Actalent

Remote Oncology Nurse/Abstractor

Posted on:

May 10, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Texas

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

We are seeking a dedicated and experienced Oncology Registered Nurse (RN) to join our team remotely. The ideal candidate will have a minimum of 2 years of experience in abstraction and a strong oncology nursing. Work Schedule: This is a full-time remote position, working 40 hours per week from 8am to 5pm CST, Monday through Friday.

Active RN license. Minimum of 2 years of experience in Oncology nursing. Minimum of 2 years of electronic medical record chart abstraction experience Additional Qualifications: Must be proficient in navigating through EMR databases. Clinical experience/pharmaceutical experience preferred. Experience in performing chart abstractions in an oncology setting; academic or research experience helpful. Excellent verbal and written communication skills. Detail-oriented with strong teamwork capabilities. Ability to multi-task and meet deadlines. Excellent computer skills, including MS Word, MS PowerPoint, MS Excel, and MS Outlook.

Perform accurate and timely abstraction of oncology data from medical records. Collaborate with healthcare providers to ensure comprehensive and precise data collection. Utilize electronic health records (EHR) systems to manage patient information. Provide remote support and guidance to patients and their families. Participate in quality improvement initiatives and clinical research projects. Maintain confidentiality and adhere to HIPAA regulations.

HarmonyCares

Telephonic RN Nurse Care Manager-Remote in Corpus Christi, TX

Posted on:

May 10, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

HarmonyCares is one of the nation’s largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health and HarmonyCares Hospice. Our Mission – To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care. Our Shared Vision – Every patient deserves access to quality healthcare. Our Values – The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other.

The Nurse Care Manager is an integral member of the care team and is vital to enhancing the health outcomes of HCMG patients. This position will manage a caseload of high-risk patients where he/she is responsible for managing their care and barriers. These duties will include, but are not limited to Transitional Care Management, Chronic Care Management, Disease Management Education, Medication Education, and the development and management of patient care plans. The Nurse Care Manager will serve as co-chair of the pod alongside the pod leader, focusing on driving and prioritizing patient needs to improve patient outcomes.

Required Knowledge, Skills and Experience: Active Registered Nurse License 2+ years of care management experience in community, health plan or hospital systems Possesses strong clinical skills and proactive thinking Effective communication skills Ability to perform extensive telephone assessment Knowledge of Medicare regulations and home care and hospice standards Experience with small group presentations and teaching/training Exhibits excellent interpersonal skills Exhibits excellent written and oral skills Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.) Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner Preferred Knowledge, Skills and Experience: Bachelor of Science in nursing or related field May be required to obtain multi-state licensing Strong knowledge of population health, quality measures, care gap closure and value-based care models

Coordinates care services with pod leader to ensure that patients have access to a comprehensive set of services tailored to their needs throughout their healthcare journey Works collaboratively within the care team to develop and manage personalized care plans, address care gaps, and engage with other resources to ensure access to care Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly and to ensure that avoidable hospital admissions do not occur Coordinates and facilitates High Risk Huddles along with ensuring that follow-up actions are completed Prioritizes patients based on the severity and urgency of their conditions to ensure that the most critical cases receive immediate attention Reviews medical records to identify gaps in care and coordinate services with the care team to manage these issues Regularly updates patient care plans Performs thorough nursing assessments via telephone of patients to maximize or improve current health outcomes Provides education to patients and/or their caregivers on disease education, medication, health maintenance, and disease prevention to promote self-management and improve health outcomes Demonstrates strong clinical skills, critical thinking abilities, and effective communication in their interactions with patients, caregivers, providers, fellow care team members, etc. Documents necessary interactions, assessments, updates, etc. in patient’s medical records according to processes and guidelines Serves as liaison between patients, providers, resources, etc. to ensure seamless care delivery Facilitates communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care and back to home In this role you may work with: Executive Directors Market Leaders Pod Leaders Clinical Social Worker Patient Health Coordinator Population Health Team

TapTalent.ai

RN Case Manager

Posted on:

May 10, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Michigan

We are seeking a dedicated and compassionate RN Case Manager to join our healthcare team. The ideal candidate will be responsible for coordinating patient care, developing individualized care plans, and ensuring patients receive the necessary services to improve their health outcomes. Location: Detroit, MI Work Mode: Work From Office Role: RN Case Manager Description: The Care Manager RN leads the coordination of a multidisciplinary team to deliver a holistic, person-centric care management program to a diverse health plan population with a variety of health and social needs. They serve as the single point of contact for members, caregivers, and providers using a variety of communication channels including phone calls, emails, text messages, and the company's online messaging platform. The Care Manager RN uses the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the member’s health across the care continuum. They work in partnership with the member, providers of care and community resources to develop and implement the plan of care and achieve stated goals.

EDUCATION AND EXPERIENCE: Nursing Diploma or Associate degree in nursing is required. Bachelor’s degree in nursing is strongly preferred. 3 years of clinical nursing experience in a clinical, acute/post-acute care, and community setting is required. 1 year of case management experience in a managed care setting is strongly preferred. Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred. CERTIFICATES, LICENSES, REGISTRATIONS: Current, active, and unrestricted Michigan Registered Nurse license required Certification in Case Management (CCM) required or to be obtained within 18 months of hire Certification in Chronic Care Professional (CCP) preferred

Lead the coordination of a regionally aligned, multidisciplinary team to provide holistic care to meet member needs telephonic and/or digitally. The multidisciplinary team is inclusive of Medical and Behavioral Health Social Workers, Registered Dietitians, Pharmacists, Clinical Support Staff and Medical Directors. Use the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the members’ health across the care continuum. Assess the member's health, psychosocial needs, cultural preferences, and support systems. Engage the member and/or caregiver to develop an individualized plan of care, address barriers, identify gaps in care, and promotes improved overall health outcomes. Arrange resources necessary to meet identified needs (e.g., community resources, mental health services, substance abuse services, financial support services and disease-specific services). Coordinate care delivery and support among member support systems, including providers, community-based agencies, and family. Advocate for members and promote self-advocacy. Deliver education to include health literacy, self-management skills, medication plans, and nutrition. 9. Monitor and evaluate effectiveness of the care management plan, assess adherence to care plan to ensure progress to goals and adjust and reevaluate as necessary. Accurately document interactions that support management of the member. Prepare the member and/or caregiver for discharge from a facility to home or for transfer to another healthcare facility to support continuity of care. Educate the member and/or caregiver about post-transition care and needed follow-up, summarizing what happened during an episode of care. Secure durable medical equipment and transportation services and communicate this to the member and/or caregiver and to key individuals at the receiving facility or home care agency. Adhere to professional standards as outlined by protocols, rules and guidelines meeting quality and production goals. Continue professional development by completing relevant continuing education and maintaining Certified Case Manager (CCM).

Children's Minnesota

Telephone Triage Nurse

Posted on:

May 10, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Minnesota

Children’s Minnesota is one of the largest pediatric health systems in the United States and the only health system in Minnesota to provide care exclusively to children, from before birth through young adulthood. An independent and not-for-profit system since 1924, Children’s Minnesota is one system serving kids throughout the Upper Midwest at two free-standing hospitals, nine primary care clinics, multiple specialty clinics and seven rehabilitation sites. As The Kids Experts™ in our region, Children’s Minnesota is regularly ranked by U.S. News & World Report as a top children’s hospital. Find us on Facebook @childrensminnesota or on Twitter and Instagram @childrensmn. Please visit childrensMN.org. Children’s Minnesota is proud to be recognized by Modern Healthcare as one of 2023’s Top Diversity Leaders. The national honor recognizes the top diverse healthcare executives and organizations influencing public policy, care delivery, and promoting diversity, equity and inclusion in their organizations and the industry.

This CHN telephone triage nurse is responsible for triaging incoming calls from clients, assessing needs, giving appropriate clinical options and facilitating referral to primary providers, health care facilities and community resources. The nurse will also educate the caller when appropriate regarding immediate care, advice and preventative behaviors.

Current unrestricted RN license (Minnesota). Ability to obtain unrestricted nursing licensure in other states. Minimum 2 years of recent nursing experience. A background in telephone triage is ideal-though not required.

Required for completely satisfactory performance in this job is knowledge of nursing functions, basic anatomy and physiology, and age competency through all stages of growth & development. The ability to demonstrate and perform generic and patient specific population critical competencies based on age and diagnosis. Critical thinking and independent problem solving skills. Positive interpersonal skills. Strong interview and communication skills; including good written and non verbal communication. The ability to utilize time and resources effectively. Ability to delegate. Proficient computer skills are essential.

Tellihealth

Chronic Care Nurse

Posted on:

May 10, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

Texas

Most people only see their doctors when they're unwell, face the stress of booking appointments, and endure lengthy waits in crowded waiting rooms. Our Chronic Care Nurses are there to step in for critical moments between visits, such as grappling with medication side effects, assistance with transportation, or helping to distinguish whether the patient should make a trip to the ER, visit an urgent care facility, or wait to speak with their provider. At TelliHealth, we've transformed remote care management to ensure that chronically ill patients are not alone. As a part of the TelliHealth team, our nurses maintain consistent connections with patients over the phone, offer them the guidance they need to navigate their health challenges, and bridge the gaps that traditional healthcare often overlooks.

This position is work from home, however, the employee must live in one of the following states: Alabama,Arkansas, Delaware, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, New Hampshire, Montana, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming. Schedule M-F 8AM-4:30PM EST or 9AM-5:30PM MST.

Active, unrestricted license LVN, LPN or RN license, required. Graduate of an accredited LVN, LPN or RN program, required. 4 years of clinical experience, required. 2 years of experience working in home health, primary care, or long-term care, required. Ability to work a full-time schedule, Monday through Friday from 8am-4:30pm EST or 9am-5:30pm MST, required. Minimum upload speed of 12 mbps and download speed of 20 mbps, required. Ability to work from home in a HIPAA compliance environment, required. Ability to effectively interact with patients through various channels (phone, email, chat) to provide exceptional service and support. Proficient using Electronic Medical Records (EMR). Excellent verbal and written communication skills. Strong organizational skills with attention to detail. Ability to manage multiple priorities simultaneously.

Engage in regular check-in calls with patients, discuss relevant condition changes, follow up on appointments, and understand new instructions from the patient's provider. Manage a caseload between 200 to 250 chronically ill patients. Provide exceptional customer service and support through various communication channels, specifically through phone and email. Ensure timely follow-up by recognizing when additional communication or intervention is required to address ongoing patient issues. Delve into rich conversations and bond with patients, understanding their unique personalities and challenges. Establish and nurture trust with new patients and their families. Act as a vital link within the patient's care team by communicating seamlessly with providers and in-office staff. Guide patients in prioritizing their health and understanding their conditions. Advocate for patients, providing answers and addressing medical concerns promptly. Use technology to manage and coordinate care. Gather resources for continuity of care. Utilize Electronic Medical Record (EMR) systems to review patient office visits, liaise with care team members and accurately document actions taken for patients.

Northwestern Memorial Hospital

Triage RN, Access, Part-time, Days/Rotating (Remote - Must reside in IL, IN, IA, or WI)

Posted on:

May 10, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Illinois

Northwestern Medicine is powered by a community of colleagues who are purpose-driven and committed to our mission to deliver world-class care. Here, you'll work alongside some of the best clinical talent in the nation leading the way in medical innovation and breakthrough research with Northwestern University Feinberg School of Medicine. We recognize where you've been, and we support where you're headed. We celebrate diverse perspectives and experiences, which fuel our commitment to equity and culture of service. Grow your career with comprehensive training and development opportunities, mentorship programs, educational support and student loan repayment. Create the life you envision for yourself with flexible work options, a Reimbursable Well-Being Fund and a Total Rewards package that support your physical, mental, emotional, and financial well-being. Make a difference through volunteer opportunities we offer in local communities and drive inclusive change through our workforce-led resource groups. From discovery to delivery, come help us shape the future of medicine.

THIS POSITION IS 20/HOURS PER WEEK. IT WILL BE FIVE 4 HOUR SHIFTS PER WEEK. ROTATING/DAY SHIFT HOURS: MONDAY-THURSDAY 5:00PM-9:00PM FRIDAY 4:00PM-8:00PM SATURDAY/SUNDAY 8:00AM-12:00PM or 4:00PM-8:00PM The Triage RN, Access reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards. The Triage RN, Access provides clinically expert virtual triage service. In their role, the triage nurses serve as a liaison between the patient and their physician by assessing the presenting problem or chief complaint, utilizing targeted evidence based triage protocols to identify acuity and develop appropriate care advice and next-step recommendations.

Required: Graduate of accredited RN program 2 years of ambulatory care experience Registered Nurse License issued by State of Illinois Current AHA BLS Provider certification Preferred: BSN Specialty certification upon eligibility

Triage nurses must demonstrate excellent customer service and communication skills and the ability to function as part of a highly effective team that consistently puts Patients First. Establish positive first impressions with patients and customers, establishing a role as patient advocate Triage all incoming telephone calls and electronic messages, prioritizing and resolving, involving the provider as appropriate, successfully completing the communication cycle. Incorporates critical thinking to develop, implement and update an individualized plan of care based on identified patient care and learning and needs Asks key questions to gain insight into the patient’s clinical condition and able to adjust approach as needed to get necessarily information Document all communications in the electronic medical record Schedules patient for visit with provider as appropriate based upon protocols Follows triage protocols in place for the department Assist in scheduling appointments for patients with providers within NM. Assist in orientation of new staff members. Assist in specific process improvement projects Participates in departmental quality improvement activities Uses effective service recovery skills to solve problems or service breakdowns when they occur

UPMC

Authorization Nurse

Posted on:

May 10, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Do you have clinical care experience? Are you an RN looking to grow your career? UPMC is looking to hire a full-time Authorization Nurse. This position works Monday through Friday, as well as rotating weekends (typically 1 every 5-6 weeks) and holidays (usually 1 per year), during daylight hours. Additionally, this position is eligible to work from home. The Authorization Nurse provides support to appropriate UPMC departments and healthcare providers by obtaining referrals and/or authorizations for any acute admissions, hospital services, and treatments. The employee uses their knowledge of acute care experience and payer regulations to assess medical necessity and ensure the presences of supporting documentation to obtain authorization. Additionally, they communicate pertinent clinical information to Physicians, Medical Directors or CFO.

RN required; BSN or Bachelor’s degree preferred. Licensed in practicing state. 5 years of acute care clinical experience. 2 years payer or care management experience. Understanding of clinical and care management process. Knowledge of medical necessity criteria (InterQual). Ability to apply InterQual criteria appropriately. Prior utilization review experience. Knowledge of payer reimbursement structure. Excellent customer service skills. Negotiation skills for obtaining appropriate level of care. Critical thinking/assessment skills. Self-motivation/autonomy. Organization/time management and prioritization skills. Proficient in Microsoft Word and Microsoft Excel. Experience working with databases preferred. Licensure, Certifications, and Clearances: Registered Nurse (RN) Act 34 *Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

Serve as a liaison between care managers and payors and facilitate payor/physician contact when indicated. Communicate to the Medical Directors, Attending Physicians and/or CFO, if indicated, regarding evaluation of medical appropriateness. Act as a resource to other departments, as well as the care managers, leveraging clinical expertise relative to the authorization process. Collaborate with other departments to ensure all information/documentation is obtained to support authorization, level of care and/or medical appropriateness. Ensure clinical review process is followed in order to meet payor deadlines. Report to management, on an ongoing basis, trends/barriers that could necessitate process improvement from a concurrent standpoint. Assist in determining system-wide care management needs through investigation of authorization process and identification of root cause. Identify and assign a root cause to each case to ensure denial reasons are tracked. Monitor and evaluate for area of process improvement related to the payor specific authorization process. Maintain current knowledge of regulatory guidelines related to authorizations. Perform clinical review for cases referred requiring authorization or adherence to payor medical policies. Maintain collaborative relationships with utilization management and departments at payor organizations. Provide ongoing education/feedback to care managers and other departments as related to the payor specific authorization process.

Ophelia

Telehealth Nurse Practitioner - Pennsylvania and/or New York Licensed

Posted on:

May 10, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Pennsylvania

Are you looking for a role in a company that's solving one of the greatest challenges of our lifetime? Ophelia helps people end their opioid use and restore their quality of life with respect for their time and dignity. Our mission is to make evidence-based treatments for opioid use disorder (OUD) accessible to everyone... and we're looking to bring more people onto our team to help us achieve it. Ophelia is a venture-backed, healthcare startup that helps individuals with OUD by providing FDA-approved medication and clinical care through a telehealth platform. Our approach is discreet, convenient, and affordable. We've been successfully operating in 14 states for almost four years and we're excited to continue our growth. We are a team of doctors, scientists, startup veterans, and White House advisors, backed by leading technology and healthcare investors working to re-imagine and re-build OUD treatment in America.

The Licensed Clinical Care Manager (CCM) is a critical part of our care team at Ophelia. As an Advanced Practice Practitioner, you will provide clinical care to stable patients receiving medication for opioid use disorder and a narrow suite of psych disorders (depression, anxiety, etc…). You’ll work closely with prescribing clinicians, triage nurses, and administrative care coordinators to deliver compassionate, evidence-based treatment to patients with OUD. The CCM offers non-judgmental, non-stigmatizing support for stable patients, acts as a liaison and advocate for them, and ensures patients receive appropriate care as their needs evolve. The CCM conducts follow up visits, induction check-in calls, and urine drug screen visits. If a patient requires more intensive or higher acuity care for a period, the CCM can escalate to the prescribing clinician or increase the cadence of visits. The schedule for this role will fall within Monday - Friday, 9-7p ET; a 40 hour, 5 day work week is required. The ideal candidate is a Nurse Practitioner who: Has a passion for serving vulnerable populations, and; Is interested in getting experience treating patients with OUD via telehealth in a supportive team environment, and; Is looking for full time work in a fast-paced, innovative start-up that puts patients first No experience with MOUD is required for this role: we will teach you what you need to know!

