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.
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.
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.
Perform case reviews and process requests for elective services and durable medical equipment.
Collaborate with physicians, vendors, and providers to ensure regulatory compliance and timely service.
Provide high-quality customer service to members and healthcare professionals.
Elderplan provides Medicare and Medicaid managed care health plans designed to help people stay independent. They are part of MJHS, a supportive community committed to excellence, respect, and collaboration.
Deliver virtual, patient-centered care with empathy and clinical excellence.
Triage patient concerns using evidence-based protocols and sound clinical judgment.
Coordinate laboratory follow-ups, referrals, and diagnostic services across the care team.
MyLaurel is a healthcare organization delivering virtual acute care support to vulnerable patients. They are a collaborative, high-performing team focused on transforming healthcare delivery.
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.
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.
Conducts utilization review to determine medical necessity of admission and continued stay using established criteria.
Communicates with payers to secure authorization and negotiate medical necessity decisions.
Educates providers on documentation requirements and participates in strategies to reduce length of stay and readmissions.
OHSU is Oregon’s only public academic health center, providing patient care and conducting groundbreaking research while training health care professionals. As Portland’s largest employer, it offers a diverse and inclusive culture with opportunities for growth across Oregon and Southwest Washington.
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.
Perform concurrent inpatient utilization review using InterQual criteria to determine medical necessity.
Engage in clinical collaboration with physicians and care teams to support appropriate level-of-care decisions.
Maintain documentation, comply with regulations, and ensure quality customer service.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations serving over 700 clients across 10 industries. With over 66,000 employees across 13 countries and 65 delivery centers, the company combines scale and expertise to create meaningful impact.
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.
Collaborate with primary care providers to coordinate care for patients with multiple chronic conditions, ensuring high-quality care through telephonic and in-person outreach.
Conduct transitional care management including post-discharge follow-up and provide education on lifestyle coaching and dietary improvements.
Operate independently to achieve goals, attend regular care team meetings, and perform other duties as assigned.
Privia Health is a technology-driven national physician enablement company that collaborates with medical groups and health systems to optimize practices and improve patient care. The company is led by top industry talent and focuses on scalable operations and cloud-based technology to reduce healthcare costs and improve outcomes.
Act as a liaison for a patient panel of medically stable patients, coordinating care between internal and external providers.
Monitor and triage lab orders and results, providing education and medical management support to patients and families.
Triage emergent issues in a time-sensitive manner and coordinate care with hospitals for medical stabilization admissions.
Equip is the leading virtual, evidence-based eating disorder treatment program on a mission to ensure everyone with an eating disorder can access treatment that works. Founded in 2019, the company is fully virtual and has been recognized as one of the most influential companies of 2023, with a diverse and passionate team.
Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
Review inpatient and outpatient medical records to support appeal submissions and apply payer-specific guidelines.
Document review findings accurately and meet assigned turnaround times while maintaining quality standards.
CorroHealth helps clients exceed their financial health goals by providing scalable solutions and clinical expertise across the reimbursement cycle. The company fosters a supportive culture that invests in professional development and personal growth.
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.
Responsible for using assessment and communication skills to engage patients in need of clinical support, determine priorities, and deliver patient-centered care.
Identify patient education needs through telephonic assessment and collaborate with healthcare teams to coordinate care and keep patients stable at home.
Serve as point of contact for patients, families, and providers, implementing interventions to improve health outcomes and reduce costs.
Vytalize Health is a value-based healthcare company that coordinates care for patients with chronic conditions, aiming to improve outcomes and lower costs. It is a rapidly growing organization with a startup culture, offering a dynamic environment.
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.
Guide patients through the healthcare system by translating medical complexity into plain language and coordinating care.
Build and own care plans that address both medical needs and social determinants like transportation and food access.
Solve real problems with persistence by navigating denied claims, missed referrals, and unaffordable medications.
Careway Health is building an advocacy-first telehealth platform to help seniors overcome complex health and social challenges and maximize independence. They are a growing company focused on democratizing access to high-quality care with a team of physicians and health advocates.
Serve as the main point of contact for patients and families transitioning from or seeking post-acute services.
Make clinical level-of-care determinations using discussions, medical records, and other clinical data.
Provide patient education on home health, hospice, palliative care, Medicare coverage, and billing.
Gentiva is a national leader in hospice, palliative, and home health care, providing compassionate care to patients in their homes. With nearly 600 locations and thousands of clinicians across 38 states, they offer a collaborative environment where inspiring achievements are recognized.
Manage the member's clinical experience from request through desired outcome, including account activation and medical history drafting.
Coordinate video or phone consults with specialists and schedule monitors in advance, troubleshooting issues as needed.
Conduct ongoing follow-up post-consult and facilitate local recommendations, communicating with primary care physicians or specialists.
Transcarent is a health and care platform that combines medical, pharmacy, and point solutions with a generative AI-powered experience for health consumers. With over 1,700 employer and health plan clients serving 21 million Members, they foster a culture of People First, Care, Resilience, Results, and Humble and Human.