Implements and supports the philosophy, mission, values, standards, policies, and procedures of The Ohio State University Wexner Medical Center.
Functions within the multidisciplinary team to secure complex pre-authorizations and prevent/appeal clinical denials.
Utilizes clinical knowledge to interpret and apply medical necessity guidelines to determine appropriateness for services provided.
The Ohio State University is a top-20 public university with one of America’s leading academic health centers. They are a team of dedicated colleagues with access to boundless resources.
Review Home Health prior authorization requests for medical necessity using CMS regulations and Clover clinical guidelines.
Perform initial and concurrent clinical reviews, ensuring appropriate care in the least restrictive setting.
Collaborate with providers and internal teams to support timely decision-making and positive member outcomes.
Clover Health is a healthcare company that uses data and technology to provide affordable, high-quality insurance plans for seniors. The company fosters a remote-first culture with a diverse and mission-driven team focused on improving member outcomes.
Provides visionary leadership and strategic direction for care coordination and service delivery teams.
Drives transformational initiatives to scale operations, enhance quality, and improve patient outcomes.
Uses data analytics and key performance indicators to monitor program effectiveness and guide evidence-based decision-making.
WellSky is a technology company that provides software, analytics, and services for intelligent, coordinated care across health and community care. The company fosters a culture of independent thinking, collaboration, and innovation, with a focus on improving outcomes and lowering costs.
Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies.
Collaborates with client personnel to resolve customer concerns and facilitates resolution of escalated cases.
Maintains written documentation per HealthHelp’s policy and ensures compliance with HIPAA, state, and federal regulations.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. With three global headquarters, operations in 13 countries, 65 delivery centers, and more than 66,000 employees, WNS combines scale, expertise, and execution to create meaningful, measurable impact.