Training and License Requirements: Nurse Practitioner Licensed in PA (dual licensed in NY is preferred) Active DEA license Required Skills: Ability to provide patient-centered, non-judgmental, non-stigmatizing compassionate care Demonstrated experience working with vulnerable or marginalized populations Comfortable working with a diverse population of people 1-3+ years post-training experience Proficient and comfortable working in a remote tele-health environment Excited about working in an early-stage healthcare startup that is fast-paced and always evolving processes and technology to meet patient and clinician needs Ability to independently manage a large panel of patients Working knowledge of differential diagnosis of common substance use disorders Basic knowledge of psychopharmacology for opioid use disorder Demonstrated ability to collaborate and communicate effectively in a team setting Ability to maintain effective and professional relationships with patient and other members of the care team Working knowledge of evidence-based psychosocial treatments, counseling techniques, or brief behavioral intervention

Treatment Plans: collaborate with Prescribing Clinician (PC) to determine individualized treatment plans for patients; facilitate changes to treatment plans when patients are not improving as expected in consultation with the PC Behavioral Interventions: use motivational interviewing, behavioral activation and other behavioral interventions as needed to motivate patients to remain in care and adherent to their treatment plan and conduct behavioral health / psych evals for the suite of psych services we treat (depression, anxiety, insomnia, etc.) Monitor/Medication Management: systematically track treatment response and monitor patients for changes in clinical symptoms and side effects, treatment adherence, the effectiveness of treatment or complications; prepare prescription requests for the PC to approve Ensure patients remain compliant with essential and recurring clinical tasks, including monthly completion of measurement based care assessments Education: provide patient education on OUD and MOUD Charting: Document all patient encounters in Ophelia’s EHR in a timely manner

Ophelia

Telehealth Triage Registered Nurse (New York + Compact State RN License Required)

Posted on:

May 10, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Are you looking for a role in a company that's solving one of the greatest challenges of our lifetime? Ophelia helps people end their opioid use and restore their quality of life with respect for their time and dignity. Our mission is to make evidence-based treatments for opioid use disorder (OUD) accessible to everyone... and we're looking to bring more people onto our team to help us achieve it. Ophelia is a venture-backed, healthcare startup that helps individuals with OUD by providing FDA-approved medication and clinical care through a telehealth platform. Our approach is discreet, convenient, and affordable. We've been successfully operating in 14 states for almost four years and we're excited to continue our growth. We are a team of doctors, scientists, startup veterans, and White House advisors, backed by leading technology and healthcare investors working to re-imagine and re-build OUD treatment in America.

Ophelia’s Telehealth Triage RN are the primary point of contact for active Ophelia patients with clinical questions or needing additional support. Triage RNs have experience working with patients with substance use and are comfortable conducting ongoing medication management, performing check-in calls and urine drug screens, assessing bridge prescription requests, and identifying escalation events requiring clinical oversight. We are looking for a full-time Telehealth Triage RN to work 40 hours per week; a Friday is required, and a weekend day is preferred.

Training, Schedule, and License Requirements: Full-time (40 hour) availability; Tuesday - Saturday schedule preferred Registered Nurse Active License in Compact State; Active NY License (can't live in NY) Weekend availability OUD experience (preferred)

Manage inbound clinical communication with patients Manage all bridge prescription requests Provide brief interventions using evidence-based treatments such as behavioral activation, problem-solving treatment, and other focused treatment activities, as needed Troubleshoot pharmacy issues Conduct check-in calls, UDS visits, and brief patient evaluations as needed Identify and manage escalation events and triage non-progressing or complex patients to clinicians Support medication management by communicating with patients regarding medication dosing, interactions, and taking meds as prescribed; discussing comfort medications during the induction phase, and educating patients on proper dosing method of buprenorphine Facilitate communication between Prescribing Clinicians and Clinical Care Managers about active clinical issues Provide thorough documentation in EMR on all patient encounters

Convatec

me+ Clinical Support Nurse

Posted on:

May 10, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New Jersey

Pioneering trusted medical solutions to improve the lives we touch: Convatec is a global medical products and technologies company, focused on solutions for the management of chronic conditions, with leading positions in advanced wound care, ostomy care, continence care, and infusion care. With around 10,000 colleagues, we provide our products and services in almost 100 countries, united by a promise to be forever caring. Our solutions provide a range of benefits, from infection prevention and protection of at-risk skin, to improved patient outcomes and reduced care costs. Convatec’s revenues in 2023 were over $2 billion. The company is a constituent of the FTSE 100 Index (LSE:CTEC). To learn more about Convatec, please visit http://www.convatecgroup.com Every day, our products improve the lives of millions of people around the world. We’re hugely proud of this, which is why we’re transforming our business to reach millions more. Join us on our journey to #ForeverCaring as a Me+ Clinical Support Nurse, and you’ll drive progress that really means something.

You will contribute to the success of ConvaTec’ s me+ Program by providing outstanding support to: consumers and caregivers, healthcare professionals and distributors. All interactions are by phone or online.

You have a broad knowledge of the healthcare environment and industry with experience handling communications via the telephone and internet while maintaining a high level of efficiency, courtesy and professionalism. You demonstrate self-motivation, integrity, flexibility, and a strong work ethic with the ability to develop and maintain relationships with clinicians and targeted ConvaTec consumers. Exceptional customer service skills is a must in this role along with having the ability to interact with a diverse consumer base at various educational levels. Required: Bachelor’s Degree and current state license in Nursing. Ostomy Nurse Certification through WOCNCB, Wound Ostomy and Continence Nursing Certification Board. 2 or more years wound, ostomy and/or continence clinical experience in either acute care or home health or clinic setting Bilingual proficiency in English and Spanish preferred Mastery of core knowledge of anatomy and physiology related to wound, ostomy and continence care Ability to adhere to company procedures and processes Strong computer skills using Microsoft applications including Outlook, Teams, Excel, Word and PowerPoint Experience with CRM application preferred Maintain WOC Nurse triple certification Proficient in using and navigating multiple computer windows with excellent working knowledge of various applications is required Working Conditions: This is a remote opportunity; the ideal candidate must have the ability to work independently and remotely from home. A quiet home office with high-speed internet access is required for remote positions

US market focus, occasional global market inquiries Exhibit broad clinical expertise, critical thinking and judgment Establish strong empathetic, caring relationships with consumers and customers Demonstrate personal accountability with a focus on superior customer service Assess consumer needs and implement a plan of action that is results oriented Identify appropriate product solutions and make product recommendations that will enhance the consumer’s quality of life Develop and maintain an in-depth knowledge of ConvaTec products, including features and benefits. Acquire and demonstrate high level of competitive product knowledge and market dynamics Foster interest in ConvaTec products through dialogue with patients. Utilize strong selling skills, based on understanding of consumer needs Document reported complaints in accordance with FDA regulations and company policies and procedures, follow-up as required to collect additional information Meet and exceed monthly efficiency targets/goals Effectively operate computer-based contact/database management program and accurately complete customer profile, relevant post call notes, sample activity, literature fulfilment requests, possible follow up steps, etc. Ensure that all customer interactions are within compliance and follow established guidelines Use clear and concise written and oral communication techniques (including good grammatical form) in all interactions Exhibit warmth and compassion during all interactions Take active part in team development including receiving coaching and training with colleagues on a regular basis Other responsibilities as assigned

Provider Resources, LLC

RN Peer Reviewers

Posted on:

May 10, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

As the largest federal provider of healthcare, the Veterans Health Administration's (VHA) peer review program is a critical element of quality management and demonstrates the agency's commitment to provide the highest quality care possible for veterans. Past audits of peer reviews conducted internally by VHA staff identified opportunities for improving the peer review process within VHA. To facilitate implementation of the requirements of VHA Directive 1190 and to develop a process for improving the rigor and objectivity of peer review, the VHA sought national contractors with proven expertise in conducting peer review across all provider disciplines. PRI is proud to be identified as one of these contractors and anticipates completing 1,500 reviews annually.

PRI is actively recruiting interested RN professionals for this work. RN’s will be needed to complete the anticipated 375 cases per quarter. RN Peer Reviewers are especially needed in the fields of: • Anticoagulation • Cardiology • Hematology/Oncology • IV/Infusion • Mental Health • Circulating • Critical Care/ICU/Cath Lab • Emergency Medicine • Home Health • Hospice/Palliative Care • Post Anesthesia • Psychiatric Mental Health • Surgical • Transplant • Wound Care • Operating Room

This contract requires that each reviewer meet minimum requirements that include holding an active license for their discipline, being in active practice at least 20 hours/month, and, when applicable, is board certified. PRI will credential each reviewer according to its established credentialing process.

Reviews are completed electronically on the VA's Community Viewer and typically take 1-2 hours to complete. Reviewers must complete an abbreviated Personal Identification Verification (PIV) process that includes being fingerprinted at a local PIV Office/VA and completing three forms. There is no charge to be fingerprinted, and reviewers will be compensated for the time spent completing the process.

Molina Healthcare

Facility Site Review Nurse (Remote)

Posted on:

May 9, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

California

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Molina's Quality Improvement function oversees, plans, and implements new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs for members in accordance with prescribed quality standards; conducts data collection, reporting and monitoring for key performance measurement activities; and provides direction and implementation of NCQA accreditation surveys and federal/state QI compliance activities.

Required Education: Completion of an accredited Registered Nurse (RN) Program or Bachelor's in Nursing. Required Experience: Minimum 3 years clinical experience. Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing. Preferred Education: Bachelor of Science Degree in Nursing Preferred Experience: 1+ year of experience in Managed Care

Responsible for timely performance of Facility reviews and appropriate follow up for network practitioners in compliance with DHS requirements; NCQA Standards and Molina Policies and Procedures. Reports, letters, and all follow up information must be submitted in compliance with set standards for content and timing requirements. Collaborates with practitioners and their staff, conveys Molina's commitment to assisting practitioners to comply with all federal, state, and local regulations and related accrediting agency standards. Maintains confidentiality of data, communications, and interactions, internally and externally. Updates and assistance in maintenance of Site Review Database, Report Preparation, and submission within set Molina Standards. Participates in internal reviews, including, but not limited to, inter-rater reliability activities, designed to maintain consistency of work process. Presents problems and recommended solutions to Quality Improvement management.

CVS Health

Utilization Management Nurse Consultant - New Jersey Registered Nurse License Required

Posted on:

May 9, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Fully remote role Must be able to work an Eastern Standard Time schedule Must be a licensed Registered Nurse, any compact licensure must cover New Jersey

Required Qualifications: Must have active, current and unrestricted RN licensure in New Jersey or Compact RN License 3+ years of clinical experience Utilization Management is a 24/7 operation and work schedule may include weekends, holidays, and evening hours. 2+ years’ experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.) Preferred Qualifications: Previous prior authorization experience Prior experience working for a health plan Education: Associates degree required BSN preferred

Utilization Management is a 24/7 operation and the work schedule may include weekends, holidays, and evening hours. Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines for services requiring precertification. The majority of the time is spent at a desk and on the phone collecting and reviewing clinical information from providers. Precertification nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed.

Alopex

LPN Care Coordinator - Skilled Nursing Experience (Indiana Compact License Preferred) (W-2 Hourly)

Posted on:

May 9, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

Job Title: LPN Care Coordinator with Skilled Nursing Experience (Indiana Compact License) (Fully Remote) (W2 Hourly) Overview: The Care Coordinator is responsible for developing and providing care coordination services directly to Alopex clients’ patients. Reports To: RN Supervisor Department: Clinical Operations Job Description: As an LPN Care Coordinator, you will play a pivotal role in managing and coordinating care for patients enrolled in Alopex’s services. You will work closely with patients, primary care providers, and other specialists to develop, implement, and monitor individualized care plans. Your goal is to ensure that patients receive the highest level of care through ongoing communication and coordination.

Qualifications and Skills Required: Possess a minimum of two (2) years’ experience providing patient-centered care. Possess a minimum of one (1) year experience in skilled nursing. Have experience working with electronic medical records. Can perform nursing assessments, problem identification, and care plan development. Is adaptable to new technology – experience with computer documentation. Has excellent time management skills. Can assess, evaluate, and problem solve patients’ conditions and concerns. Possesses strong verbal and written communication skills. Is meticulous and dedicated to providing accurate documentation. Is dependable and focused on achieving goals. Work Location, Shift & Schedule: This position is remote (please see remote requirements below). Shifox/Alopex full-time employees generally work Monday-Friday 8:00am-5:00pm or according to the business hours of your clients’ practices. If working part-time, you and your supervisor will agree on a work schedule. Remote Position Requirements: Reliable Internet – all programs used by care coordinators are internet based PC or Laptop capable of running multiple internet programs at once A quiet and professional work environment suitable for speaking with patients about sensitive information and Protected Health Information (PHI).

Conduct a detailed review of EMR records. Develop and maintain individualized Care Plans for management of patients. Implement and coordinate all care management activities relating to patients across the continuum of care. Communicate with the patient’s clinical care team. Care management must be performed in a timely manner. Monitor patient progress toward desired outcomes through assessment and evaluation. Maintain accurate and detailed documentation related to medication, problems, goals, interventions, preventative care, etc. Conduct monthly care calls to the patients enrolled in the program. Address all needs/concerns including any follow up needed for patients. Educate patients on chronic conditions and reinforce the provider’s directions related to chronic conditions. Evaluate and address social determinants to health and begin to link community resources; then, enter them in the system. Evaluate/assess medical conditions and be able to identify and address changes in a clinically appropriate manner. Adhere to all policies & procedure as outlined by Medicare and Shifox/Alopex Perform other duties as assigned.

Alopex

LPN Care Coordinator - Skilled Nursing Experience

Posted on:

May 9, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Nevada

Job Title: LPN Care Coordinator with Skilled Nursing Experience (Fully Remote) (1099) Overview: The Care Coordinator is responsible for developing and providing care coordination services directly to Alopex clients’ patients. Reports To: RN Supervisor Department: Clinical Operations Job Description: As an LPN Care Coordinator, you will play a pivotal role in managing and coordinating care for patients enrolled in Alopex’s services. You will work closely with patients, primary care providers, and other specialists to develop, implement, and monitor individualized care plans. Your goal is to ensure that patients receive the highest level of care through ongoing communication and coordination.

Qualifications and Skills Required: Possess a minimum of two (2) years’ experience providing patient-centered care. Possess a minimum of one (1) year experience in skilled nursing. Have experience working with electronic medical records. Can perform nursing assessments, problem identification, and care plan development. Is adaptable to new technology – experience with computer documentation. Has excellent time management skills. Can assess, evaluate, and problem solve patients’ conditions and concerns. Possesses strong verbal and written communication skills. Is meticulous and dedicated to providing accurate documentation. Is dependable and focused on achieving goals. Work Location, Shift & Schedule: This position is remote (please see remote requirements below). Shifox/Alopex full-time employees generally work Monday-Friday 8:00am-5:00pm or according to the business hours of your clients’ practices. If working part-time, you and your supervisor will agree on a work schedule. Remote Position Requirements: Reliable Internet – all programs used by care coordinators are internet based PC or Laptop capable of running multiple internet programs at once A quiet and professional work environment suitable for speaking with patients about sensitive information and Protected Health Information (PHI).

Conduct a detailed review of EMR records. Develop and maintain individualized Care Plans for management of patients. Implement and coordinate all care management activities relating to patients across the continuum of care. Communicate with the patient’s clinical care team. Care management must be performed in a timely manner. Monitor patient progress toward desired outcomes through assessment and evaluation. Maintain accurate and detailed documentation related to medication, problems, goals, interventions, preventative care, etc. Conduct monthly care calls to the patients enrolled in the program. Address all needs/concerns including any follow up needed for patients. Educate patients on chronic conditions and reinforce the provider’s directions related to chronic conditions. Evaluate and address social determinants to health and begin to link community resources; then, enter them in the system. Evaluate/assess medical conditions and be able to identify and address changes in a clinically appropriate manner. Adhere to all policies & procedure as outlined by Medicare and Shifox/Alopex Perform other duties as assigned.

Alopex

Director of Regulatory Compliance and Quality Assurance

Posted on:

May 9, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Nevada

The Director of Regulatory Compliance and Quality Assurance is responsible for developing, implementing, and overseeing compliance, HIPAA privacy, and quality assurance programs within the healthcare organization. This role ensures compliance with federal, state, and local regulations, as well as internal policies and procedures. The Director will lead initiatives that promote patient safety, quality care, and organizational integrity. Reports To: Chief of Staff (in the absence of Chief Clinical Operations Officer) Department: Regulatory Compliance and Quality Assurance

Required: Minimum of Bachelor’s degree in healthcare administration, nursing, or a related field (master's degree preferred). Alternatively, 5+ years regulatory compliance and quality assurance experience in a healthcare setting. HIPAA Privacy certification from accepted accredited body versus 3 or more years in a HIPAA Privacy Officer role for a healthcare organization. Certification (preferred): Certified in Healthcare Compliance (CHC), Certified Professional in Healthcare Quality (CPHQ), or similar credentials. In-depth understanding of healthcare laws and regulations, including HIPAA, OSHA, Medicare CCM/RPM regulations, and accreditation standards. Proven experience in regulatory audits, risk management, and developing compliance programs. Strong technical proficiency with SaaS platforms, CRMs, and Microsoft applications. Excellent analytical, problem-solving, and decision-making skills. Proven leadership in managing compliance programs and cross-functional teams using strong communication and interpersonal skills. Work Location, Shift & Schedule: This position is fully remote with strict adherence to a Work from Home policy. Occasional travel may be required to offsite locations to participate in regional meetings, client new business opportunities, or industry conferences or tradeshows. Shifox/Alopex full-time employees’ work hours are generally Monday-Friday 8:00am-5:00pm or according to the business hours of your clients’ practices. If working part-time, you and your supervisor will agree on a work schedule. Remote Position Requirements: Stable, high-speed internet for professional calls and video conferencing, A quiet and professional work environment suitable for speaking with clients and staff about sensitive information and Protected Health Information (PHI).

Develop and enforce Standard Operating Procedures (SOPs), conduct staff training on compliance, quality assurance, and HIPAA privacy regulations. Investigate complaints and breaches, ensuring corrective actions align with industry standards. Serves as the company’s HIPAA Privacy Officer, overseeing HIPAA compliance, privacy and security practices in collaboration with the HIPAA Security Officer. Conduct regular audits and assessments to identify potential areas of risk and implement corrective action using regulatory documentation tools, as necessary. Serve as the company’s point person in overseeing the Risk Management Committee charter and efforts managing all cross-functional action items. Develop and maintain compliance programs in alignment with CMS/HHS/Medicare/Medicaid, commercial payors, OIG, HIPAA, OSHA, and other regulatory requirements (e.g., Stark Law, Anti-Kickback Statute, Telehealth, etc.). Monitor regulatory and industry developments, updating internal policies and procedures accordingly. Collaborate with operations, development, human resources, legal and compliance teams to stay updated on changes in HR compliance requirements, Medicare/CMS. OIG, and any HIPAA regulations to ensure organizational adherence. Collaborate with various departments to ensure that compliance and quality assurance practices are recognized, prioritized, and integrated into daily operations and workflows. Oversee the Clinical Quality Assurance program, ensuring adherence to state and federal clinical certification requirements, licensure standards, and billing compliance (e.g., “incident to” physician billing). Ensure compliance with payor regulations, medical necessity, guidelines, and coding for CCM/RPM programs. Collaborate with Clinical Operations to monitor payor performance metrics (HEDIS, HCAHPS, MIPS, NCQA, etc.). Act as the primary liaison with regulatory agencies and external auditors, facilitating audits, investigations, and corrective actions, as needed and as directed by Executive Leadership. Prepare and submit required reports to senior management and the board of directors as requested. Promote diversity, equity, and inclusion in the workplace. Other reasonable duties as requested.

