HJ Staffing

Medical Director

• Evaluate hospital admissions, continued stays, and post-acute services for Medicare Advantage members
• Conduct timely medical necessity determinations for inpatient admissions and post-acute settings, including SNF, IRF, LTACH, and Home Health
• Apply MCG/InterQual evidence-based guidelines and CMS criteria to assess acute care services
• Lead peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care
• Serve as primary physician reviewer for escalated or complex utilization management cases
• Collaborate with utilization and care management teams to ensure consistent, cost-effective care
• Participate in utilization management committee meetings
• Document decisions according to NCQA and CMS requirements
• Support audit preparedness and delegated oversight
• Identify utilization trends and support interventions to reduce unnecessary admissions or extended stays
• Use data to design and implement clinical programs and population health management initiatives
• Report to the Chief Medical Officer

Medical Director – Utilization Management

Support Engineer

• Support, troubleshoot, and resolve EDI production issues related to claims and trading partner transactions
• Participate in on-call support rotations
• Analyze, map, and validate healthcare data exchanges including 270/271, 834, 835, and 837 transactions
• Write and maintain SQL queries for production support, reporting, testing, and data validation
• Use Splunk, App Insights, SOAP UI, and Postman to monitor and validate system performance
• Create and execute test plans, process test files, document results, and resolve defects
• Develop technical specifications, mapping documents, and process flows
• Support API integrations, ETL processes, and enterprise data exchange initiatives
• Develop dashboards to monitor data quality
• Maintain compliance with HIPAA requirements and healthcare EDI standards including TR3, CAQH CORE, and Blue Exchange guidelines
• Partner with business and technical teams to troubleshoot production issues and ensure successful data exchange between trading partners

EDI Technical Analyst – Claims

Cloud Engineer

• Design, code, debug, test, document, and implement Salesforce Health Cloud solutions
• Develop application customizations and third-party integrations
• Analyze, design, and develop system interfaces and data integration services using Salesforce SOAP and REST APIs
• Convert logical designs into program code using Apex, Lightning Web Components, Visualforce, JavaScript, and Flows
• Evaluate and test vendor-supplied software packages, patches, and upgrades
• Research application modules, understand business processes, and recommend process improvements
• Partner with the Salesforce Health Cloud Administrator to guide system modifications
• Serve as a technical resource for entry-level developers
• Provide escalation support for complex trouble tickets
• Develop test plans, conduct unit and system testing, review defect logs, participate in code reviews, and rewrite programs as requirements change
• Participate in Agile/Scrum ceremonies using Jira
• Leverage Salesforce DevOps toolsets and CI/CD pipelines
• Prepare system design documents, technical reports, user manuals, and change control documentation
• Perform on-call support duties as needed
• Deploy system changes, including occasional weekend or evening work

Senior Salesforce Health Cloud Developer

Medical Reviewer

• Lead scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests
• Analyze member clinical documentation, utilization management reviews, applicable criteria, and rationale before peer-to-peer discussions
• Evaluate medical necessity and level of care, including inpatient versus observation/outpatient status
• Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies
• Discuss clinical rationales professionally with treating providers
• Consider new clinical information and adjust medical necessity determinations or overturn proposed adverse determinations when supported and within delegated authority
• Document peer-to-peer discussions, clinical details, participants, outcomes, and rationale within required regulatory and organizational turnaround times
• Maintain strict HIPAA compliance
• Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership
• Lead case review discussions on clinical Joint Operating Committees
• Identify recurring clinical, documentation, or provider-education opportunities and communicate trends to utilization management leadership

Medical Director – Utilization Management

EDI Technical Analyst – Claims

Senior Salesforce Health Cloud Developer

Physician Advisor – Peer-to-Peer Medical Reviewer