Conduct quality assurance audits of clinical review activities to ensure compliance with regulatory, accreditation, and client contract requirements.
Identify trends and root causes of issues to prevent client escalations and implement corrective actions.
Facilitate quality improvement projects and support cross-department collaboration on audit findings and process improvements.
WNS is an AI-powered leader in intelligent operations and transformation serving over 700 clients across industries like banking, healthcare, and insurance. With 66,000+ employees across 13 countries, the company focuses on human-led solutions and sustainable outcomes.
Audit medical claims for government payers, applying medical review guidelines and documenting findings.
Generate letters articulating audit findings and support them during the appeals process.
Collaborate with the audit team and clients to improve medical policies and minimize appeals.
Machinify is a healthcare intelligence company providing AI-powered payment solutions for health plans. It serves over 85 health plans and more than 270 million lives, with a culture focused on innovation and reducing healthcare costs.
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.
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.
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.
Acts as a patient advocate coordinating transitions to the next level of care per regulations and agency policies.
Collaborates with MJHC and inpatient facilities to evaluate inpatients for transitional planning and home health services.
Uses telephonic outreach with discharge planners and case managers for Elderplan's SNP.
Elderplan and HomeFirst are Medicare and Medicaid managed care health plans under MJHS, offering personalized care to help people remain independent. MJHS fosters a collaborative culture focused on excellence, respect, work-life balance, and career development.