Alopex

LPN Care Coordinator - Skilled Nursing Experience (Indiana Compact License Preferred) (1099)

Posted on:

May 9, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

Job Title: LPN Care Coordinator with Skilled Nursing Experience (Indiana Compact License) (Fully Remote) (1099) Overview: The Care Coordinator is responsible for developing and providing care coordination services directly to Alopex clients’ patients. Reports To: RN Supervisor Department: Clinical Operations Job Description: As an LPN Care Coordinator, you will play a pivotal role in managing and coordinating care for patients enrolled in Alopex’s services. You will work closely with patients, primary care providers, and other specialists to develop, implement, and monitor individualized care plans. Your goal is to ensure that patients receive the highest level of care through ongoing communication and coordination.

Possess a minimum of two (2) years’ experience providing patient-centered care. Possess a minimum of one (1) year experience in skilled nursing. Have experience working with electronic medical records. Can perform nursing assessments, problem identification, and care plan development. Is adaptable to new technology – experience with computer documentation. Has excellent time management skills. Can assess, evaluate, and problem solve patients’ conditions and concerns. Possesses strong verbal and written communication skills. Is meticulous and dedicated to providing accurate documentation. Is dependable and focused on achieving goals. Work Location, Shift & Schedule: This position is remote (please see remote requirements below). Shifox/Alopex full-time employees generally work Monday-Friday 8:00am-5:00pm or according to the business hours of your clients’ practices. If working part-time, you and your supervisor will agree on a work schedule. Remote Position Requirements: Reliable Internet – all programs used by care coordinators are internet based PC or Laptop capable of running multiple internet programs at once A quiet and professional work environment suitable for speaking with patients about sensitive information and Protected Health Information (PHI).

Conduct a detailed review of EMR records. Develop and maintain individualized Care Plans for management of patients. Implement and coordinate all care management activities relating to patients across the continuum of care. Communicate with the patient’s clinical care team. Care management must be performed in a timely manner. Monitor patient progress toward desired outcomes through assessment and evaluation. Maintain accurate and detailed documentation related to medication, problems, goals, interventions, preventative care, etc. Conduct monthly care calls to the patients enrolled in the program. Address all needs/concerns including any follow up needed for patients. Educate patients on chronic conditions and reinforce the provider’s directions related to chronic conditions. Evaluate and address social determinants to health and begin to link community resources; then, enter them in the system. Evaluate/assess medical conditions and be able to identify and address changes in a clinically appropriate manner. Adhere to all policies & procedure as outlined by Medicare and Shifox/Alopex Perform other duties as assigned.

Trustpoint.One

Legal Nurse Consultant (Project-Based)

Posted on:

May 9, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Georgia

Job Title: Legal Nurse Consultant (Project-Based) Location: Remote (U.S.-based preferred) Job Type: Contract / Project-Based Compensation: Competitive, based on experience About the Opportunity: We are seeking detail-oriented, experienced Legal Nurse Consultants to assist with potential upcoming legal projects involving complex medical records review and analysis. This role is ideal for a registered nurse with litigation experience who can bridge the gap between medicine and the legal process. This is a W-2 position.

Qualifications: Active RN license (U.S.) required. Minimum 5 years of clinical nursing experience. Prior experience in legal nurse consulting, insurance review, or medical-legal case analysis strongly preferred. Excellent written and verbal communication skills. Strong organizational skills and attention to detail. Proficient in electronic medical record systems and Microsoft Office Suite. Preferred Experience: Background in areas such as critical care, emergency nursing, or long-term care. Familiarity with personal injury, medical malpractice, or workers’ compensation cases. Certification(s) such as Legal Nurse Consultant Certified (LNCC), Certified Legal Nurse Consultant (CLNC), or other relevant credentials strongly preferred.

Review and analyze medical records for accuracy, completeness, and relevance to the case. Identify deviations from standards of care and provide medical insight into causation and damages. Prepare concise written reports and summaries for attorneys. Assist with chronologies, timelines, and interpretation of medical terminology. Collaborate with legal team to support case strategy and expert witness coordination. Participate in case discussions as needed, offering informed clinical perspective.

UnitedHealth Group

HSS Clinical Coordinator RN - Lima, OH and surrounding counties - Remote

Posted on:

May 9, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Ohio

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

The RN Clinical Care Coordinator will be the primary care manager for a panel of members with complex medical/behavioral needs. Care coordination activities will focus on supporting members’ medical, behavioral, and socioeconomic needs to promote appropriate utilization of services and improved quality of care. This is a home-office based position with field responsibilities. You will spend approximately 50% to 75% of the time in the field within an assigned coverage area. Candidates must be in Lima, OH/Allen County and willing to commute to surrounding counties. If you reside in Allen county or surrounding counties, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Current, unrestricted independent licensure as a Registered Nurse in Ohio 2+ years of clinical experience as an RN 1+ years of experience with MS Office, including Word, Excel, and Outlook Reliable transportation and the ability to travel up to 75% within Allen County and surrounding counties in OH to meet with members and providers Reside in Lima, OH/Allen County and surrounding counties, Putnam, Hancock and Hardin Preferred Qualifications: BSN, Master’s Degree or Higher in Clinical Field CCM certification 1+ years of community case management experience coordinating care for individuals with complex needs Experience working in team-based care Background in Managed Care

Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medication management and member safety in alignment with evidence-based guidelines Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan Provide education and coaching to support member self-management of care needs and lifestyle changes to promote health Support proactive discharge planning and manage/coordinate Care Transition following ER visit, inpatient or Skilled Nursing Facility (SNF) admission Advocate for members and families as needed to ensure the member’s needs and choices are fully represented and supported by the health care team

MUSC Health

Utilization Management Nurse II

Posted on:

May 9, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Job Summary/Purpose: Conducts utilization reviews to determine if patients are receiving care appropriate to severity of illness or condition and intensity of services required. Monitors patient charts and records to evaluate care concurrent with the patients treatment. Reviews treatment plans and status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Consults with providers and other stakeholders as needed.

Minimum Training and Education: Bachelor's degree in Nursing from an accredited school of nursing and five years of nursing work experience to include two years utilization / case management experience in a hospital setting required. Prior leadership experience preferred. Evidence of committee involvement within a healthcare setting needed (either departmental or hospital-wide). Must possess excellent verbal and written communication skills. Familiarity with InterQual and/or MCG screening criteria desired. Required Licensure, Certifications, Registrations: Licensure as a registered nurse by the state of South Carolina or compact state required.

Conducts utilization reviews to determine if patients are receiving care appropriate to illness or condition. Monitors patient charts and records to The Utilization Management Nurse (UMN) reports to the Manager of Case Management and Care Transitions. Under general guidance of the Nurse Case Manager Team Leader of the Service Line, the UM Nurse functions as a member of the clinical service line team facilitates optimal reimbursement through accurate certification of their assigned patients. This position conducts initial admission reviews and refers cases for secondary review when appropriate. This role ensures the adherence to regulatory requirements with Medicare, FFS Medicaid, and other government payers. The UM Nurse refers and consults with the multidisciplinary team to promote appropriate communication of the review results to hospital revenue professionals to ensure proper utilization of hospital resources for accurate reimbursement

MUSC Health

Advanced Practice Provider (NP/PA) | Telemedicine Endocrinology | MUSC Health, SC

Posted on:

May 9, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

South Carolina

MUSC is looking for a full time Physician Assistant or Nurse Practitioner to join its team of Advanced Practice Providers. The APP will provide diagnostic, therapeutic, and preventive health care services for patients across the state of South Carolina as part of a fully virtual specialty practice accepting new and return visit types. Job Summary/ Purpose: MUSC is looking for a full time Physician Assistant or Nurse Practitioner to join its team of Advanced Practice Providers. The APP will provide diagnostic, therapeutic, and preventive health care services for patients across the state of South Carolina as part of a fully virtual specialty practice accepting new and return visit types. Fair Labor Standards Act Status: Salaried/Exempt Hours per week: 40 Scheduled Work Hours/Shift: Monday through Friday Patient Population Focus: Endocrinology Patient Population Age Range: 18years-death

Required Minimum Training and Experience Completion of an accredited Physician Assistant program and currently licensed or eligible for licensure as a Physician Assistant or completion of an accredited Nurse Practitioner Program and currently licensed or eligible for licensure as an APRN as noted below. Physician Assistant or APRN FNP (Family NP): Stable chronic disease state management, primary care across the lifespan. Required Experience: Minimum of 2 years’ experience as an APP in Endocrinology, hematology preferred. Degree of Supervision: Advanced Practice Registered Nurse or Physician Assistant will be assigned a Primary Supervising/Collaborating Physician employed by MUSC and will collaborate regularly with this physician. Required Licensure, Certifications, Registrations: All certifications must be current and complete prior to start date: Basic Life Support (BLS). DHEC and DEA license Physical Requirements: Continuous requirements are to perform job functions while standing, walking, and sitting. Ability to bend at the waist, kneel, climb stairs, reach in all directions, fully use both hands and legs, possess good finger dexterity, perform repetitive motions with hands/wrists/elbows and shoulders, reach in all directions. Ability to be qualified physically for respirator use, initially and as required. Maintain 20/40 vision corrected, see and recognize objects close at hand and at a distance, work in a latex safe environment and work indoors. Frequently lift, lower, push and pull and/or carry objects weighing 50 lbs (+/-) unassisted, exert up to 50 lbs of force, lift from 36" to overhead 25 lbs. Infrequently work in dusty areas and confined/cramped spaces.

Takes comprehensive history and performs physical examinations Evaluates and treats on the basis of history, physical examination, radiological, laboratory, and other diagnostic test results pursuant to the practice agreement or scope of practice guideline Initiates referrals to other health care providers, and/or consults with the attending physician or the collaborating physician Documents and bills for direct care provided Utilizes current research and evidence-based decision-making in all clinical practice Performs and participates in quality/performance improvement activities and clinical research Participates in and supports accreditation, compliance, and regulatory activities of the organization Demonstrates responsibility for professional practice through active participation in professional organizations and continuing education Potential to precept students at MUSC enrolled as an advanced practice provider student; and facilitates the learning of other new team members APRN or PA must maintain licenses, certifications, CNEs/CMEs, etc., as required by applicable policies and state law Provide tele-Endocrinology services using the MUSC Virtual Care platform

w3r Consulting

Utilization Review Nurse

Posted on:

May 9, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Michigan

Job Title: Registered Nurse – Review Analyst Contract Duration: 8 Months Location: Detroit, MI (Remote) Job Type: Contract We are seeking an experienced and detail-oriented Registered Nurse – Review Analyst for an 8-month remote contract based in Detroit, MI.

Top 3 Required Skills/Experience: Minimum 2 years of acute care experience with an unrestricted Registered Nurse license Experience should not be limited to specialized areas such as NICU, OB, BH, or Substance Abuse ICU or ER experience strongly preferred Familiarity with InterQual, MCG, or other utilization review criteria/tools Required Skills/Experience: Advanced computer proficiency Typing speed of 40+ WPM Strong verbal and written communication abilities Excellent organizational and multitasking skills Preferred Skills/Experience: Previous Utilization Review experience with a health insurance company (medical or surgical admissions) Utilization Review experience within an acute care setting Education and Certifications: Must hold a current, unrestricted Registered Nurse (RN) license in the United States

The selected candidate will be responsible for the review of precertifications, admission approvals, telephone triage, and benefit interpretation. This role requires clinical judgment, attention to detail, and strong communication skills to ensure appropriate care decisions are made. Data entry and interaction with clinical guidelines and internal systems are essential aspects of this role.

w3r Consulting

Clinical Review Registered Nurse

Posted on:

May 9, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Top 3 Required Skills/Experience – Subject Matter Expertise Strong knowledge base in health care delivery systems, health insurance, medical care practices and trends, regulatory and accreditation agencies/standards, and provider network management. Strong knowledge of all Plan products and services benefits that effect clinical decision making. Strong knowledge of clinical nursing practice. Computer Skills – Proficient in all Microsoft Office applications; proficient in CPT, HCPCS coding and ICD-10 diagnosis codes. Proficient in specialized computer applications preferred including SalesForce Health Cloud, Acuity, Microsoft CRM, Onbase(or similar document mgt system), Jira Analytical Skills – Strong analytical skills, including statistical data analysis. Required Skills/Experience – The rest of the required skills/experience. Communication Skills – Strong written and oral communication skills Interpersonal Skills – Strong interpersonal skills Organizational Abilities – Strong organizational skills Preferred Skills/Experience – Optional but preferred skills/experience. Include: 5 – 7 years of clinical practice required 1- 3 years of insurance related experience desired. Willing to participate in required on-going CEU training. Education/Certifications – Include: Licensed RN ; BSN desired; Licensed in compact state desired

This position executes utilization management processes to ensure the delivery of medically necessary and appropriate, cost-effective and high-quality care through the performance of clinical reviews. Reviews requests against standardized medical necessity and appropriateness criteria for an initial and a continued service authorization. Identifies questionable cases and refers to superior or a medical director for review.

CorVel Corporation

Hospital Bill Audit Nurse I

Posted on:

May 9, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Texas

CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

The Hospital Bill Audit Nurse conducts hospital bill charge audits by reviewing medical records to verify that services were provided and charges are appropriate based on medical documentation and industry guidelines. The types of audits performed could include, but are not limited to inpatient, outpatient, NICU, and hospice. Charge audits identify overcharges, undercharges, and unbundled items per payor contract and industry standards. This candidate will be responsible for independent scheduling requiring flexibility and travel to provider location. This is a remote position.

KNOWLEDGE & SKILLS: Knowledge and understanding of hospital billing/charging including UB-04’s, itemized bills, revenue codes, CPT/HCPCS codes, ICD10 diagnosis and procedure codes Strong working knowledge of CMS, payor, and other industry guidelines preferred Computer skills necessary to manage correspondence, information entry and retrieval from system, and the ability to create and participate in virtual meetings Reasonable proficiency in Microsoft office applications including Excel Exceptional attention to detail Must have advanced organizational, strategic, and critical thinking skills Excellent professional communication skills necessary to interact positively with both external and internal customers Ability to handle stressful situations and adapt accordingly Ability to work in a fast paced environment Ability to think and work independently EDUCATION & EXPERIENCE: Associate Degree in Nursing or higher required Must maintain current licensure as a Registered Nurse in the state of employment Previous external or internal medical bill audit experience highly preferred Minimum of 5 years’ experience in the OR, ICU, or ER as an RN highly preferred Hospice experience a plus

Onsite scheduling and travel – acknowledge work that is assigned, maintain timely communication with Audit Coordinator, schedule and complete audits in an efficient and timely manner Travel onsite as needed to perform audits Review medical records to verify services were provided and charges are accurate – Identify overcharges, undercharges, unbundled items, errors, duplicates, and routine services, equipment and supplies Identify discrepancies if they exist and document the findings using standard documentation guidelines applicable to the position Understand audit and data information to make decisions with accurate results Document all unsupported charges identified in the course of an audit for each case Report any problems in the audit process to the manager and/or supervisor for resolution Comply with all HIPAA and other regulations regarding the confidentiality of patient information Comply with all provider and internal policies and guidelines Must represent CorVel/CERIS in a professional and knowledgeable manner Additional duties/responsibilities as assigned by manager and/or supervisor

Conviva Senior Primary Care

Compliance Nurse 2

Posted on:

May 9, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of CenterWell Senior Primary Care, Conviva’s innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health – addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being.

The Compliance Nurse 2 reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. The Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. This position is 100% remote; expectation at minimum one team meeting with travel required. Hours are generally M-F 8-5; flexibility upon request to manager Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Required Qualifications: Bachelor’s degree in nursing (BSN) A minimum of three years varied nursing experience Active RN license in the state(s) in which the nurse is required to practice Ability to be licensed in multiple states without restrictions Preferred Qualifications: Minimum of 3 years of Compliance Nursing Clinical documentation improvement (CDI) knowledge Health Plan experience working with large carriers Previous Medicare/Medicaid experience a plus Previous experience in chronic disease management, utilization management, case management, discharge planning and/or home health or rehab Previous experience working in/with the primary care setting Risk adjustment experience Auditing experience Coding background Ability to work independently under general instructions and with a team Must be passionate about contributing to an organization focused on continuously improving patient experiences Strong communication skills Proficient with Microsoft Office products including Word, Excel and Outlook

The Compliance Nurse 2 ensures mandatory reporting completed. Conducts and summarizes compliance audits. Collects and analyzes data daily, weekly, monthly or as needed to assess outcome and operational metrics for the team and individuals. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Somatus

Case Manager RN

Posted on:

May 9, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

As the largest and leading value-based kidney care company, Somatus is empowering patients across the country living with chronic kidney disease to experience more days out of the hospital and healthier at home. It takes a village of passionate and tenacious innovators to revolutionize an industry and support individuals living with a chronic disease to fulfill our purpose of creating More Lives, Better Lived. Does this sound like you? Showing Up Somatus Strong We foster an inclusive work environment that promotes collaboration and innovation at every level. Our values bring our mission to life and serve as the DNA for every decision we make: Authenticity: We believe in real dialogue. In any interaction, with patients, partners, vendors, or our teammates, we are true to who we are, say what we mean, and mean what we say. Collaboration: We appreciate what every person at Somatus brings to the table and believe that together we can do and achieve more. Empowerment: We make sure every voice gets heard and all ideas are considered, especially when it comes to our patients’ lives or our partners’ best interests. Innovation: We relentlessly look for ways to improve upon the status quo to continuously deliver new solutions. Tenacity: We see challenges as opportunities for growth and improvement — especially when new solutions will make a difference for our patients and partners.

This position is responsible for ensuring the continuity of care in both the inpatient and outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. Facilitates continuum of patients’ care utilizing basic nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management functions on-site or telephonically as the need arises. This is a fully remote role where compact licensure is strongly preferred. **The schedule for this position includes some evening hours where you will be expected to work until approximately 8pm, based on member availability. For example: 11am-8pm OR a split shift 8am-12pm and then 4pm-8pm**

Active RN license in current state of residence with the ability to qualify for additional state licenses as requested 2+ years of nursing experience in a hospital, acute care, or direct care setting Renal, Chronic Kidney Disease or Dialysis Care experience as a main focus of your job Computer proficiency utilizing MS Office (Word, Excel, PowerPoint and Outlook), including the ability to type and talk at the same time while navigating a Windows environment Access to dedicated workspace from home for in home office set up Ability to work schedule listed Reside in a location that can receive a high speed internet connection or can leverage existing high-speed internet service Preferred Qualifications: BSN Certified Case Manager (CCM) Diabetic educator experience ICU, Cardiology or Critical Care experience Telephonic case management experience Experience with discharge planning Solid working knowledge of hypertension and/or diabetes

Consistently exhibits behavior and communication skills that demonstrate our company's commitment to superior customer service, including quality, care and concern with each and every internal and external customer. Prioritizes patient care needs upon initial visit and addresses emerging issues. Virtually meets with patients, patients’ family and caregivers as needed to discuss care and treatment plan telephonically. Virtually identifies and assists with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings. Consults with physician and other team members to ensure that care plan is successfully implemented. Coordinates treatment plans with the care team and triages interventions appropriate to the skill set of the team members. Uses protocols and pathways in line with established disease management and care management programs and approved by medical management in order to optimize clinical outcomes. Monitors and coaches patients using techniques of motivational interviewing and behavioral change to maximize self-management. Oversees provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care. Works in coordination with the care team and demonstrates accountability with patient management and outcome. Maintains effective communication with the physicians, hospitalists, extended care facilities, patients and families. Assist member to maximize benefits according to health plan. Participates actively in assigned Care Management Coordination Committee (CMCC) meetings. Documents pertinent patient information and Care Management Plan in Electronic Health Record and Care Management Systems as appropriate. Coordinates care with larger interdisciplinary team on assigned patient caseload or panel. Adheres to departmental policies and procedures.

