Manage the standard credentialing review process for pharmacies.
Review exclusion lists to identify any excluded pharmacies.
Manage the development and maintenance of a credentialing database.
Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans. They have solutions such as Capital Rx and Judi® which consolidates all claim administration-related workflows in one scalable, secure platform.
Lead and develop a team, setting clear expectations, managing performance directly, and building a team that surfaces problems and drives solutions independently
Own provider quality program and define what quality means at Grow, setting and maintaining the clinical standard across the provider network, and driving measurable improvement in provider quality across the network
Oversee MIC program integrity and VBC performance monitoring by ensuring Grow is on track against payor contract targets, identifying clinical risks early, and partnering with Operations and Product to close gaps
Grow Therapy aims to be the trusted partner for therapists growing their practice, and patients accessing high-quality care, operating as a three-sided marketplace that empowers providers, augments insurance payors, and serves patients. They have empowered more than ten thousand therapists and hundreds of thousands of clients across the country.
Determines denials from remittance and explanation of benefits, trend root cause.
Crafts detailed appeal letters and contacting insurance payers for resolution.
Documents all actions taken for each claim within a claims recovery system.
TREND Health Partners is a tech-enabled payment integrity company with a mission to facilitate collaboration between payers and providers. They aim to improve access to healthcare by aligning common goals through a shared technology platform and seamless workflows. It is a dynamic, growing organization that promotes a collaborative and innovative work environment.
Valeris is a fully integrated life sciences commercialization partner that provides comprehensive solutions that span the entire healthcare value chain. They are backed by proven industry expertise, a deep commitment to patient care, the latest technology, and exceptionally talented team members.
Receive, Track, Identify and analyze claims data and clinical information as appropriate for the pre-renewal, medical underwriting, and cost containment processes.
Accurate setup of incoming and outgoing referral and review documents, utilizing medical underwriting and cost containment platforms including intake logs, Conexure, Access, Sharepoint, OneDrive, etc.
Communicate verbally and in writing of all activities and problems within assigned area of responsibility with team and manager.
Crum & Forster (C&F) provides specialty and standard commercial lines insurance products through our admitted and surplus lines insurance companies. Its most valuable asset is its people: more than 2000 employees in locations throughout the United States and they are winning recognition as a great place to work.
Enter patient referrals accurately and efficiently into the electronic referral portal in accordance with established workflows and timelines.
Review referral documentation for completeness and follow up with clinical staff to obtain missing information as needed.
Contact patients by phone or secure messaging to communicate referral status, appointment scheduling information, or follow-up instructions.
Ladder Health reimagines early childhood developmental care by delivering proactive, holistic, and family-centered support for children with or at risk of developmental delays. Built in collaboration with Boston Children’s Hospital, their virtual-first care model brings together expert clinicians, thoughtful technology, and a powerful belief: that every child deserves the chance to thrive.
Supervises the coding function and corresponding staff.
Oversees reimbursement process.
Manages auditing and quality control and improvement initiatives.
Piedmont Healthcare aims to provide exceptional patient outcomes. They value diverse teams, a shared purpose, and flexibility, offering wellness programs and comprehensive benefits to support employees' needs and future plans.
Reviews, analyzes, and codes medical record documentation for surgical specialties using ICD-10, CPT, and/or HCPCS codes.
Abstracts demographic and coding information into the information system accurately and completely; reviews documentation for medical necessity.
Provides technical guidance to physicians and staff, identifies and resolves issues, and develops effective working relationships with stakeholders.
Piedmont Healthcare aims to provide real career change. They value diverse teams and offer schedule flexibility, recognizing contributions to patient outcomes and investing in employee success.
Submit and manage prior authorization requests for surgical procedures
Review patient charts and ensure medical necessity documentation meets payer requirements
Communicate directly with payers, clinical staff, and other departments to resolve issues
Metro Vein Centers is a rapidly growing healthcare practice specializing in state-of-the-art vein treatments. With over 60 clinics across 7 states and growing, they're building the future of vein care with compassionate, results-driven care in a modern, patient-first environment.
Design and oversee patient safety initiatives, safety reporting programs, and continuous clinical care improvement initiatives informed by safety data, audit findings, and peer review outcomes
Provide oversight of clinical care standards across all disciplines — therapy, dietary, medical, and psychiatry — ensuring alignment with evidence-based eating disorder treatment standards.
Develop and maintain clinical practice guidelines and documentation standards in partnership with discipline-specific leaders and the Compliance team.
Equip is a virtual, evidence-based eating disorder treatment program with a mission to ensure everyone with an eating disorder can access treatment. Founded in 2019, Equip has been a fully virtual company and is recognized as one of the most influential companies of 2023.