Manages medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.
Utilizes clinical background to address the clinical denials, as well as write sound, compelling factual arguments for appealing denials.
Responsible for maintaining a detailed knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria, as well as filing compliant appeals.
Shriners Children’s respects, supports, and values each other. They are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact and were named as the 2025 best mid-sized employer by Forbes.
Review patient charts and documentation against defined coverage criteria.
Work with internal AI software that enables review productivity and apply structured processes to determine documentation sufficiency.
Produce clear, standardized written summaries of review outcomes and meet daily throughput and quality targets.
Verse Medical is building the modern software infrastructure to make hospital-quality care accessible everywhere. They're a well-funded Series C company, backed by notable investors, on a mission to heal a fragmented system by connecting providers, payors, and patients.
Conduct telephonic case management including comprehensive patient assessments and developing collaborative treatment plans.
Monitor and evaluate intervention effectiveness, maintain detailed documentation, and perform utilization reviews.
Advocate for patients, negotiate cost management strategies, and maintain relationships with providers and caregivers.
Personify Health provides a personalized health platform integrating health plan administration, holistic wellbeing solutions, and care navigation. The company has a mission-driven culture that values diversity and inclusion, empowering a team dedicated to improving health outcomes.