Humana

RN Utilization Management Nurse 2

Posted on:

May 8, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members.

Active Florida license or Compact Registered Nurse Clinical license without restrictions. A minimum of 2 years clinical experience in an acute care, skilled or rehabilitation clinical setting. A minimum of 3 years experience in Utilization Management with Medicare and/or Medicaid guidelines. Excellent computer and communication skills. Ability to work independently under general instructions and with a team. Preferred Qualifications Health Plan experience MCG Certified Bilingual is a plus Additional Information: This is a weekday position, the work schedule is Monday - Friday, 8:30am - 5:00pm Eastern Standard Time (EST). Work-At-Home Requirements: To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested Satellite, cellular and microwave connection can be used only if approved by leadership Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. This is a weekday position, the work schedule is Monday - Friday, 8:30am - 5:00pm Eastern Standard Time (EST).

AmeriHealth Caritas

Utilization Management Review Nurse

Posted on:

May 8, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Your career starts now. We are looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. We want to connect with you if you're going to make a difference. Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred. An active OH or compact state Registered Nurse (RN) license in good standing is required. 3+ years of diverse clinical experience in an Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC), home health care, or medical office setting. Proficiency in Electronic Medical Record Systems to efficiently document and assess patient cases. Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance. Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment. Availability to work Monday through Friday, 8:00 AM EST to 5:00 PM EST, flexible for holidays, occasional overtime, and weekends based on business needs. Current driver's license required.

Under the direction of a supervisor, the Clinical Care Reviewer – Utilization Management evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Clinical Care Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient’s needs in the least restrictive and most effective manner. The Clinical Care Reviewer must maintain a strong working knowledge of federal, state, and organizational regulations and consistently apply them in decision-making. Productivity expectations include meeting established turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment. Conduct concurrent reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines. Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care. Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines. Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions. Identify and escalate complex cases requiring physician review or additional intervention. Ensure compliance with Medicaid industry standards. Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment

Oscar Health

Bilingual NP/PA - Virtual Urgent Care (overnights)

Posted on:

May 8, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

Hi, we're Oscar Medical Group. We’re hiring a Bilingual APP to join our Virtual Urgent Care team. At Oscar Medical Group, we are refactoring healthcare. We want to help each of our members achieve their healthcare goals in a personalized way. To help us achieve that goal we are looking for innovative leaders who think big and push boundaries to refactor healthcare and the healthcare delivery system.

You will provide virtual based care to Oscar Health Insurance members within designated Oscar states. The role provides compassionate, evidence based care to patients utilizing audio and written forms of communication You will report into the Medical Director, Virtual Urgent Care. Hours: This is an overnight shift. 11p - 7a EST (full time, 40 hrs a week) Work Location: Oscar Medical Group is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission. This is a remote / work-from-home role. You must reside in one of the following states: Arizona, California, Colorado, Florida, Georgia, Illinois, Massachusetts, Michigan, Nevada, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Texas, or Virginia. Note, this list of states is subject to change. #LI-Remote Pay Transparency: The base pay for this role is: $140,000 - $155,000 per year. You are also eligible for employee benefits, annual vacation grant of up to 18 days per year, and annual performance bonuses.

DNP, FNP, ENP, or PA from accredited program Board Certification (NCCPA or AANP or ANCC) Compact RN license (if an APRN) Spanish language fluency 3+ years of urgent care experience 2+ years of experience delivering virtual care Licensed in Georgia, Texas, and Florida Bonus points: Experience working with remote diagnostic and home monitoring tools Able and willing to obtain additional licensure in Oscar Medical Group states

Provide high quality care for patients in a virtual setting Collaborate with Physicians and/or Advanced Practice Leads on the Care Team as needed when working with complex patients Follow up on labs, imaging, and closed loop communication with patients and other providers as needed Use tooling to allow virtual “exams” including remote home monitoring equipment, remote physical exam, remote point of care diagnostics Participate in collaborative care model with various care team members including but not limited to registered nurses, medical assistants, PCPs, behavioral health clinicians, and clinical supervisor where applicable Participate in required meetings to support patient care including huddles, case conferencing and regular service line All Hands Provide feedback to support improvement in operational workflows and product features Compliance with all applicable laws and regulations Other duties as assigned

Oscar Health

1099 NP/PA - Virtual Urgent Care

Posted on:

May 8, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Compact / Multi-State

Hi, we're Oscar Medical Group. We’re hiring a 1099 APP to join our Virtual Urgent Care team. At Oscar Medical Group, we are refactoring healthcare. We want to help each of our members achieve their healthcare goals in a personalized way. To help us achieve that goal we are looking for innovative leaders who think big and push boundaries to refactor healthcare and the healthcare delivery system.

You will deliver patient care on Oscar’s platform(s) both via messaging and phone. As an Oscar Medical Group provider, you’ll have the opportunity to re-imagine how we diagnose, treat and follow up with members virtually. You will work remotely, and work hand in hand with our team to provide exceptional patient care. You must be available 15-20 hours per week, working a minimum of 4 hour blocks. Shifts in EST: 7a - 5p, 8a - 6p, 11a - 9p, 1p - 11p, 11p - 7a We are looking for candidates who can work weekends and mid-day weekday hours. You will report into the Medical Director, Virtual Urgent Care. Work Location: Oscar Medical Group is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission. This is a remote / work-from-home role. You must reside in one of the following states: Arizona, California, Colorado, Florida, Georgia, Illinois, Massachusetts, Michigan, Nevada, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Texas, or Virginia. Note, this list of states is subject to change. #LI-Remote Pay Transparency: The base pay for this role is: $65 - $75 per hour. Malpractice and supervising physician provided by Oscar Medical Group.

DNP, FNP, ENP, or PA from accredited program Board Certification (NCCPA or AANP or ANCC) Compact RN license (if an APRN) 3+ years of urgent care experience 2+ years of experience delivering virtual care Licensed in all three of these core Oscar States (FL, GA, TX) Bonus points: Spanish language fluency Experience working with remote diagnostic and home monitoring tools Able and willing to obtain additional licensure in Oscar Medical Group states: AZ, CA, CT, IA, IL, KS, MI, MO, NC, NE, NJ, NY, OH, OK, PA, TN, VA

Provide medical care virtually (both by phone and message) Provide patient care in alignment with Oscar Medical Group guidelines, practices and policies Focus on efficiency and quality of care delivery Ensure patient access to VUC services Collaborate with MAs, RNs, and other providers across service lines (e.g. primary care and health assessments) Compliance with all applicable laws and regulations Other duties as assigned

CareHarmony

Remote - Licensed Practical Nurse (LPN) - Michigan & Compact Licensure Required

Posted on:

May 8, 2025

Job Type:

Full-Time

Role Type:

License:

LPN/LVN

State License:

Compact / Multi-State

CareHarmony’s Care Coordinators (LPN) (NLC) (LVN) work comprehensively with providers to deliver value-based care management initiatives for their patients

CareHarmony is seeking an experienced Licensed Practical Nurse – LPN Nurse (LPN) (NLC) (LVN) with at least 3 years of direct patient-facing work experience; that thrives in a fast-paced environment, is self-motivated, has impeccable attention to detail, and values the impact they can have on a patient’s healthcare journey. You will have experience identifying resources and coordinating needs for chronic care management patients. What's in it for you? Fully remote position - Work from the comfort of your own home in cozy clothes without a commute. Score! Consistent schedule - Full-Time Monday – Friday, no weekends, rotational on-call-once per year on average. Career growth - Many of our team members move up in the company at a faster-than-average rate. We love to see our people succeed!

Active Michigan and Compact License (LPN) Technical aptitude – Microsoft Office Suite Excellent written and verbal communication skills Plusses: Epic Experience Bilingual Additional state licensures (LPN) Remote Requirements: Must have active high-speed Wi-Fi Must have a home office or HIPAA-compliant workspace Physical Requirements: This position is sedentary and will require sitting for long periods of time This position will require the ability to speak clearly and listen attentively, often by telephone, for an extended period of time The position will require the ability to understand, process, and take thorough notes in real-time on telephone conversations

Manage patient census with a resolution-driven approach to close gaps in clinical and non-clinical patient care. Identify and coordinate community resources with patients that would benefit their care. Provide patient education and health literacy on the management of chronic conditions. Perform medication management, including identifying potential medication concerns, reconciliation, adherence, and coordinating refills. Assist in ensuring timely delivery of services to your patients; Home Health, DME, Home Infusion, and other critical needs. Resolve patients' questions and create an open dialogue to understand needs. Assist/Manage referrals and appointment scheduling.

AMOpportunities

Clinical Outreach Specialist - Nursing

Posted on:

May 8, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Illinois

AMOpportunities is the pioneer of CTaaS, Clinical-Training-as-a-Service, and the preferred clinical training provider for healthcare trainees worldwide. Our platform provides a comprehensive solution to clinical training capacity and access issues. Through our software and services, hospitals can earn revenue and attract new talent without expending additional resources. Educational institutions can benefit from our software and services too with guaranteed U.S. training which meets their unique curriculum requirements and allows for expanded student enrollment. The creation of this unique software and our services is inspired by the growing global shortages of healthcare professionals. We’re changing the future by providing a learning model that empowers healthcare trainees to learn and work anywhere. Over 3,200 medical trainees have benefited from our 250+ clinical experiences. We’re breaking down traditional borders and building the future of healthcare education.

We are seeking a Clinical Outreach Specialist - Nursing who will join the clinical recruitment team. The Nursing Recruitment Specialist will develop relationships with new clinicians and clinics to add to the AMO platform of nursing educational experiences. They will drive nursing recruitment to generate leads and follow through until the new programs are handed over to program operations. They will provide additional support to the recruiting team for hospital & other clinical recruitment efforts. This person will be working closely with our partnership & operations team to fulfill requests from our school partners. Must be someone who thrives in a fast paced, dynamic environment and who is ready to be a proactive member of an innovative team.  Up to 60% domestic travel required. While this position can be fully remote, we are looking for candidates to be residents of Illinois, Ohio, Michigan, Indiana, New York, Florida, Alabama, or Minnesota only.

Skills: Possess a strong work ethic Sales mindset, driven by KPIs/commissions, operates in a self-directed manner to achieve goals from leadership Knowledge of the U.S. medical system – particularly around the day-to-day of licensing and educational requirements of nursing and clinical sites Ability to communicate effectively and credibly, verbally and in writing, with clinicians and others associated with the clinical education industry Thrive in a fun, fast-paced, startup environment Represent the team professionally and ethically Ability to manage and prioritize multiple tasks and projects while working in a results-oriented environment Detail oriented, and ability to prioritize effectively, multi-task, and meet deadlines Positive attitude and ability to take and receive constructive feedback Advanced knowledge and understanding of healthcare and medical education terminology preferred, or ability to learn quickly A high level of written and oral communication skills as well as the ability to think creatively Proficient in Microsoft office; including Word, Excel, and Outlook Education/Experience: Bachelor’s degree in nursing (BSN), MSN strongly preferred Nursing recruitment/sales or clinical site acquisition experience strongly preferred Thorough understanding of the clinical competencies and educational pathways for nurses at every level— LPN and RN to BSN and FNP Experience working in a fast-paced startup culture Experience with Hubspot CRM or similar CRM strongly preferred Experience transitioning successful recruitment to onboarding team Experience managing multiple tasks   Understanding of clinical education market

This role requires operating in a sales/commissions driven environment, contacting primarily nurses, but also physicians and physician assistants, clinical sites, and their teams via email, phone, Zoom, and in person meetings to communicate to clinicians the benefit of precepting AMOpportunites trainees Detailed understanding of the sales process pipeline, with demonstrated competence in driving new leads into the sales funnel  Deep knowledge of and experience with CRMs (Hubspot preferred) and experience developing lead generation campaigns using a CRM (HubSpot training available)  Build and maintain strong relationships with potential preceptors to ensure customer satisfaction and success for the operations team Guide medical contacts through AMO’s process from lead generation to onboarding Creating new leads through the CRM system (Hubspot) and driving them to join as a preceptor/clinical training site  Negotiate stipends with clinical sites Collect and prepare contract requirements Collaborate with other AMO teams and serve as a resource regarding program information and availability Up to 60% domestic travel required Other duties as assigned

w3r Consulting

Registered Nurse-Review Analyst

Posted on:

May 8, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Michigan

Job Reference ID: 48094 Category: Registered Nurse/LPN, Case Manager Job Type: Contract Location: Detroit, Michigan 48226 Post Date: May 7, 2025 We are seeking a highly skilled and experienced Registered Nurse (RN) to join our team as a Medical Policy Specialist.

Top 3 Required Skills/Experience: Policy development and analysis experience: The ideal candidate should have experience in developing, analyzing, and interpreting medical policies, procedures, and guidelines. They should be able to identify areas for improvement and update policies accordingly. Medical knowledge and background: A strong foundation in medical terminology, medical coding and billing, CMS Medicare regulations, and clinical practices are necessary. Health Insurance experience: Must have Medicare Advantage experience working for a health insurance provider. Utilization Management experience is a plus. Required Skills/Experience – The rest of the required skills/experience: Strong writing and communication skills - The ability to write clear, concise, and accurate policies and procedures is essential. The writer should be able to communicate complex medical concepts in a straightforward and accessible way. Research and analytical skills: The ability to conduct research, analyze data, and draw conclusions to inform policy development is essential. The writer should be able to stay up-to-date with industry trends, best practices, and emerging issues. Attention to detail and organizational skills: Medical policy writers must be meticulous and organized, with the ability to manage multiple projects and deadlines. They should be able to prioritize tasks, maintain accurate records, and ensure version control. Preferred Skills/Experience – Optional but preferred skills/experience: Technical Skills: Proficiency in Microsoft Office, particularly Word, and experience with content management systems, document management software, or other relevant tools are necessary. Collaboration and stakeholder management: The writer should be able to work effectively with various stakeholders, including healthcare professionals, administrators, and other subject matter experts, to gather input and feedback on policies. Prepare and format documents according to industry standards, journal guidelines, and client specifications, including manuscript formatting, reference formatting, and document styling, to facilitate submission and publication. Review and revise draft documents for content accuracy, clarity, coherence, and consistency, incorporating feedback from subject matter experts, project stakeholders, and regulatory reviewers to ensure document quality and compliance with requirements. Education/Certifications: Bachelor’s degree in nursing minimum, prefer Master’s in Nursing or related field Current RN Licensure

As a key member of our team, you will play a critical role in reviewing and maintaining our medical policies and procedures to ensure they are grounded in scientific evidence, aligned with professional guidelines, and compliant with CMS regulations. Your expertise will help us uphold our organization's mission and goals, while also supporting our commitment to delivering high-quality patient care. This position will include responding to questions from internal stakeholders on medical policy and coding matters.

Amedisys

Hospice Afterhours Triage Nurse - Part Time Weekends

Posted on:

May 8, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Overview: Schedule- Sat/Sun Day (Mid Shift) Shift Hours 10 hours shifts (example of hours 10a-8p, 11a-9p, 12p-10p, 1p-11p) with additional shift of 5p-8p scattered from Mon-Fri depending on business needs. Holidays will be required and those may include up to 4 of the 6 Holiday observed under Amedisys Policy Are you looking for a rewarding career in homecare? If so, we invite you to join our team at Amedisys, one of the largest and most trusted home health and hospice companies in the U.S.

Current, unencumbered license to practice as a registered nurse in the state you are assigned to work. One year of experience as a registered nurse. Current CPR certification. Knowledge of physical, psychosocial, and spiritual needs of terminally ill patients and their caregivers. Must be comfortable with technology. Must be willing and eligible to obtain additional RN licenses in other states (reimbursed). Preferred: Compact license with additional licensure in MA, CA, OR CT, or willing to obtain additional licensure Previous hospice experience. Telephone triage experience. Spanish speaking. Schedule: Schedule- Sat/Sun Day (Mid Shift) Shift Hours 10 hours shifts (example of hours includes: 10a-8p, 11a-9p, 12p-10p, 1p-11p) with additional shift of 5p-8p scattered from Mon-Fri depending on business needs. Holidays will be required and those may include up to 4 of the 6 Holiday observed under Amedisys Policy (New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas day)

Assesses physical, environmental, and emotional factors telephonically to determine hospice needs. Utilizes EHR, including the patient's plan of care to develop recommendations. Provides recommendations, patient/caregiver education/instructions and hospice support telephonically based on the situation and the plan of care. Collaborates with pharmacies, DME vendors and other agencies for effective patient management. Facilitates delivery or maintenance of provided medical equipment to meet patient needs. Assigns all visits, admissions and follow-up calls to on-call field staff (RN, LPN, HA, CH, SW) as needed. Submits accurate and detailed documentation in real-time to promote continuity of care. Utilizes a combination of agency resources and nationally recognized standards of practice to achieve excellent pain and symptom management and high-quality end-of-life care. Participates in agency performance improvement initiatives. Performs other duties as assigned.

Skin Clique

Tennessee: Nurse Practitioner

Posted on:

May 8, 2025

Job Type:

Contract

Role Type:

License:

NP/APP

State License:

Tennessee

Skin Clique is a nationwide leader in personalized, in-home aesthetic care, offering expert treatments from board-certified providers. Through comprehensive skin evaluations and long-term treatment plans, Skin Clique integrates skin health into the broader health conversation. As the only practice with a certified curriculum for in-home aesthetic medicine, we prioritize expert care and overall skin health to deliver medical-grade results directly to patients. This innovative approach positions Skin Clique at the forefront of delivering high-quality aesthetic services as an essential part of overall wellness.

As an Expert Aesthetic Provider at Skin Clique, you will deliver treatments directly to patients at their homes or other preferred settings, following our established safety protocols and best practices.

Board Certification as a Nurse Practitioner (NP) or Physician Assistant (PA) Master's Degree from an accredited NP or PA program Current BLS or ACLS certification Auto-Insurance Coverage Availability to dedicate 10+ hours per week to growing your Skin Clique practice Commitment to complete Skin Clique training and demonstrate safe, effective administration of treatments Proficient fine motor skill for performing procedural treatments Preferred experience in patient acquisition Capability to work independently while also collaborating seamlessly with other Skin Clique providers Positive, friendly, and energetic attitude Motor Skills Requirement: Candidates must possess adequate motor function to physically interact with patients, such as assessing anatomy and physiology to determine appropriate dosage and treatment plans. They must be able to perform motor tasks necessary for delivering general aesthetic care and emergency interventions, such as first aid or CPR. Additionally, candidates must be able to carry out the motor movements required for aesthetic injections and procedures, which involve coordination of fine motor skills, and effective use of both touch and vision.

