LogoFresh Jobs Ahead
Guide Healthcare
Guide Healthcare
51 – 200 Darbuotojai
ĮdarbinimasSveikatos draudimasSveikatos priežiūra
„Guide Healthcare“ veikia giminingų sveikatos priežiūros paslaugų ir sveikatos priežiūros specialistų įdarbinimo srityse, daugiausia dėmesio skirdama vyresnio amžiaus žmonių palaikymui ir gydymui. 2018 m. įkurta įmonė bendradarbiauja su klientais, partneriais ir komandomis, kad sveikatos priežiūros sektoriuje kurtų praktinę vertę, ir kitaip žvelgia į paslaugų teikimą bei įdarbinimą. Jos veikla gali būti aktuali specialistams, besidomintiems sveikatos priežiūra, giminingomis sveikatos sritimis, įdarbinimu ir vyresnio amžiaus žmonėms skirtomis paslaugomis.
LinkedIn
Darbai įmonėje

Registered Nurse Clinical Compliance Auditor

Audit utilization management and clinical compliance for Guidehealth, a data-powered value-based healthcare company. Review documentation, regulatory adherence, and delegated services.

USJungtinės ValstijosPAPensilvanija
82 000 $ – 87 000 $ / metai
NuotolinisVisas etatasVidutinis lygisVyresnysis specialistasPrivaloma Kalba: anglųAuditorius

Aprašymas

  • Conduct clinical compliance audits of utilization management, denial documentation, clinical reporting, authorization compliance, and delegated services.
  • Check compliance with UM and PHM Plans, Managed Services Agreements, and client contractual and regulatory requirements.
  • Carry out routine, scheduled, and ad hoc audits.
  • Provide secondary review of denial documentation.
  • Track audit findings, clinical workflows, and reporting processes to identify trends, risks, documentation deficiencies, and process gaps.
  • Create and maintain audit tools, protocols, compliance monitoring frameworks, UM and PHM Plans, and clinical compliance procedures.
  • Mentor and advise Clinical Compliance Auditors and clinical operations staff, sharing subject matter expertise.
  • Help leadership identify training needs and opportunities to improve clinical compliance.
  • Coordinate audit reviews, reporting, and compliance committee activities.
  • Analyze audit results and clinical data to find trends, root causes, and opportunities for improvement.
  • Present audit findings and compliance reports to clinical leaders and operational stakeholders.
  • Help develop reporting tools, dashboards, and audit metrics.
  • Adjust to changing business needs and contribute to cross-functional initiatives.

Reikalavimai

  • Hold an active, unrestricted Registered Nurse (RN) license.
  • Know utilization management processes, clinical documentation, and regulatory compliance requirements.
  • Have 3–5 years of experience in utilization management, clinical auditing, clinical compliance, or managed care.
  • Know Medicare, commercial managed care, and delegated services compliance requirements.
  • Work independently and exercise sound professional judgment.
  • Use Microsoft Office, including Excel, Word, and reporting tools proficiently.
  • Preferred: at least 2 years of clinical compliance or healthcare auditing experience.
  • Provide an internet connection with at least 100 Mbps download and 10 Mbps upload speeds.
  • Be available during stated working hours and attend virtual meetings with the camera on.
  • Follow security policies and procedures to protect PHI, PII, and Guidehealth intellectual property.

Privalumai

  • Fully remote work with work-from-home flexibility.
  • Medical, dental, and vision plans.
  • 401(k) plan with a 3% employer match when employees contribute 6%.
  • Life and disability insurance.
  • Optional life insurance coverage.
  • Employee Assistance Program (EAP).
  • Paid time off plans.
  • Paid parental leave.
  • Learning and development resources.
  • Necessary work equipment provided at no cost.
  • Equal opportunity employment.

Susiję darbai

BlueCross BlueShield of South Carolina

Auditor II, Medicare Cost Reporting

BlueCross BlueShield of South Carolina
KonsultavimasSveikatos priežiūraTeisė
USJungtinės ValstijosALAlabamaAKAliaskaAZArizonaCAKalifornijaCOKoloradasCTKonektikutasFLFloridaHIHavajaiIDAidahasILIlinojusIAAjovaKSKanzasasKYKentukisLALuizianaMEMeinasMDMerilandasMAMasačusetsasMIMičiganasMNMinesotaMSMisisipėMOMisūrisMTMontanaNENebraskaNVNevadaNHNaujasis HampšyrasNJNaujasis DžersisNMNaujoji MeksikaNYNiujorkasNCŠiaurės KarolinaNDŠiaurės DakotaOHOhajasOKOklahomaOROregonasPAPensilvanijaRIRod AilandasSCPietų KarolinaSDPietų DakotaTNTenesisTXTeksasasUTJutaVTVermontasVAVirdžinijaWAVašingtonasWIViskonsinasWYVajomingas
49 447 $ – 94 737 $ / metai
NuotolinisVisas etatasVidutinis lygisVyresnysis specialistasPrivaloma Kalba: anglųAuditorius

Conducts financial, compliance, and operational audits for BlueCross Blue Shield of South Carolina, with a focus on Medicare cost reports. Evaluates controls and business risks, recommends corrective actions, and supports remote audits across the United States.

Atidaryti
Cotiviti

Senior Appeals Auditor – Cotiviti (Remote, US)

Cotiviti
5 001 – 10 000 Darbuotojai
H1B vizos rėmėjasKonsultavimasLogistikaSveikatos priežiūra
USJungtinės Valstijos
47 $ – 57 $ / valanda
NuotolinisVisas etatasVyresnysis specialistasPrivaloma Kalba: anglųAuditorius

Defend Cotiviti’s recovery decisions by reviewing Medicare claims, clinical records, coding, medical necessity, and provider appeals. Prepare evidence-based appeal responses and support cases progressing to Administrative Law Judge hearings.

Atidaryti