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.
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.
Performs pre-admission, admission, and continued stay reviews using approved medical necessity criteria.
Coordinates patient care and communicates with physicians, patients, caregivers, and third-party payers.
Manages patient progression through the healthcare system and proactively works with payers to secure certification and minimize denials.
Ochsner Health is a leading not-for-profit healthcare provider in the Gulf South, with 46 hospitals and 370+ care centers. It employs more than 38,000 team members and has been recognized as a top workplace and the No. 1 hospital in Louisiana.
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals.
Assess payment determinations using clinical information and established coverage guidelines.
Educate teams on medical review processes and support quality control activities.
Broadway Ventures is a veteran-owned small business delivering mission-critical support to federal health and defense customers. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it is built on integrity, collaboration, and excellence.
Conduct comprehensive reviews of home health pre-claim review packages for Medicare compliance.
Document review outcomes with clinical rationale and meet a 7-business-day turnaround.
Maintain 98% accuracy and complete required training and quality assurance sessions.
Broadway Ventures is a consulting firm providing program management, technology, and innovative solutions to government and private sector clients. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business, it emphasizes integrity, collaboration, and excellence in its culture.
Conduct medical necessity reviews and continued stay reviews using approved clinical criteria to support quality and financial outcomes.
Collaborate with liaisons, physicians, and revenue cycle teams to manage denials, appeals, and appropriate levels of care.
Maintain documentation, monitor utilization trends, and facilitate patient care planning across the care team.
Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They empower associates to challenge the status quo and put people first, fostering a collaborative and innovative culture.