The Director of Utilization Management oversees clinical and non-clinical teams to ensure efficient prior authorization and appeals processes while maintaining regulatory compliance. They collaborate with executives and medical directors to operationalize UM programs, manage quality improvement activities, and support business development efforts.
The UM Nurse performs pre-service and post-service utilization reviews to determine medical necessity for DMEPOS requests. They collaborate with the Medical Director and non-clinical teams to process appeals and ensure compliance with accrediting agency standards.
The Training Specialist designs, develops, and facilitates operations training programs to support business objectives and organizational needs. They collaborate with leadership to assess skill gaps, implement training roadmaps, and monitor the effectiveness of learning initiatives.
The Compliance Analyst will conduct audits of healthcare providers and manage Fraud, Waste, and Abuse (FWA) investigation processes. They will also support the corporate compliance program, monitor training, and ensure adherence to regulatory requirements and security standards.
The analyst serves as the subject matter expert for external audits and regulatory inquiries, performing detailed data analysis and research within the Essette system. They are responsible for drafting professional audit responses, developing corrective action plans, and ensuring organizational compliance with healthcare regulations.
The UM Nurse Supervisor provides direct leadership and oversight to the nursing team, ensuring productivity, compliance, and professional development. They manage daily operations, including case assignments, authorization workflows, and performance evaluations while serving as a mentor to frontline staff.
The Utilization Management Coordinator supports the clinical team by processing prior authorizations and appeals using ICD-10 and HCPCS codes. They are responsible for verifying eligibility, maintaining documentation, and communicating with providers to ensure regulatory deadlines are met.
The analyst is responsible for monitoring and documenting production quality through claims auditing and evaluating interactions within the Revenue Cycle Management function. They will identify trends, report findings to leadership, and facilitate training to drive continuous operational improvement.
The Compliance Manager will administer the corporate compliance program, oversee audits, and manage fraud, waste, and abuse investigations. They will also collaborate with internal teams and external payers to ensure adherence to regulatory requirements and security standards.
The Implementation Manager leads complex, post-sale health plan implementations from initiation through operational handoff. They are responsible for managing project plans, client relationships, cross-functional coordination, and ensuring readiness activities are completed on time and within scope.
The Lead Full Stack Software Engineer will drive the design, architecture, and development of scalable, cloud-native healthcare applications. This role involves providing technical leadership, mentoring engineers, and ensuring high-quality delivery through code reviews and production support.
