As an Investigative Clinician, you will blend clinical expertise with investigative acumen to detect, prevent, and resolve fraudulent, exaggerated, or non-medically necessary claims. You'll collaborate with adjusters, legal teams, and investigators to analyze medical documentation and uncover inconsistencies or red flags. Responsibilities include reviewing medical records, identifying patterns of fraud, providing clinical expertise, interviewing claimants, and preparing clinical summary reports.
As Senior Medical Director for Utilization Management (UM), you will be an effective change leader and help develop and guide the strategic direction for Utilization Management initiatives. It is essential to be a self-directed and results-oriented physician who leads by example to serve as Wellmark's subject matter expert on effective and efficient processes to reduce overuse and improve quality for our members. Internal + external relationship and trust building is essential for success.
Design and build a health plan from the ground up as an Clinical Appeals Coordinator. Reporting to the Health Plan Manager of Utilization Review, the Appeals Nurse, will be an integral member of the health plan’s medical management team. The Appeals Nurse will investigate and process medical necessity requests from both members and providers. The Clinical Appeals Coordinator is a collaborative member of the Medical Management team.
This individual will be responsible for the day-to-day recruitment, consultation, and project management of activities for various cardiovascular clinical studies. This person will identify, build, nurture, and maintain relationships to recruit participating sites and patients to achieve program goals. Building on established relationships with hospitals, health systems and clinics, this role will provide in-depth process and quality improvement consultation including individual site support, facilitation of educational opportunities, intervention tracking, and process mapping.
Serves customers by answering incoming calls utilizing Denver Health and Departmental policies/processes to resolve customer health information requests and directing calls to the appropriate area when necessary.
Provides assistance to Denver Health staff by collecting demographic, medical complaint and key information required to facilitate appropriate patient care and call resolution.
Educates customers on additional services by recognizing opportunities to enhance the customers' experience and meet their needs.
The Coding Auditor - DRG/APC Coordinator ensures accuracy and quality of coding assignments for all records requiring DRG and/or APC coding, and ensures optimal and timely reimbursement. Performs data quality reviews on inpatient and outpatient records to ensure proper coding guidelines have been followed and appropriate DRG or APC assignments have been made for appropriate reimbursement.
Support attorneys by reviewing claim files, compiling factual summaries, identifying key documents and facilitating legal analysis regarding liability, potential defenses, exposure valuations, and settlement strategies. Review and analyze health care claim files involved in payor/provider disputes, identifying patterns and administrative issues. Evaluate merits and potential liability of claim batches to assess applicability to claims in dispute.