Lead the Quality Assurance Nurse Investigations Unit, guiding complex investigations into healthcare fraud and regulatory non-compliance.
Apply advanced clinical expertise to ensure accurate, compliant, and defensible investigative outcomes.
Coordinate with executive leadership, review investigation reports, and support strategic initiatives.
Our partner is a state agency that safeguards public healthcare programs by conducting clinical investigations, audits, and regulatory oversight. The organization cultivates a culture of integrity, accountability, and continuous improvement, offering a supportive team environment and comprehensive public-sector benefits.
Conduct clinical and billing reviews of claims, itemized bills, and UB-04 forms to ensure accuracy.
Perform utilization reviews to assess medical necessity and validate charges against policies.
Mentor reviewers, meet productivity targets, and maintain active RN licensure with CEUs.
Our partner is a healthcare services company that conducts medical claims and utilization reviews to ensure accurate billing and appropriate care. They offer a collaborative, quality-focused remote environment with opportunities for professional development.
Conduct quality audits and validate provider data to ensure accuracy, integrity, and compliance with regulatory standards.
Analyze trends, investigate discrepancies, and recommend corrective actions to strengthen provider network operations.
Collaborate with cross-functional teams to document evidence, support accreditation reviews, and drive continuous improvement.
Alliance Health is a managed care organization that coordinates services for individuals with complex needs in North Carolina. They foster a collaborative, mission-driven culture focused on quality, compliance, and remote work flexibility.
Visit our UK care homes and retirement villages, writing detailed reports to keep clinical, operational and quality standards high.
Track and analyse CQC or equivalent regulator reports, feeding regulatory insight back to the relevant teams.
Support educational days, networking events and sector conferences to share best practice.
Octopus is an investor and entrepreneur, with a healthcare fund investing in UK care homes and retirement villages. We're an accredited B Corp that values employees, customers, communities, environment and shareholders.
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.
Review a variety of claim types including Radiology, Ambulance, Physical Therapy, and Surgical for medical necessity and coverage.
Document medical rationale for payment or denial decisions using Medicare guidelines and established criteria.
Educate internal and external staff on medical review, terminology, coverage determinations, and coding.
We transform 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, we are built on integrity, collaboration, and excellence.
Lead, coach, and onboard Utilization Management nurses while managing daily workloads and escalations.
Ensure reviews and determinations are timely, accurate, and compliant with CMS and Clover policies.
Collaborate with Medical Directors and cross-functional teams to improve workflows and member outcomes.
Clover Health provides data-driven healthcare plans for seniors, using the Clover Assistant to support physician decisions. The company is a mission-driven team of diverse experts focused on improving members' quality of life.
Review and validate assigned assessments (SOC, ROC, Recert, Transfer, Discharge) for accuracy and completeness.
Identify and correct errors impacting reimbursement, quality measures, or compliance before submission.
Provide actionable feedback and education to field clinicians to improve documentation and process outcomes.
Adaptive Home Health is a Texas-based home health agency building a higher-acuity, patient-centered care model. They use technology to streamline documentation and QA workflows, supporting clinical operations and compliance teams in a remote-first environment.
Assess patients' immediate and long-term needs through evaluation of social and medical history.
Develop and continuously evaluate individualized plans of care in collaboration with the interdisciplinary team.
Act as a patient advocate, coordinating resources, ensuring compliance, and negotiating cost-effective quality care.
Independent Health provides innovative health care products and benefits designed to engage consumers in their health and well-being. The company serves nearly 400,000 members and fosters a culture of growth, innovation, and collaboration.
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.
Leads claims quality assurance strategy and execution to ensure accurate, timely payments and compliance with Medicare, Medicaid, and regulatory requirements.
Drives continuous improvement through data-driven auditing, trend analysis, and cross-functional collaboration.
Directly supervises team members, evaluates performance, and identifies training gaps to strengthen workflows.
WelbeHealth serves vulnerable seniors through shared intention, pioneering spirit, and the courage to love. It is a growing healthcare organization focused on team culture and mission.
Lead and oversee multiple healthcare audit projects, including PMV and HEDIS activities, from planning through reporting.
Supervise and mentor audit staff, manage budgets and schedules, and serve as a liaison with state Medicaid agencies.
Drive quality improvement, prepare proposals, and present results to clients and stakeholders.
HSAG is a nationally recognized healthcare quality improvement organization specializing in audits, data analysis, measure development, and survey research. The company fosters a supportive culture with work-life balance, flexible schedules, and a commitment to growing staff into future healthcare leaders.
Perform prospective, concurrent, and retrospective utilization review to ensure medical necessity and appropriate level of care.
Research and respond to appeals, coordinate discharge planning, and analyze care patterns.
Collaborate with providers and internal teams to resolve benefit and eligibility issues.
HealthEdge provides AI-powered operational infrastructure for health insurance companies, helping them modernize operations and compete effectively. The company is expanding and investing in its people, offering opportunities to shape the future of healthcare technology.