go the extra mile for their team and community. It appears to be a large company, that values its employees, as they are consistently voted one of the “Best Places to Work in PA”.
Oversee enrollment and billing operations across all Government Programs including Medicare Advantage, Medicare Supplement, CHIP, and ACA products to ensure accuracy and operational performance.
Lead Medicare Advantage appeals and grievances operations to ensure timely, compliant resolution and audit readiness in accordance with CMS requirements.
Drive process improvement initiatives and cross-functional coordination to enhance regulatory outcomes, member experience, and operational efficiency.
Capital Blue Cross is a health insurance company and independent licensee of the Blue Cross Blue Shield Association that promises to go the extra mile for its team and community. It is consistently voted one of the 'Best Places to Work in PA,' fosters a flexible environment prioritizing health and wellbeing, and invests heavily in employee training and continuing education.
Primarily responsible for making outbound calls to healthcare providers.
Accepting inbound calls from healthcare providers.
Answer questions about participation requirements, registration, assessment completion and scoring results.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With over 66,000 employees, we combine scale, expertise and execution to create meaningful, measurable impact.
Analyzes and answers inquiries regarding pharmacy claims adjudication.
Adjudicates pharmacy claims and processes pharmacy claims for payment.
Performs varied activities and moderately complex administrative/operational/customer support assignments.
Humana is committed to helping people live healthy lives, creating personalized experiences, and working collaboratively. They offer medical, dental, and vision benefits, a 401(k) retirement savings plan, and paid time off.