Conducting thorough treatment and skincare consultations Administering Skin Clique treatments such as neurotoxin injections, chemical peels, and dermaplaning on a regular basis to maintain required skills Educating patients on our services and providing detailed aftercare instructions Monitoring follow-up care to ensure satisfaction with results Responding promptly and professionally to patient questions and concerns Adhering to Skin Clique's policies, procedures, and maintaining high sanitation and sterilization standards Keeping detailed records of all treatments in our electronic medical record system Promoting Skin Clique's services and products to drive patient acquisition and retention Contributing to a positive work environment by upholding our core values and maintaining a positive attitude Attending and actively participating in training sessions and virtual staff meetings regularly

UnitedHealthcare

RN Clinical Care Coordinator - Remote in TN

Posted on:

May 8, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Tennessee

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

The RN Clinical Care Coordinator – will be the primary care manager for a panel of members with complex medical/behavioral needs. Care coordination activities will focus on supporting member’s medical, behavioral, and socioeconomic needs to promote appropriate utilization of services and improved quality of care. This is a home-based position with field responsibilities, approximately 25% of the time within Knoxville, TN and surrounding areas. If you are located in or within commutable distance to Knoxville, TN, you will have the flexibility to work remotely* as you take on some tough challenges

Required Qualifications: Current, unrestricted independent licensure as a Registered Nurse in Tennessee 2+ years of clinical experience 1+ years of experience with MS Office, including Word, Excel, and Outlook Access to reliable transportation and ability to travel up to 25% within Knoxville, TN and surrounding areas to meet with members and providers Live in TN Preferred Qualifications: BSN, Master’s degree or higher in clinical field CCM certification – must be obtained within 18 months of hire 1+ years of community case management experience coordinating care for individuals with complex needs Experience working in team-based care Background in Managed Care

Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medication management and member safety in alignment with evidence-based guidelines Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan Provide education and coaching to support member self-management of care needs and lifestyle changes to promote health Support proactive discharge planning and manage/coordinate Care Transition following ER visit, inpatient or Skilled Nursing Facility (SNF) admission Advocate for members and families as needed to ensure the member’s needs and choices are fully represented and supported by the health care team

Molina Healthcare

Delegation Oversight Nurse Remote based in CA (Must have a CA License)

Posted on:

May 8, 2025

Job Type:

Full-Time

Role Type:

License:

LPN/LVN

State License:

California

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Responsible for continuous quality improvements within the Delegation Oversight Department. Oversees delegated activities to ensure compliance primarily with NCQA, CMS and State Medicaid requirements including delegation standards and requirements contained in the delegation agreement.

Required Education: Completion of an accredited Licensed Vocational Nurse (LVN), or Licensed Practical Nurse (LPN) Program Required Experience: Minimum two years Utilization Review experience. Knowledge of audit processes and applicable state and federal regulations. Required License, Certification, Association: Active, unrestricted State Licensed Vocational Nurse or Licensed Practical Nurse in good standing. Preferred Education: Completion of an accredited Registered Nurse (RN) Program or a bachelor’s degree in Nursing. Preferred Experience: Three-year NCQA, CMS, and/or state Medicaid UM auditing experience. Three years’ experience in delegation oversight process and working knowledge of state and federal regulations. Preferred License, Certification, Association: Active and unrestricted Certified Clinical Coder Certified Medical Audit Specialists (CMAS) Certified Case Manager (CCM) Certified Professional Healthcare Management (CPHM) Certified Professional in Health Care Quality (CPHQ) or other healthcare or management certification

The Delegation Oversight Nurse is responsible for ensuring that Molina Healthcare's UM delegates are compliant all applicable State, CMS, and NCQA requirements, as well as Molina Healthcare business needs. In addition, the Delegation Oversight Nurse will assist the Delegation Oversight Manager with additional duties of the team. Coordinates, conducts, and documents pre-delegation and annual assessments as necessary to comply with state, federal, NCQA, and any other applicable requirements. Distributes audit results letters, follow up letters, audit tools, and annual reporting requirement as needed. Works with Delegation Oversight Analyst on monitoring of performance reports from delegated entities. Develops corrective action plans when deficiencies are identified, and documents follow up to completion. Assists with meetings of the Delegation Oversight Committee. Works with the Delegation Oversight Manager to develop and maintain delegation assessment tools, policies, and reporting templates. Assists with preparation of delegation summary reports submitted to the EQIC and/or UM Committees. Participates as needed in Joint Operation Committees (JOC's) for delegated groups. Assists in preparation of documents for CMS, State Medicaid, NCQA, and/or other regulatory audits as needed.

HarmonyCares

Nurse Practitioner PRN Ocean County NJ - Per Visit

Posted on:

May 8, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

New Jersey

HarmonyCares is one of the nation’s largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health and HarmonyCares Hospice. Our Mission – To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care. Our Shared Vision – Every patient deserves access to quality healthcare. Our Values – The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other.

The Nurse Practitioner delivers annual risk assessment in a residential setting or telehealth, within the scope of practice for a Nurse Practitioner, as delegated by the Collaborative Physician.

Required Knowledge, Skills, and Experience: Active/unrestricted medical license. Active CPR Certification Board eligible or board certified in family medicine. Outstanding EHR skills Preferred Knowledge, Skills and Experience: Geriatric training/experience Skill in teamwork and maintaining effective working relationships with patients, medical staff, and the public Conditions of this role to be aware of: Adaptability to differing weather conditions and patients’ home/residential environments Full range of body motion including handling/lifting patients. Manual and finger dexterity, eye-hand coordination, normal visual acuity, normal hearing, standing, bending, walking and stair climbing Regular lifting/carrying items weighing up to 50 pounds Ability to ride in automobile or van up to 150 miles daily in urban and/or rural settings. Ability to drive, if necessary

Conduct comprehensive in-home health risk assessments to identify all active and chronic disease conditions, as well as determine all physical, mental, and social needs present at the time of the visit Takes history, examines, determines diagnoses. Provides written documentation of patient visit, per NCQA standards Takes patient vital signs, as necessary. Places case management referrals and communicates with PCP as necessary. Communicates with patients, caregivers, agency nurses, other providers and vendors as necessary to assure proper diagnosis. Performs all clinical duties while observing OSHA Universal Precautions Maintains patient confidentiality Attends required meetings and in-services and participates in committees, as requested Participates in professional development activities and maintains professional licenses and affiliations

Molina Healthcare

Care Review Clinician, Inpatient Review (RN) California Night Shift

Posted on:

May 7, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

EMERGENCY ROOM ADMISSIONS REVIEW NURSE 3-12 NIGHT SHIFT: 7:30PM - 08:30AM PACIFIC HOURS NON EXEMPT, 3 days a week will rotate. TRAINING SCHEDULE WILL BE Monday thru Friday 8:30AM to 5:30PM PACIFIC throughout a 2 - 3 month training and then will move to a 3 day/12 hour shift after training is completed. Training hours are mandatory. This position supports our California Health Plan. Candidates can live anywhere in the USA if they have a valid CALIFORNIA RN license and must work the Pacific Time Zone shift hours as posted. Job Summary Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Required Education: Graduate from an Accredited School of Nursing. Required Experience: 3+ years hospital acute care/medical experience. Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. State Specific Requirements: Currently licensed for the state of California Preferred Education: Bachelor's Degree in Nursing Preferred Experience: Previous experience in Hospital Acute Care, ER or ICU, Inpatient/ Concurrent Review, Utilization Review / Utilization Management and knowledge of InterQual / MCG guidelines. Preferred License, Certification, Association: Active, unrestricted Utilization Management Certification (CPHM).

Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed. Processes requests within required timelines. Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner. Requests additional information from members or providers in consistent and efficient manner. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote Molina Care Model. Adheres to UM policies and procedures. Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

CVS Health

Appeal Nurse Associate - Prefer candidate live in IL

Posted on:

May 7, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Illinois

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

This is a full-time telework position.

Required Qualifications: 2+ years of clinical experience LPN/LVN with current unrestricted state licensure Preferred Qualifications: Managed Care experience preferred Education: LPN/LVN with current unrestricted state licensure required

Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies. Responsible for the review and resolution of clinical complaints/grievances and appeals. Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires LPN/LVN with unrestricted active license. Assists with reviewing clinical complaint/grievance and appeal requests of all clinical determinations/clinical policies. Considers all previous information as well as any additional records/data presented to prepare a recommendation. Assists with data gathering that requires navigation through multiple system applications. Contacts the provider of record, vendors, or internal Aetna departments to obtain additional information Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR), RN, MD, etc.). Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, and ERO eligibility which are required to support the clinical complaints/grievances and appeals determinations. Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements. Assists with condensing information from multiple sources (i.e., contract, coding, regulatory, etc.) into a clear and precise clinical picture for presentation to an appropriate clinician for determination. Seeks guidance from other healthcare professionals in the coordination and administration of the appeal and grievance process.

ArchWell Health

Utilization Management Nurse

Posted on:

May 7, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Tennessee

Reporting to the Director of Utilization Management, the Utilization Management Nurse is responsible for ensuring that patients receive appropriate, cost-effective care by reviewing and evaluating medical services, treatments, and procedures. This role identifies trends for opportunities to educate and collaborate with healthcare providers, patients, and specialists to optimize resource utilization and improve patient outcomes.

Required Skills/Abilities: Strong knowledge of utilization management functions in value-based care, including data analysis, claims review, reimbursement practices, and medical records reviews. Thorough, in-depth knowledge of evidence-based practice, legal rules and regulations and best practices in healthcare Ability to effectively leverage business and organizational knowledge within and across functional areas Must possess a high degree of emotional intelligence and integrity, driven and focused work ethic Continuous desire to learn and embrace new methods; ability to adapt and be resilient. Self-starter with the ability to think creatively and work effectively Ability to build a relationship and work effectively with various seniorities and diverse populations. Excellent critical reasoning, decision-making, and problem-solving skills to make informed decisions and ensure effective resource utilization while maintaining quality patient care. Willingness and ability to travel, up to 20% Education and Experience: AA/AS degree in Nursing required; BA/BS degree in Nursing (BSN) or Healthcare Administration preferred A valid, active Registered Nurse (RN) license in state(s) of employment required A minimum of 3 years’, current direct utilization management required Work in an acute care facility, community-based clinic, public health department or specialization with the senior population preferred Proficient PC skills Fluency in Spanish or other languages spoken by people in the communities we serve is desirable, but not required

Conducts prospective, concurrent, and retrospective utilization reviews for medical necessity to ensure treatment and services are appropriate and necessary by reviewing medical records and treatment plans. Works collaboratively with healthcare providers and Medical Directors to provide guidance on approvals or requests for health plan determination reviews as applicable utilizing CMS clinical guidelines and insurance policies. Maintains accurate and detailed records of reviews, interventions, and communications to ensure adherence to health plan requirements and organizational policies. Analyze utilization trends to ensure progress towards organizational goals Educates healthcare providers and patients regarding appropriate levels of care and service criteria and guidelines. Collaborates with Network and specialists to identify opportunities to educate on value-based care, resolve specialty gaps by markets, improve cost-effectiveness and coordination of care to meet patient needs.

SSM Health

RN-Virtual Health, Clinic

Posted on:

May 7, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

Missouri

It's more than a career, it's a calling MO-REMOTE Worker Type: Regular Job Highlights: Department: Primary Care and OBGYN Clinic Schedule: M-F Day Shift | No Weekends or Holidays Starting Pay: 29.30+/hr. (Offers are based on years of experience and equity for this role.) Sign On Bonus: Available for external qualified candidates Location: MO-REMOTE (Must Reside in Missouri) We are seeking a dedicated and motivated individual to join our team at our Saint Charles, MO office. This position requires a comprehensive 90-day in-office training period to ensure you are fully equipped with the knowledge and skills needed to excel in your role. After the training period, you will be required to work in the office one day every other month to maintain a strong connection with the team and stay updated on any new developments. Job Summary: Provides remote care to patients under the direction of a qualified health care provider, functioning within the scope of license to support different clinics and/or specialty clinics. Participates in program development and process improvement.

Graduate of accredited school of nursing or education equivalency for licensing EXPERIENCE: One year experience registered nurse experience PHYSICAL REQUIREMENTS: Constant use of speech to share information through oral communication. Constant standing and walking. Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, reaching and keyboard use/data entry. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of smell to detect/recognize odors. Frequent use of hearing to receive oral communication, distinguish body sounds and/or hear alarms, malfunctioning machinery, etc. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Occasional lifting/moving of patients. Occasional bending, stooping, kneeling, squatting, twisting, gripping and repetitive foot/leg and hand/arm movements. Occasional driving. Rare crawling and running. REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS State of Work Location: Illinois Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) State of Work Location: Missouri Registered Nurse (RN) - Missouri Division of Professional Registration Or Registered Nurse (RN) Issued by Compact State State of Work Location: Oklahoma Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) State of Work Location: Wisconsin Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Completes nursing workflows per department protocols including virtual/telephonic patient program admission, virtual/telephonic patient assessments and education, patient care planning and care coordination, and remote patient monitoring (RPM) escalation follow-up. Delivers safe and quality care in line with provider orders, remote patient monitoring department protocols, and established nursing care standards. Provides documentation that follows the established treatment plan, supports coordination of patient care, meets regulatory requirements, and ensures reimbursement. Communicates with management team, patient care team (including clinical staff and providers), and patient/patient caregiver(s) per department protocols. Uses electronic technology for data collection, documentation, information gathering, and communication. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service. Works in a constant state of alertness and safe manner. Performs other duties as assigned.

SSM Health

Registered Nurse – Pediatric Phone Triage

Posted on:

May 7, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

It's more than a career, it's a calling MO-REMOTE Worker Type: Regular Job Highlights: Department: Pediatric Clinic Schedule: M-F Day Shift | No Weekends or Holidays Starting Pay: 29.30+/hr. (Offers are based on years of experience and equity for this role.) Sign On Bonus: Available for external qualified candidates Location: MO-REMOTE (Must Reside in Missouri) Job Summary: Provides direct nursing care in accordance with established policies, procedures and protocols of the healthcare organization.

EDUCATION: Graduate of accredited school of nursing or education equivalency for licensing EXPERIENCE: No experience required PHYSICAL REQUIREMENTS: Constant use of speech to share information through oral communication. Constant standing and walking. Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, reaching and keyboard use/data entry. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of smell to detect/recognize odors. Frequent use of hearing to receive oral communication, distinguish body sounds and/or hear alarms, malfunctioning machinery, etc. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Occasional lifting/moving of patients. Occasional bending, stooping, kneeling, squatting, twisting, gripping and repetitive foot/leg and hand/arm movements. Occasional driving. Rare crawling and running. REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS State of Work Location: Illinois Basic Life Support HealthCare Provider (BLS HCP) - American Heart Association (AHA) And Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) State of Work Location: Missouri Basic Life Support HealthCare Provider (BLS HCP) - American Heart Association (AHA) And Registered Nurse (RN) - Missouri Division of Professional Registration Or Registered Nurse (RN) Issued by Compact State State of Work Location: Oklahoma Basic Life Support HealthCare Provider (BLS HCP) - American Heart Association (AHA) And Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) State of Work Location: Wisconsin Basic Life Support HealthCare Provider (BLS HCP) - American Heart Association (AHA) And Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Implements and monitors patient care plans. Monitors, records and communicates patient condition as appropriate. Serves as a primary coordinator of all disciplines for well-coordinated patient care. Notes and carries out physician and nursing orders. Assesses and coordinates patient's discharge planning needs with members of the healthcare team. May round with physician in an inpatient setting. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's Scope of Service. As an SSM Health nurse, I will demonstrate the professional nursing standards defined in the professional practice model. Uses the ANA Code of Ethics for Nurses to guide his/her response to the current and evolving health and nursing needs of our patients and our patient populations. Works in a constant state of alertness and safe manner. Performs other duties as assigned.

Wellbox Health

LPN Chronic Care Coordinator (PST/MST)

Posted on:

May 7, 2025

Job Type:

Part-Time

Role Type:

Primary Care

License:

LPN/LVN

State License:

Compact / Multi-State

Wellbox is a rapidly growing healthcare company focused on empowering people to live healthier lives through comprehensive preventative care solutions delivered by an elite team of experienced nurses. We are currently seeking tech-savvy LPN Patient Care Coordinators to conduct monthly telephonic outreach to chronically ill patients, developing personalized care plans that address their health challenges.

Position Type and Expected Hours of Work We are seeking full-time LPN team members who can work 40 hours per week, between the hours of 8 am – 6 pm PST/MST, Monday – Friday.

Active Compact LPN License. Minimum two years of clinical experience; care coordination experience preferred. Proficient with Electronic Medical Records and Microsoft Office. Excellent communication and problem-solving skills. Candidates who reside in Mountain Standard Time (MST) or Pacific Standard Time (PST) are preferred; candidates that reside in Central or Eastern time zones will not be considered for this position.

Manage patients’ healthcare needs via virtual phone conversations. Document visits using technology platforms and EHRs. Develop personalized care plans addressing physical, mental, and preventative health. Coach patients on treatment plans, including nutrition and wellness. Connect patients with resources and prepare them for medical appointments.

ECCO Select

Senior Clinical Nurse Informaticist

Posted on:

May 7, 2025

Job Type:

Contract

Role Type:

Informatics

License:

RN

State License:

Missouri

ECCO Select is certified as a Women-owned, Minority-owned, Small Business Enterprise. Through best-in-class talent acquisition, IT program management, and being an established government contractor, ECCO Select specializes in providing people, process, and technology solutions for our clients’ needs. ECCO Select has experience in assisting our commercial and government clients successfully manage projects and programs that transform their business operations through a variety of IT solutions. We’re the talent behind the technology. To find out more about ECCO visit www.eccoselect.com.

Duration: 15 months+ contract Target Start Date: May Location/Travel: Must be willing to go up to 100% travel as required by the site. All associates must have a strong, reliable Wi-Fi network, and a quiet, dedicated space for remote work. Schedule: 3 waves to complete. Expect short gaps of work between waves. Hours: Mon – Friday, time zones may vary dependent on site location. No guarantee of hours or a consistent schedule, all driven by the VA. Other: *Must be able to pass Federal background check and drug screen **Must obtain interim Public Trust eligibility during onboarding ***Certification Requirement: See below ****Vaccination Requirements: See below Summary: Responsible for driving the client through the design of clinical and business processes, solution and technology workflow, and successful adoption that will lead to achieved value. Manage ongoing relationships with clients, providing account management and clinical subject matter expertise focusing on client success in utilizing Cerner solutions. Through the use of Cerner implementation approach and methodology, the Consultant will assist in change management, help identify opportunities for improvement, and is accountable for achieving the project’s targeted out, to deliver functional and technical solutions on moderately complex customer engagements.

Minimum 8 years of total combined related work experience and completed higher education, including at least 1 year of licensed health care practice, clinical consulting and/or other clinical healthcare information technology (HCIT) work experience 5+ years of experience in Cerner modules, ideally with a background in federal healthcare environments (federal experience preferred but not required) Priority given to Registered Nurses (RNs) with a Clinical Informaticist background Certification: Registered Nurse - State Board Education: Bachelor’s degree in Nursing Required Vaccinations: Must have all vaccination records ready to provide upon offer: TB Skin Test (completed within the last 12 months) Influenza vaccination (current season) Two Measles, Mumps, and Rubella vaccinations Two Varicella vaccinations Three Hepatitis B vaccinations, positive titer, or signed declination form Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccination – given within the last 10 years Covid (latest recommended vaccination)

An experienced professional who is a domain and process expert with a broad understanding of practices and solutions within the relevant area of focus. Design, develop, and execute data- and technology, clinical-centered solutions for the client. Performs independently varied and complex analysis on external customer engagements. Advise leaders on execution and completion of projects within area of focus. Effectively consults with management of external customer organizations to handle escalations and lead customer discussions. Strong communication and relationship-building skills Strong problem-solving and critical thinking abilities Experience with Cerner solutions preferred Strong knowledge of clinical and business processes

City of Hope

Registered Nurse - Nurse Navigator REMOTE

Posted on:

May 7, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

City of Hope's mission is to make hope a reality for all touched by cancer and diabetes. Founded in 1913, City of Hope has grown into one of the largest and most advanced cancer research and treatment organizations in the U.S., and one of the leading research centers for diabetes and other life-threatening illnesses. City of Hope research has been the basis for numerous breakthrough cancer medicines, as well as human synthetic insulin and monoclonal antibodies. With an independent, National Cancer Institute-designated comprehensive cancer center that is ranked top 5 in the nation for cancer care by U.S. News & World Report at its core, City of Hope’s uniquely integrated model spans cancer care, research and development, academics and training, and a broad philanthropy program that powers its work. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and cancer treatment centers and outpatient facilities in the Atlanta, Chicago and Phoenix areas.

The Nurse Navigator RN functions as a member of the multidisciplinary team as an advocate and educator for patients from the initial intake phone assessment, through diagnostic studies, diagnosis, and treatment plan. The Nurse Navigation utilizes the nursing process, including assessment, diagnosis, planning, implementation, and evaluation to navigate new patients through the intake and evaluation process to treatment plan. The Nurse Navigator utilizes effective assessment skills and clinical knowledge to evaluate whether the patient’s condition makes them an appropriate candidate for travel and treatment. The Nurse Navigator serves as a liaison between the patient and family, primary care physician, internal and external care providers, specialists, and referring providers. The Nurse Navigator acts in compliance with hospital site (ATL, CHI, CAL, PHX) and enterprise policies/procedures as well as the state specific Nurse Practice Act.

Graduate of an accredited school of nursing State-issued Registered Nursing (RN) license. Successful completion and verification of the California state registered nursing license within 90 days of employment. BLS Oncology Certified Nurse highly preferred

Must be able to work Monday - Friday 8:00a - 6:00p Pacific Standard Time. Uncover and assess cancer treatment history which includes diagnosis, type of treatment, names and addresses of treating physicians and or facilities. Works closely with OIS representatives and new patient schedulers when evaluating patient’s appropriateness for visiting CTCA. Upon initial visit, interview patients and meets with them to ascertain clinical appropriateness to receive care at affiliated facilities, as well as clinical appropriateness for any clinical trials. Complete preadmission clinical evaluations and makes recommendations assessing the patient’s needs related to the medical diagnosis, treatment providers, treatment options and financial resources. Ensure proper and timely documentation in patient’s EMR and all outside records, imaging is received and current for evaluation. Follow patient through treatment decision to ensure there are no gaps in care to keep the patient moving timely through to treatment decision, resolving barriers as they arise. Promote inter and intra departmental collaboration, nurture relationships with others and is viewed positively by co-workers. Respond appropriately to negativity, seeks to promote understanding and mutual achievement of goals. Strong orientation toward services excellence. Utilize brand platform for consistent deployment of services. Seek opportunities for organization improvement, consistently apply thinking to departmental operations to enhance or improve services. Demonstrate an orientation toward achievement and professional growth, actively seek and initiate self-improvement through continuing education and/or participation in work projects that offer developmental challenges. Facilitate and/or assist with admissions via the intake process. Collaborate and develop plans of care (huddles) with teams from intake, medical oncology, specialty clinics and CAM ensuring the patient is educated on the proposed plan of care. Provide clarity and address concerns the patient and family may have. Facilitate multi-disciplinary patient education to ensure a thorough understanding of the proposed plan of care. Act as liaison between Oncology Information Services (OIS) and the Medical Center care providers in all aspects of service recovery anticipating the needs of the patient. Facilitate a positive interaction between OIS and the Medical Center to ensure optimum attention to the Mother Standard of Care. Carry own share of responsibility and willingly help others. Support the goals of the department and participates in department performance improvement. Attend required staff meetings. Plan workflow to assure timely completion of relevant responsibilities. Ensure that encounters are documented, new chart is complete and contains necessary items for physician. Apply problem solving techniques to the intake evaluation process. Plan workflow to assure timely completion of relevant responsibilities. Ensure that new chart is complete and contains necessary items for physician. Assess special travel needs and work closely with support staff to ensure all details are coordinated for the upcoming patient visit. Demonstrate knowledge of patient safety goals relevant to the work environment. Demonstrate knowledge of hospital variance reporting system and appropriate management procedures for unexpected occurrences. Demonstrate appropriate response to organizational disaster codes. Complete annual department Hazardous Communications Training. Complete required CE Direct. Consistently follow organizational guidelines for effective hand hygiene. As indicated, follow guidelines for standard and transmission-based precautions. Adhere to facility policies and procedures including assisting in maintaining the Joint Commission standards.

EPITEC

Utilization Review Nurse

Posted on:

May 7, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Michigan

Top 3 Required Skills/Experience – 2 years acute care experience with an unrestricted Registered Nurse license ICU/ER preferred *should not just be 2 years in a specialized field such as NICU/OB/BH/Substance Abuse * InterQual/MCG or other utilization review experience preferred Required Skills/Experience – The rest of the required skills/experience. Include: Advanced computer skills 40+ WPM typing Good verbal and written communication skills Good organizational skills Preferred Skills/Experience – Optional but preferred skills/experience. Include: Utilization Review experience at a previous insurance company (medical, surgical admissions) Utilization Review experience in an acute care setting Education/Certifications – Include: Must be a RN with a current and unrestricted Registered Nurse license

Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments. Two (2) of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc. Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. One (1) year health insurance plan experience or managed care environment preferred. Registered Nurse with current unrestricted Michigan Registered Nurse license required. Other requirements: Associate Degree or nursing diploma required, Triage, case management or utilization review experience, Expertise in the use of medical terminology, InterQual knowledge preferred and some weekends and corporate holidays.

Ageatia Global Solutions

Nurse, Clinical Appeals

Posted on:

May 7, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Maryland

The Clinical Appeals Specialist completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Specialist utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and Government Programs lines of business in order to formulate a professional response to the appeal request.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education Level: High School Diploma Education Details: Experience: 2 years medical-surgical or similar clinical experience OR 3 years experience in mental health, psychiatric setting. Preferred Qualifications: 2 years experience in Medical Review, Utilization Management or Case Management at Client , or similar Managed Care organization or hospital preferred. BSN/MSN Degree: Knowledge, Skills and Abilities (KSAs) Knowledge and understanding of medical terminology., Advanced Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals., Proficient Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task , Proficient Ability to effectively communicate and provide positive customer service to every internal and external customer., Advanced Knowledge of Microsoft Office programs., Proficient Excellent analytical and problem solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis, including issues pertaining to members with mental health treatment needs or those with substance disorders and addictions., Proficient Licenses/Certifications: RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req CCM - Certified Case Manager Upon Hire Pref LNCC - Legal Nurse Consultant Certified Upon Hire Pref

35% Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other initiators. Responds to such requests with original letters, complex and technical in nature, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates. 35% Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence. Formulates recommendations for disposition. Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers including an explanation of the final decision and all External appeal rights. 25% Investigates, interprets, analyzes and prioritizes appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate. Interpret and apply, as appropriate Regulatory and accredidation requirements. Collaborates with Independent Review Organizations and contracted Panel Physicians in obtaining clinical opinions from physician specialists, to determine if adverse decisions are appropriate. Interacts and responds to complaints from Regulatory Agencies and CMS. 5% Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical, mental health and substance abuse/addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications.

Covenant Health

Acute Care RN *Virtual. .9, Night Shift*

Posted on:

May 7, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Texas

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

We are hiring Virtual Nurses for a Night shift for .9 Full Time role. Applicants must have their Texas RN license upon hire. Are you an experienced nurse pursuing a new way to apply your clinical expertise with technology? Healthcare is quickly evolving as technology becomes more common place in our lives, nursing care is evolving as well. We are seeking a currently experienced acute care team player who embraces technological tools to care for patients remotely from home, using bi-directional video and virtual resources. In this new role, the virtual nurse works closely with the bedside nurse and caregivers as one team. Be part of the Providence team that leads the way to transform care! Providence nurses are not simply valued – they’re invaluable. You will thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best nurses, we must empower them. Learn why nurses choose to work at Providence by visiting our Nursing Institute page. Join our team at Providence Strategic And Management Services. As a Providence caregiver, you’ll apply your specialized training to deliver world-class health with human connection and make a difference every day through your extraordinary care.

Graduation from an accredited nursing program. Upon hire: Texas Registered Nurse License 1 year of Nursing experience.

Duties include direct communication with patients (and family) during entire length of stay at an acute care nursing unit to assist the bedside nurse with admissions, patient education, reviewing medications, discharges, coordinating care, etc.

Netsmart

Utilization Review Nurse, Full-Time (9a-9p EST), Remote

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Kansas

Responsible for utilization review work for emergency admissions and continued stay reviews

Required: Current and unrestricted RN license At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 2 years utilization management experience in acute admission and concurrent reviews Intermediate level experience with InterQual and/or MCG criteria within the last two years Proficiency in medical record review in an electronic medical record (EMR) Experience in Microsoft Suite including Office and basic Excel Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs Passing score(s) on job-related pre-employment assessment(s) Preferred: At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 3 years utilization management experience within the hospital setting Bachelor's of Science in Nursing (BSN) Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC) Expectations: Comfortable with remote work arrangements and virtual collaboration tools Physical demands include extended periods of sitting, computer use, and telephone communication

Review and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteria Apply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resources Participate in telephonic discussions with emergency department physicians relative to documentation and admission status Enter clinical review information into system for transmission to insurance companies for authorization Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources

Morgan Stephens

Utilization Management Nurse – Behavioral Health Focus (Remote)

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Ohio

Job Title: Utilization Management Nurse – Behavioral Health Focus (Remote) Location Requirements: Candidates must be located in one of the following preferred states: Arizona (AZ), Florida (FL), Georgia (GA), Idaho (ID), Iowa (IA), Kentucky (KY), Michigan (MI), Nebraska (NE), New Mexico (NM), New York (NY – outside greater NYC), Ohio (OH), Texas (TX), Utah (UT), Washington (WA – outside greater Seattle), or Wisconsin (WI). Time Zone Preference: Eastern Time Zone is preferred, but not required. Work Schedule: Tuesday through Saturday, 8:00 AM – 5:00 PM EST Compensation: $40 per hour Position Type: Temporary to Permanent Position Summary: A Managed Care Organization is seeking a Utilization Management Nurse to review provider-submitted service authorization requests and evaluate medical necessity, with a primary focus on behavioral health services. This position plays a key role in ensuring members receive appropriate and timely care by performing prior authorizations and concurrent reviews.

Must-Have Requirements: Background in Behavioral Health services and/or experience with a Managed Care Organization (MCO) in Utilization Management Licensure Requirements: Active, unrestricted RN, LPN, LCSW, or LPC license in any U.S. state Required Education and Experience: Completion of an accredited Registered Nursing program (or equivalent combination of experience and education) 2 years of clinical experience, preferably in hospital nursing, utilization management, or case management Knowledge, Skills, and Abilities: Understanding of state and federal healthcare regulations Experience with InterQual and NCQA standards Strong organizational, communication, and problem-solving skills Proficient in Microsoft Office and electronic documentation systems Ability to work independently and manage multiple priorities Professional demeanor and commitment to confidentiality and compliance with HIPAA standards Team-oriented with the ability to build and maintain positive working relationships

Review provider submissions for prior service authorizations, particularly in behavioral health Evaluate requests for medical necessity and appropriate service levels Provide concurrent review and prior authorization according to internal policies Identify appropriate benefits and determine eligibility and expected length of stay Collaborate with internal departments, including Behavioral Health and Long Term Care, to ensure continuity of care Refer cases to medical directors as needed Maintain productivity and quality standards Participate in staff meetings and assist with onboarding of new team members Foster professional relationships with internal teams and provider partners

Morgan Stephens

Utilization Management Clinician – Behavioral Health (Remote)

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Washington

Job Title: Utilization Management Clinician – Behavioral Health (Remote) Location Requirements: Candidates must reside in one of the following states: Arizona (AZ), Florida (FL), Georgia (GA), Idaho (ID), Iowa (IA), Kentucky (KY), Michigan (MI), Nebraska (NE), New Mexico (NM), New York (NY – outside greater NYC), Ohio (OH), Texas (TX), Utah (UT), Washington (WA), or Wisconsin (WI). Licensure must be in Washington (WA), regardless of physical location. Time Zone Requirements: Pacific Standard Time (PST) hours required. Work Schedule: Monday–Friday or Tuesday–Saturday, 9:00 AM – 5:00 PM PST Position Type: Temporary to Permanent Compensation: Up to $45 per hour Remote Work: 100% Remote Required Equipment: In addition to a laptop, keyboard, mouse, and headset, candidates will need a monitor and docking station. Position Summary: A Managed Care Organization is seeking a Behavioral Health Utilization Management Clinician to support the review of inpatient and outpatient services, ensuring appropriate care and resource utilization. This role involves evaluating prior authorization requests and conducting concurrent reviews to determine medical necessity for behavioral health services.

Must-Have Requirements: Behavioral Health background Utilization Management experience Licensure in the state of Washington as one of the following: Licensed Independent Clinical Social Worker (LICSW) Licensed Professional Clinical Counselor (LPCC) Licensed Mental Health Counselor (LMHC) Marriage and Family Therapist (LMFT) Psychiatric Nurse Registered Nurse (RN) Preferred Experience: 2–4 years of clinical experience, ideally in hospital settings, utilization review, or case management Familiarity with InterQual criteria and NCQA standards Previous work within a managed care or health plan environment Knowledge, Skills, and Abilities: Excellent communication, critical thinking, and decision-making skills Ability to manage multiple priorities and work independently Knowledge of federal/state regulations and behavioral health utilization review protocols Proficiency with Microsoft Office and electronic medical record systems Commitment to ethical standards and professional conduct

Process utilization review cases across various levels of care Conduct prior authorization and concurrent reviews for behavioral health services Determine eligibility, benefits, and expected length of stay Collaborate with interdisciplinary teams to promote continuity of care Refer cases to medical directors as appropriate Maintain productivity and quality performance standards Participate in team meetings and contribute to onboarding of new clinicians Adhere to regulatory guidelines, organizational policies, and HIPAA compliance

Morgan Stephens

Case Manager II LTSS (REMOTE) - $50/hr

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

LPN/LVN

State License:

Virginia

This opportunity is with one of the country’s most respected managed care organizations, serving Medicaid and Medicare members through high-quality, community-based programs. The company focuses on improving member outcomes through person-centered care coordination, behavioral health integration, and social support services. Employees are mission-driven and committed to delivering compassionate care with measurable impact across underserved populations.

Case Manager II Location: Remote – Must reside in Virginia (Tidewater or Central regions) Pay: $50/hour Assignment Type: Temp-to-Perm Start Date: As soon as available Work Schedule: Monday – Friday, 8:00 AM – 5:00 PM EST (No weekends) Tax Work Location: Remote Benefits: Medical, dental, vision, and 401(k) with 50% employer contribution towards premiums Position Overview: The Case Manager II will serve members in Virginia’s Tidewater and Central regions, supporting individuals receiving Long Term Services and Supports (LTSS) under Medicaid. This position is remote but requires regular in-field visits to members' homes and nursing facilities to conduct face-to-face assessments. You will coordinate care plans tailored to the health needs and personal goals of members while collaborating with interdisciplinary teams to ensure comprehensive support.

Required Qualifications: Must reside in Virginia (Tidewater or Central region) 1–3 years of experience in case management, disease management, managed care, or in a medical or behavioral health setting Valid driver’s license, reliable transportation, and good driving record Strong computer and multitasking skills required (for system navigation, documentation, and member engagement) Home office with high-speed internet connectivity Required Education / Licensure One of the following is required: Completion of an accredited LVN or LPN program Bachelor's or Master’s degree in social science, psychology, public health, gerontology, social work, or related field Graduation from an accredited School of Nursing (BSN preferred) If licensure is required, it must be active, unrestricted, and in good standing

Complete clinical assessments of members within regulated timelines to determine care management eligibility Develop and execute individualized care plans in collaboration with members, families, healthcare providers, and support networks Conduct telephonic, face-to-face, or home visits as needed Monitor and adjust care plans to reflect progress, interventions, and changing member needs Maintain regular outreach and ongoing case load management Coordinate integration of behavioral health and long-term care services for enhanced continuity Support wellness programs, such as asthma or depression management initiatives Facilitate interdisciplinary care team (ICT) meetings and informal team collaborations Use motivational interviewing to engage, educate, and promote behavioral change Identify and address barriers to care, connecting members to appropriate resources Collaborate with RN case managers, supervisors, and peers to optimize support Travel locally (30% or more) within the Tidewater and Central Virginia areas; mileage is reimbursed

Morgan Stephens

Case Manager II – EHR Team (Emerging High Risk) - REMOTE - $50/hr

Posted on:

May 6, 2025

Job Type:

Contract

Role Type:

Case Management

License:

LPN/LVN

State License:

Virginia

This position is with a mission-driven managed care organization that specializes in Medicaid and Medicare services for underserved populations. Known for its community-based model of care, the organization focuses on empowering members to live healthier, more independent lives. Employees are part of a collaborative environment that values innovation, equity, and measurable health outcomes.

Case Manager II – EHR Team (Emerging High Risk) Location: Remote – Must reside in Virginia (Tidewater, Central, or Southwest region) Pay: $50/hour Assignment Type: Contract | Duration: May 12, 2025 – June 30, 2025 Work Schedule: Monday – Friday, 8:00 AM – 5:00 PM EST (No weekends) Tax Work Location: Remote ZIP Code: 23803 (central to Tidewater, Central, and Southwest VA regions) Benefits: Medical, dental, vision, and 401(k) with 50% employer contribution towards premiums Position Overview: The Case Manager II will work on the Emerging High Risk (EHR) team, supporting Medicaid members across Virginia. This position is remote with regular fieldwork to complete face-to-face assessments in members’ homes. You will help build care plans tailored to members' clinical and social needs while working alongside an interdisciplinary team to ensure coordination of care and ongoing member engagement.

Required Qualifications: Must reside in Virginia within the Tidewater, Central, or Southwest region 1–3 years of experience in case management, disease management, managed care, or in a medical/behavioral health setting Strong computer and documentation skills are essential for managing systems and maintaining accuracy Home office setup with high-speed internet is required Valid driver’s license, clean driving record, and reliable transportation Required Education / Licensure One of the following: Completion of an accredited LVN or LPN program Bachelor’s or Master’s degree in a relevant field (social work, psychology, gerontology, public health, or social science) Graduate of an accredited School of Nursing (BSN preferred) Licensure (if required) must be active, unrestricted, and in good standing

Complete timely clinical assessments to determine case management eligibility Create and execute individualized case management plans with input from the member, their caregivers, physicians, and support network Conduct telephonic and in-home visits as needed, adhering to regulatory timelines Monitor care plans and document changes, interventions, and member progress Maintain an active case load and conduct regular outreach to assigned members Promote integration of services, including behavioral health and long-term support programs Participate in or facilitate interdisciplinary care team (ICT) meetings Utilize motivational interviewing techniques to support behavioral change Address barriers to care and connect members to needed services and supports Travel locally (30% or more) across assigned territory (Tidewater, Central, and Southwest VA); mileage is reimbursed

Morgan Stephens

Utilization Management (Remote) California License

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

California

A leading Managed Care Organization is seeking an experienced and detail-oriented Care Review Clinician II (RN or LVN) to join their Utilization Management team. This remote position plays a key role in reviewing clinical service requests, supporting continuity of care, and ensuring appropriate, cost-effective healthcare decisions are made in compliance with regulatory and clinical guidelines.

Required Qualifications: Active, unrestricted LVN or RN license in California 3–5 years of clinical experience (inpatient, outpatient, or hospital setting strongly preferred) Prior experience in Utilization Management, Concurrent Review, or Prior Authorization Strong analytical and critical thinking skills in a fast-paced, metric-driven environment Solid computer proficiency, including ability to toggle between multiple databases and tools Experience using InterQual or similar medical necessity criteria tools Knowledge of HIPAA and regulatory compliance standards Excellent verbal and written communication skills Preferred Qualifications: Experience in Managed Care, Health Plans, or payer-side healthcare operations Familiarity with NCQA standards Previous case management or care coordination experience Additional Information: Must provide your own secure and quiet workspace for remote work Equipment (laptop, monitors, etc.) will be provided by the organization Must be available to work 8-hour shifts during PST business hours, Monday–Friday

Perform clinical reviews of service requests including concurrent and prior authorization determinations Serve as clinical support to the Continuity of Care (COC) and Community Support teams Determine whether requests meet COC or community support criteria and escalate for MD review when needed Conduct provider outreach as appropriate to support authorizations and care coordination Utilize InterQual and other clinical guidelines to assess medical necessity and appropriate length of stay Ensure documentation meets compliance, quality, and turnaround standards Create and manage authorizations in accordance with established UM processes Participate in team meetings and collaborate with other departments to support member care

Morgan Stephens

Utilization Review Nurse – LTSS (Contract-to-Perm) - REMOTE

Posted on:

May 6, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

This is your chance to join one of the nation’s most respected Managed Care Organizations, known for its commitment to delivering high-quality, cost-effective healthcare to underserved populations. With a culture of compassion and innovation, this organization is recognized for prioritizing patient outcomes and creating opportunities for professional growth across the country.

Utilization Review Nurse – LTSS (Contract-to-Perm) Location: Remote however Candidates must reside in one of the following states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY, OH, TX, UT, WA, or WI Schedule: Monday–Friday | 8:00 AM – 4:30 or 5:00 PM EST Pay Rate: $42.00 per hour + Full Health Benefit Plan Offered Contract-to-Hire Opportunity Position Overview The Utilization Review Nurse (LTSS) supports the Utilization Management team and is responsible for reviewing long-term services and supports (LTSS) provider requests, primarily by evaluating clinical documentation to ensure appropriateness of care, cost efficiency, and compliance with state and federal regulations. The role plays a critical part in ensuring members receive the right care at the right time, particularly under Virginia Medicaid guidelines.

Active, unrestricted RN license in Virginia or Compact State (required) Completion of an accredited Registered Nursing program 0–2 years of clinical practice experience (hospital, utilization management, or case management preferred) Experience with LTSS highly preferred Familiarity with Virginia Medicaid is a strong plus Knowledge of InterQual, Milliman, or other medical necessity tools Experience with NCQA standards and utilization review policies Comfortable working independently in a fully remote environment Strong written/verbal communication and organizational skills Proficient with Microsoft Office products; experience with clinical systems a plus Work Environment & Schedule: 100% Remote Candidates must be available to work EST business hours

Review LTSS provider service requests against case management documentation Conduct prior authorization and concurrent reviews in accordance with clinical guidelines and organizational policy Complete reviews within turnaround time (TAT) expectations Identify member eligibility, applicable benefits, and appropriate levels of care Collaborate with internal care teams, including Behavioral Health and Long-Term Care Refer cases to medical directors when needed for clinical decision-making Participate in staff meetings and cross-functional collaboration Provide mentorship to new team members as assigned Maintain documentation standards, compliance, and productivity benchmarks Ensure HIPAA and regulatory compliance at all times

IntellaTriage

Remote Hospice Triage RN- PT 2 shift 3:30p-12a + rotating Sat & Sun 7:30-4 CST

Posted on:

May 6, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Built around a mission to improve the lives of nurses and patients, IntellaTriage has been providing after-hours nurse triage for hospice and home health providers since 2008. Utilizing best-in-class technology, IntellaTriage provides round-the-clock direct access to licensed, registered nurses using client-customized protocols for patient-centered, compassionate care. We are growing rapidly and excited to support our clients’ nursing staff in the field by leveraging our outsourced team of nurses to manage after-hours care delivery. Our triage nurses become an extension of our clients’ care team, and they trust us to support them and their patients during their non-core hours. Learn more at www.intellatriage.com.

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

MUST have or be willing to obtain a Compact RN license (states with pending or future implementation dates are not considered current compact states until the implementation date) You must remain in good standing and ensure your home state license remains active. IntellaTriage will cover the cost of non-compact state licensure if necessary for client support. Hospice, palliative, end-of-life care is strongly preferred Experience in a fast-paced environment: ED, surgical services, or critical care, etc. Must be comfortable accessing multiple technology applications to document during calls Ability and comfort with typing in a fast-paced environment Fluency in English is required, additional languages are a bonus Must physically reside in the U.S. and be legally eligible to work for any employer Must be able to complete three weeks of remote paid training that is conducted during days and evenings Must be available to work every other Saturday & Sunday Must be available to work some Holidays as required Must be able to handle stress and multitask when receiving calls (minimum of 5 calls per hour on weekdays, and up to 8 per hour on weekends) Must be able to communicate empathically with patients while adhering to protocols Must maintain CEU’s as designated by the states in which you are answering calls Must attend any in-services, and additional training on an as needed basis Must pass background check and nurse licensing check

Our Hospice Triage Nurses: Have experience in hospice, palliative, end-of-life care and in fast-paced environments: ED, critical care, surgical services, etc. Part-time nurses work a minimum of 1 week day shift & every other weekend both Saturday & Sunday Receive three weeks of remote paid training. The training schedule varies based on availability You can pick up additional shifts, if available, for the clients’ you are trained to support. We will provide you with a laptop and headset. You’re required to use your own high-speed internet You’ll need a quiet space, away from noise and distraction, while you work (privacy/HIPAA compliant space is required). You’ll access EMRs for charting and utilize our internal applications to perform job functions You MUST be able to follow instructions, read directions, and be confident using technology A minimum of 30 minutes paid shift prep is required prior to taking calls You’ll spend 30 minutes to 2 hours, at the end of your shift, completing remaining charting before clocking out

IntellaTriage

Remote Hospice Triage RN- PT 2 shift 3:30p-12a + rotating Sat & Sun 7:30-4

Posted on:

May 6, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Built around a mission to improve the lives of nurses and patients, IntellaTriage has been providing after-hours nurse triage for hospice and home health providers since 2008. Utilizing best-in-class technology, IntellaTriage provides round-the-clock direct access to licensed, registered nurses using client-customized protocols for patient-centered, compassionate care. We are growing rapidly and excited to support our clients’ nursing staff in the field by leveraging our outsourced team of nurses to manage after-hours care delivery. Our triage nurses become an extension of our clients’ care team, and they trust us to support them and their patients during their non-core hours. Learn more at www.intellatriage.com.

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

MUST have or be willing to obtain a Compact RN license (states with pending or future implementation dates are not considered current compact states until the implementation date) You must remain in good standing and ensure your home state license remains active. IntellaTriage will cover the cost of non-compact state licensure if necessary for client support. Hospice, palliative, end-of-life care is strongly preferred Experience in a fast-paced environment: ED, surgical services, or critical care, etc. Must be comfortable accessing multiple technology applications to document during calls Ability and comfort with typing in a fast-paced environment Fluency in English is required, additional languages are a bonus Must physically reside in the U.S. and be legally eligible to work for any employer Must be able to complete three weeks of remote paid training that is conducted during days and evenings Must be available to work every other Saturday & Sunday Must be available to work some Holidays as required Must be able to handle stress and multitask when receiving calls (minimum of 5 calls per hour on weekdays, and up to 8 per hour on weekends) Must be able to communicate empathically with patients while adhering to protocols Must maintain CEU’s as designated by the states in which you are answering calls Must attend any in-services, and additional training on an as needed basis Must pass background check and nurse licensing check

Our Hospice Triage Nurses: Have experience in hospice, palliative, end-of-life care and in fast-paced environments: ED, critical care, surgical services, etc. Part-time nurses work a minimum of 1 week day shift & every other weekend both Saturday & Sunday Receive three weeks of remote paid training. The training schedule varies based on availability You can pick up additional shifts, if available, for the clients’ you are trained to support. We will provide you with a laptop and headset. You’re required to use your own high-speed internet You’ll need a quiet space, away from noise and distraction, while you work (privacy/HIPAA compliant space is required). You’ll access EMRs for charting and utilize our internal applications to perform job functions You MUST be able to follow instructions, read directions, and be confident using technology A minimum of 30 minutes paid shift prep is required prior to taking calls You’ll spend 30 minutes to 2 hours, at the end of your shift, completing remaining charting before clocking out

Avery Telehealth

Registered Nurse - Remote

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Now Hiring: Bilingual (Spanish/English) Telehealth Registered Nurses Location: Remote Must be licensed in California, Illinois, and Nevada (All 3 single states required) Compact License (NLC) required Avery Telehealth is expanding our team and actively seeking dedicated, bilingual Registered Nurses to deliver high-quality virtual care. If you're fluent in Spanish, hold licenses in California, Illinois, and Nevada, and have a Compact License, we want to hear from you.

Must have an active license in the states of California, Illinois and Neveda (REQUIRED). A Compact License (NLC) is required. Bilingual (English/Spanish) required – candidates must be fluent in both English and Spanish to be considered for this role. Strong communication skills and a friendly, outgoing personality. Enjoy working with patients and providing top-notch care, especially to seniors and underserved communities. Graduate of an approved school of nursing. Minimum of one (2) year of experience as an RN. Experience in telehealth is a significant plus. Demonstrated honesty, loyalty, and leadership. Telehealth Registered Nurse (RN) - Physical Requirements: Ability to read, write, hear, and speak English as required by job duties. Ability to work remotely using various telehealth technologies.

Conduct visits via virtual and telephonic platorms. Follow a script and checklist while using clinical judgment during calls and virtual visits. Maintain accurate and thorough documentation for assessments. Ensure all required forms are completed by patients. Cascade necessary information to physicians promptly. Provide excellent patient interaction, specifically with the senior and underserved populations, via phone and virtual methods. Perform other duties as requested and qualified.

EXL

Skilled Nursing Facility (SNF) Auditor III

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New York

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world's leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 55,000 employees spanning six continents. For more information, visit http://www.exlservice.com. About EXL Health We leverage Human Ingenuity and domain expertise to help clients improve outcomes, optimize revenue and maximize profitability across the healthcare ecosystem. Technology, data and analytics are at the heart of our solutions. We collaborate closely with clients to transform how care is delivered, managed and paid. EXL Health combines deep domain expertise with analytic insights and technology-enabled services to transform how care is delivered, managed, and paid. Leveraging Human Ingenuity, we collaborate with our clients to solve complex problems and enhance their performance with nimble, scalable solutions. With data on more than 260 million lives, we work with hundreds of organizations across the healthcare ecosystem. We help payers improve member care quality and network performance, manage population risk, and optimize revenue while decreasing administrative waste and reducing health claim expenditures. We help Pharmacy Benefit Managers (PBMs) manage member drug benefits and reduce drug spending while maintaining quality. We help provider organizations proactively manage risk, improve outcomes, and optimize network performance. We provide Life Sciences companies with enriched data, insights through advanced analytics and data visualization tools to get the right treatment to the right patient at the right time.

Are you passionate about healthcare auditing? Do you have a keen eye for detail and a deep understanding of Skilled Nursing Facility (SNF) billing and reimbursement? If so, EXL wants you on our team as an Auditor III – SNF/RUG! Remote Opportunity – Work from Home! At EXL, we bring together sharp, innovative professionals eager to make an impact in healthcare. In this role, you'll apply your clinical expertise to review claims, validate charges, and ensure compliance—all while working in a dynamic, collaborative environment.

Required: LPN or RN (Associate’s or Bachelor’s degree preferred). 3+ years of skilled nursing experience (RAC certification, reimbursement, or MDS coordinator experience a plus!). Familiarity with PDPM, RUG, Medicaid 48 grouper reimbursement, and HIPPS codes billing. Skills That Set You Apart: Strong analytical and problem-solving skills. Excellent written and verbal communication. Effective time management and ability to prioritize work. Proficiency in Excel, Word, and OneNote. A collaborative, team-oriented mindset with the ability to work independently.

Conduct in-depth clinical reviews to verify skilled nursing facility (SNF) billing accuracy. Analyze claims paid under PDPM, RUG, and per diem payment models to identify overpayments. Apply ICD-10 coding guidelines to validate diagnoses on Minimum Data Set (MDS) assessments. Document audit findings clearly and concisely using EXL tools, CMS guidelines, and payer policies. Stay up to date on changes in clinical guidelines, reimbursement trends, and regulations. Meet or exceed productivity and quality goals in a remote, independent work environment.

EXL

Skilled Nursing Facility (SNF) / Resource Utilization Group (RUG) - Auditor III, Healthcare

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

New York

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world's leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 55,000 employees spanning six continents. For more information, visit http://www.exlservice.com. About EXL Health We leverage Human Ingenuity and domain expertise to help clients improve outcomes, optimize revenue and maximize profitability across the healthcare ecosystem. Technology, data and analytics are at the heart of our solutions. We collaborate closely with clients to transform how care is delivered, managed and paid. EXL Health combines deep domain expertise with analytic insights and technology-enabled services to transform how care is delivered, managed, and paid. Leveraging Human Ingenuity, we collaborate with our clients to solve complex problems and enhance their performance with nimble, scalable solutions. With data on more than 260 million lives, we work with hundreds of organizations across the healthcare ecosystem. We help payers improve member care quality and network performance, manage population risk, and optimize revenue while decreasing administrative waste and reducing health claim expenditures. We help Pharmacy Benefit Managers (PBMs) manage member drug benefits and reduce drug spending while maintaining quality. We help provider organizations proactively manage risk, improve outcomes, and optimize network performance. We provide Life Sciences companies with enriched data, insights through advanced analytics and data visualization tools to get the right treatment to the right patient at the right time.

Are you passionate about healthcare auditing? Do you have a keen eye for detail and a deep understanding of Skilled Nursing Facility (SNF) billing and reimbursement? If so, EXL wants you on our team as an Auditor III – SNF/RUG! Remote Opportunity – Work from Home! At EXL, we bring together sharp, innovative professionals eager to make an impact in healthcare. In this role, you'll apply your clinical expertise to review claims, validate charges, and ensure compliance—all while working in a dynamic, collaborative environment.

LPN or RN (Associate’s or Bachelor’s degree preferred). 3+ years of skilled nursing experience (RAC certification, reimbursement, or MDS coordinator experience a plus!). Familiarity with PDPM, RUG, Medicaid 48 grouper reimbursement, and HIPPS codes billing. Skills That Set You Apart: Strong analytical and problem-solving skills. Excellent written and verbal communication. Effective time management and ability to prioritize work. Proficiency in Excel, Word, and OneNote. A collaborative, team-oriented mindset with the ability to work independently.

Conduct in-depth clinical reviews to verify skilled nursing facility (SNF) billing accuracy. Analyze claims paid under PDPM, RUG, and per diem payment models to identify overpayments. Apply ICD-10 coding guidelines to validate diagnoses on Minimum Data Set (MDS) assessments. Document audit findings clearly and concisely using EXL tools, CMS guidelines, and payer policies. Stay up to date on changes in clinical guidelines, reimbursement trends, and regulations. Meet or exceed productivity and quality goals in a remote, independent work environment.

EXL

Telephonic Utilization & Case Management RN

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world's leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 55,000 employees spanning six continents. For more information, visit http://www.exlservice.com. About EXL Health: We leverage Human Ingenuity and domain expertise to help clients improve outcomes, optimize revenue and maximize profitability across the healthcare ecosystem. Technology, data and analytics are at the heart of our solutions. We collaborate closely with clients to transform how care is delivered, managed and paid. EXL Health combines deep domain expertise with analytic insights and technology-enabled services to transform how care is delivered, managed, and paid. Leveraging Human Ingenuity, we collaborate with our clients to solve complex problems and enhance their performance with nimble, scalable solutions. With data on more than 260 million lives, we work with hundreds of organizations across the healthcare ecosystem. We help payers improve member care quality and network performance, manage population risk, and optimize revenue while decreasing administrative waste and reducing health claim expenditures. We help Pharmacy Benefit Managers (PBMs) manage member drug benefits and reduce drug spending while maintaining quality. We help provider organizations proactively manage risk, improve outcomes, and optimize network performance. We provide Life Sciences companies with enriched data, insights through advanced analytics and data visualization tools to get the right treatment to the right patient at the right time.

Are you passionate about ensuring patients receive the care they need? Join our team as a Utilization Management & Complex Case Management Nurse, where you will play a crucial role in reviewing and approving authorization requests for appropriate care and provide comprehensive case management services for beneficiaries with multiple or complex conditions. You will follow established guidelines and policies, and when necessary, forward requests to the appropriate stakeholders. You'll also use your clinical knowledge, communication skills, and collaborative spirit to help our beneficiaries regain their optimum health or improve their functional capabilities. This involves performing comprehensive assessment, care planning, implementation, monitoring, and evaluation activities via telephonic contact and digital outreach. Our team works diligently to ensure that beneficiaries progress toward desired outcomes with quality care that is medically appropriate and cost-effective. Our goal is to assist beneficiaries in regaining their optimal health or improved functional capability, support effective self-care management, and promote access to healthcare services and community resources. Work schedule Monday - Friday 5 days x 8 hours Shift time for remote telephonic work is aligned to state of residence and time zone: Pacific Time Zone 9 am - 6 pm PT Mountain Time Zone 10 am - 7 pm MT Central Time Zone 11 am - 8 pm CT Eastern Time Zone 11 am - 8 pm ET

Required: Current, unrestricted RN license in of residence with multi-state privileges (an active compact state license), or the ability to obtain multi-state privileges in the state of residence. 3+ years of experience as a nurse in a clinical setting. 2+ years’ experience performing the utilization review for a health plan or inpatient facility. 1+ year of experience as a case manager for a health plan or inpatient facility. Strong technical proficiency with MS Office Suite Word, Excel, Power Point, Microsoft Teams and SharePoint and ability to navigate multiple systems under periods of high volume. Must hold United States Citizenship status. Ability to obtain Federal Security Clearance required. Current DOD Security Clearance preferred. Secure, private home office work environment. Preferred: Bachelor’s degree in nursing from an accredited college, university, or school of nursing. Experience working in a NCQA and URAC accredited program. Previous experience in Hospital Acute Care, Prior Auth, Utilization Review / Utilization Management and knowledge of InterQual and/or MCG guidelines. Health Plan experience working with large carriers. Previous Federal government plan program experience such as Tricare, Medicare Medicaid and commercial health insurance experience. Active, Certified Case Management Certification (CCM). Experience working remotely.

Review authorization requests using clinical judgment and evidenced-based clinical decision support criteria to ensure medical necessity and appropriate level of care. Assesses services for beneficiaries to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Identifies appropriate benefits and eligibility for requested treatments and/or procedures. Conducts authorization reviews to determine financial responsibility for the payer and its beneficiaries. Approve services or refer cases to internal stakeholders based on findings. Makes appropriate referrals to other clinical programs. Refers appropriate authorization requests to and collaborates with Medical Directors. Educate providers on utilization and medical management processes. Enter and maintain clinical information in various medical management systems. Make evidenced-based independent decisions regarding work methods, even in ambiguous situations, with minimal direction. Analyzes clinical service requests from beneficiaries or providers against evidence based clinical guidelines. Processes requests within required timelines. Collaborates with multidisciplinary teams to promote the care model. Adheres to all UM policies and procedures, federal, state and regulatory guidelines. Conduct a comprehensive assessment with beneficiaries and analyze assessment findings to identify and prioritize clinical, psychosocial, and behavioral concerns and potential gaps in care. Develop and document a case management care plan in direct collaboration with the beneficiary, the beneficiary's family or significant other(s), the primary physician and other health care providers. Identify and include key concerns, needs, and preferences of the beneficiary and family/caregiver. Document identified issues, prioritized and individualized goals (long & short term), evidence-based interventions, collaborative approaches and resources, anticipated time frames, and barriers to achieving goals in the care plan. Coordinate and implement the activities specified in the care plan to provide optimal benefits coverage as well as promote continuity of care and integration of services for the beneficiary across care transitions. Collaborate and communicate with the beneficiary, family, significant other(s), physician, and other health care providers to accomplish the goals on the care plan. Monitor and continually evaluate the care plan on a scheduled basis to ensure it remains effective and to determine if desired outcomes are met and the goals are achieved. Revise and update the care plan as needed in collaboration with the beneficiary and the health care team. Collaborate with beneficiaries and their support system/caregivers, providers, the multi-disciplinary team, and health care and community resources throughout the case management process. Be familiar with and understand the scope of professional licensure and carry out case management activities consistent with the scope of this licensure.

Community Health Systems

Remote Denial Coordinator - Registered Nurse (RN)

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Tennessee

The Denial Coordinator is responsible for reviewing, tracking, and resolving denied claims, ensuring that appropriate appeals are submitted, and working closely with payers, internal departments, and revenue cycle teams to identify and address denial trends. This role plays a critical part in the denials management process, supporting efforts to improve claims resolution, reduce future denials, and ensure compliance with payer guidelines. This position requires a valid Registered Nurse (RN) license.

Qualifications: H.S. Diploma or GED required Associate Degree or higher in Healthcare Administration, Business, Finance, or a related field preferred Valid Registered Nurse (RN) license 1-3 years of experience in denials management, insurance claims processing, or revenue cycle operations required Experience in revenue cycle processes in a hospital or physician office required Experience with payer appeals, claim resolution, and healthcare billing systems preferred Knowledge, Skills And Abilities: Strong understanding of payer guidelines, claim adjudication processes, and denial management strategies. Proficiency in Artiva, HMS, Hyland, BARRT, and other revenue cycle applications. Excellent problem-solving skills, with the ability to analyze denial trends and recommend corrective actions. Strong written and verbal communication skills, with the ability to engage effectively with payers, internal teams, and leadership. Detail-oriented with strong organizational and documentation skills, ensuring compliance with payer appeal deadlines. Ability to work independently and manage multiple priorities in a fast-paced environment.

Monitors assigned denial pools and work queues in Artiva, HMS, Hyland, BARRT, and other host systems, ensuring timely follow-up on denials and appeals. Conducts follow-up calls and payer portal research to track the status of submitted appeals and claim determinations, documenting all actions taken. Communicates with key stakeholders across revenue cycle, billing, and clinical teams to resolve denial trends and improve claim submission accuracy. Tracks and documents all denial and appeal activity, maintaining accurate records in system logs, account notes, and tracking reports. Ensures compliance with all payer guidelines and regulatory requirements, keeping up to date with policy changes and appeal submission rules. Manages BARRT requests (Outbound/Inbound) in a timely manner, ensuring that all required documentation and system updates are completed. Identifies root causes of denials and collaborates with internal teams to implement process improvements that reduce future denials. Prepares and submits appeal documentation, ensuring that all required medical records, forms, and supporting materials are included. Performs other duties as assigned. Complies with all policies and standards.

Atrium

Remote Oncology Nurse Navigator - 155068

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

The Remote Oncology Nurse Navigator will provide triage, support and education to members during their cancer journey via phone, email and video.

The Oncology Nurse Navigator must possess OCN. Must possess compact license and/or licensure in MI, NY or IL. Must have recent oncology navigation or oncology case management experience. Minimum 5 years of nursing experience, including 2 years in direct patient care experience in outpatient infusion or navigation. Education Requirements: Bachelor of Science in Nursing.

Establish trusting relationships with members and their care network as a Remote Oncology Nurse Navigator. Support members throughout their cancer care journey including screening, survivorship and end of life care. Assist members with care coordination, symptom management, nutritional support, discharge planning and provider referrals. Assist with urgent clinical escalations and provide clinical consult support.

First Stop Health

Pre-Certification/Utilization Management Nurse

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Illinois

First Stop Health provides care that people love® with our convenient, high-quality, and confidential virtual care solutions – Telemedicine, Virtual Mental Health, and Virtual Primary Care. We help our patients save time and money through compassionate care that’s available 24/7 via app, website, or phone. First Stop Health offers a comprehensive benefits package that includes various health and medical coverage options, dental and vision coverage, disability, and life coverage, making healthcare easily accessible. For those that choose to waive medical coverage a monthly medical waiver allowance will be provided. First Stop Health offers a remote-first work environment and flexible paid time off, including Summer Fridays. Furthermore, the employer match 401k plan and monthly phone stipend demonstrate the company's commitment to employee financial well-being. The First Stop Health membership benefit is another added perk for employees and provides Virtual Urgent Care, Virtual Mental Health, and Virtual Primary Care from their very first day!

The Utilization Management (UM) Clinician is a registered nurse responsible for conducting utilization and quality management activities for First Stop Health in accordance with Utilization Management policies and procedures. The position responsibilities include the management of medical costs through timely prospective, concurrent, and retrospective review activities. The UM Nurse is responsible for conducting clinical reviews and authorizing services based on established medical necessity criteria and benefit guidelines. Working independently, the UM Nurse evaluates inpatient and outpatient service requests to determine appropriateness and medical necessity using clinical judgment and standardized tools such as InterQual or MCG. The UM Nurse collaborates closely with Intake Coordinators, Case Managers, and provider offices to ensure timely determinations and seamless care coordination. This role requires strong attention to detail, working knowledge of CPT/HCPCS and ICD-10 codes, and the ability to manage multiple reviews while maintaining compliance with all regulatory and contractual requirements.

RN with a current, unrestricted license to practice as a health professional in a state or territory of the United States required. HCQM, HRM or similarly acceptable certification preferred. At least 2-3 years of experience in utilization review, quality assurance, discharge planning or other cost management programs and/or a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review preferred. Two (2) years’ experience in a hospital-based nursing required. Medical-surgical care experience preferred for positions in medical management areas. Strong communication, documentation, clinical and critical thinking skills essential. Working knowledge of utilization management/case management preferred. Strong problem solving and decision-making skills essential. Strong typing and computer skills essential.

Contributes to UM program goals and objectives in containing health care costs and maintaining a high-quality medical delivery system through the ongoing development and refinement of program procedures for conducting UM activities. Apply clinical guidelines (e.g., InterQual, MCG) to support decision-making for prior authorizations Maintain compliance with regulatory requirements, including NCQA, URAC, and HIPAA. Performs telephonic review for inpatient and outpatient services using First Stop Health approved medical review healthcare criteria and behavioral health criteria. Collects only pertinent clinical information and documents all UM review information using the appropriate software system. Identify and refer complex cases to Case Management or Medical Director when appropriate Promotes alternative care programs and research available options including costs and appropriateness of patient placement in collaboration with health plan clients. Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services. Communicates directly with the designated medical director/physician advisor regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues. Recommends, coordinates, and educates providers regarding alternative care options. Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital and health plan client discharge planners and social workers in the early identification of potential home care candidates or less restrictive level of care placement. Works collaboratively if Case Management is involved with member. Participates in UM program CQI (Continuous Quality Improvement) activities. Communicates all UM review outcomes in accordance with the health plan’s requirements. Follows relevant client time frame standards for conducting and communicating UM review determination. Maintains and submits reports and logs on review activities as outlined by the UM program operational procedures when directed. Identifies and communicates to the appropriate supervisory personnel all hospital, ancillary provider, physician provider and physician office concerns and issues. Identifies and communicates to the appropriate supervisory personnel all potential quality of care concerns and patient safety. Serves as liaison for provider staff and the health plan client. Maintains courteous, professional attitude when working with internal staff, hospital and physician providers, and health plan client. Identifies and communicates to health plan client and/or contracted ancillary providers all catastrophic and high-risk cases for case management referral. Actively participates in team and First Stop Health company meetings; and Performs other duties as requested by the appropriate supervisory personnel. Customer Services - Internal: Supports a positive working environment. Identifies and resolves potential personnel/peer problems and issues proactively, readily utilizing appropriate supervisors and team members as resources. Communicates to the appropriate supervisory personnel all problems, issues and/or concerns as they arise. Communicates to the appropriate supervisory personnel any issues or concerns related to quality of care. Maintains a courteous and professional attitude when working with all First Stop Health staff members and the management team. Readily available to non-clinical staff to answer questions and ensure that non-clinical administrative staff is performing within the scope of the non-clinical role. Actively participates in team meetings, as designated. Customer Services – External: Timely identifies and communicates to applicable practitioners, providers, and the health plan/client staff all issues and concerns related to the case at hand. Communicates to the client/health plan staff any issues or concerns related to quality of care, using First Stop Health policies/procedures. Works, communicates, and collaborates in harmony and in a courteous and professional manner with the patient, practitioner, provider, and multidisciplinary health care team members all issues, concerns and/or as the UM Plan is revised and/or new services are implemented/terminated. Serves as a liaison and patient advocate when deemed applicable for quality of care and cost outcomes; and Communicates appropriately and according to policy, and/or regulatory requirements with the practitioner(s), provider(s), patient/patient’s legally appointed representative any UM coverage determination(s).

CircleLink Health

On-Call Registered Nurse (RN) Remote 1099 Contractor

Posted on:

May 6, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

CircleLink Health is a company of passionate clinicians, technologists and business people tackling the $600B problem of preventable chronic and post-acute complications. We’re building a world-class Care Management platform to enable providers while accelerating the shift to preventative care instead of status quo reactive care.

We are seeking an experienced and dependable Registered Nurse (RN) to join our team in a remote, part-time, on-call capacity. This is a great opportunity for RNs who are passionate about supporting patient care, enjoy flexible scheduling, and want to work from home in a non-clinical role.

Fluent in English Self-directed, able to work independently with little supervision while meeting performance metrics Passion for nursing and improving patient outcomes Comfortable with technology and eager to learn new systems and platforms Excellent organizational and time management skills Strong communication and telephonic skills Strong critical thinking and problem-solving abilities Education and Experience: Current, unrestricted Compact Multi-State RN License (required) 3+ years of experience as a Registered Nurse (required) Case Management or Chronic Disease Management experience Proficiency with electronic health records and web-based applications Scheduling and Other Requirements: You must have a reliable, high-speed internet-connected computer (equipment not provided) Minimum of 20–25 hours of availability per week required This role cannot be held alongside a full-time position Shifts are scheduled in advance and must fall between 9:00 AM – 6:00 PM ET, Monday through Friday Evening and weekend hours are not available You will self-schedule your shifts using our scheduling software Must be available by phone for the full 8-hour on-call shift

As an on-call RN, you will be available to assist with complex cases that are escalated by case management care coaches (LPNs). This may include triage and taking over a patient call or subsequent follow-up directly with the patient.

Wellbox Health

LPN Remote Chronic Care Management: (Time zone: PST/MST)

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Compact / Multi-State

Wellbox is a rapidly growing healthcare company focused on empowering people to live healthier lives through comprehensive preventative care solutions delivered by an elite team of experienced nurses. We are currently seeking tech-savvy LPN Patient Care Coordinators to conduct monthly telephonic outreach to chronically ill patients, developing personalized care plans that address their health challenges.

We are seeking full-time LPN team members who can work 40 hours per week, between the hours of 8 am – 6 pm PST/MST, Monday – Friday.

Active Compact LPN License. Minimum two years of clinical experience; care coordination experience preferred. Proficient with Electronic Medical Records and Microsoft Office. Excellent communication and problem-solving skills. Candidates who reside in Mountain Standard Time (MST) or Pacific Standard Time (PST) are preferred; candidates that reside in Central or Eastern time zones will not be considered for this position.

Manage patients’ healthcare needs via virtual phone conversations. Document visits using technology platforms and EHRs. Develop personalized care plans addressing physical, mental, and preventative health. Coach patients on treatment plans, including nutrition and wellness. Connect patients with resources and prepare them for medical appointments.

UnitedHealth Group

APR-DRG CVA RN Auditor - National Remote

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Minnesota

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

In this position as a DRG CVA RN Auditor, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: nAssociate’s degree (or higher) Unrestricted RN (Registered Nurse) license CCS/CIC or willing to obtain certification within 6 months of hire 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies 2+ years of ICD-10-CM coding experience including but not limited to expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM) 2+ years of ICD-10-PCS coding experience including but not limited to expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers Preferred Qualifications: Experience with prior DRG concurrent and/or retrospective overpayment identification audits Experience working with Utilization Management Experience with readmission reviews of claims Experience with DRG encoder tools (ex. 3M) Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry Healthcare claims experience Managed care experience Knowledge of health insurance business, industry terminology, and regulatory guidelines Soft Skills: Ability to use a Windows PC with the ability to utilize multiple applications at the same time Ability to work independently in a remote environment and deliver exceptional results Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail Excellent time management and work prioritization skills Physical Requirements and Work Environment: Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computer Have a secluded office area in which to perform job duties during the work day Have reliable high – speed internet access and a work environment free from distractions *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification Utilize expert knowledge to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements Maintain and manage daily case review assignments, with a high emphasis on quality Provide clinical support and expertise to the other investigative and analytical areas Work in a high-volume production environment that is matrix driven

Molina Healthcare

Care Review Clinician, Inpatient Review (RN) Remote based in Arizona

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Arizona

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. This position will support the Arizona state Plan. We are seeking a candidate with an Arizona RN licensure. The ideal candidate will have experience with UM and prior authorization with both inpatient and outpatient. Candidates with a Behavioral Health background are highly preferred. Further details to be discussed during our interview process. Remote position, must reside in Arizona. Work hours: Monday - Friday 8:30am- 5:00pm Mountain Time with some weekends and holidays.

JOB QUALIFICATIONS Required Education: Graduate from an Accredited School of Nursing. Required Experience: 3+ years hospital acute care/medical experience. Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. State Specific Requirements: Licensed within the appropriate state. Preferred Education: Bachelor's Degree in Nursing Preferred Experience: Recent hospital experience in ICU, Medical, or ER unit. Prior working experience with MCG and/or InterQual guidelines Prior experience in Behavioral Health and Physical Health Utilization Mangement reviews. Preferred License, Certification, Association: Active, unrestricted Utilization Management Certification (CPHM).

Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed. Processes requests within required timelines. Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner. Requests additional information from members or providers in consistent and efficient manner. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote Molina Care Model. Adheres to UM policies and procedures. Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

UnitedHealth Group

Nurse Practitioner - Part Time - FL Licensed - Telephonic After Hours Remote

Posted on:

May 5, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual’s physical, mental and social needs – helping patients access and navigate care anytime and anywhere. As a team member of our Senior Community Care (SCC) product, we work with a team to provide care to patients at home in a nursing home, assisted living for senior housing. This life-changing work adds a layer of support to improve access to care. We’re connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

The Home and Community Care (HCC) program is a longitudinal, integrated care delivery program. The HCC National On Call advanced practice clinician (APC) is responsible for providing telephonic care and direction to members and facility staff during various evening, overnight, weekend, and holiday hours. This role is responsible for the delivery of medical care services to a pre-designated group of enrollees. In this remote role you will provide afterhours virtual (primarily telephonic) care for aging residents in various settings. This excellent opportunity affords an autonomous role bringing enormous satisfaction in the care and comfort of our aging population. In this role you will have the ability to achieve work life balance. Optum is transforming care delivery with innovative and personal care. As one of the largest employers of APCs, Optum offers unparalleled career development opportunities. Scheduling: This is a full time, work from home position requiring variable shift coverage on weeknights, weekends, and holidays While your shift times can vary, we provide coverage to members: on weeknights from 5pm- 8am local time, and continuous weekend coverage from Friday at 5pm to Monday at 8am, and Holiday coverage beginning at 5pm of the end of the last business day to 8am of the resumption of business hours Weekday Shifts are 5PM-2AM or 11PM-8AM Weekend Shifts are 11AM-11PM or 1AM-1PM Holiday scheduling is completed at the beginning of the year for advanced planning Experience Preference: Candidates with recent experience in high-acuity geriatric care (e.g., SNF, LTACH, Hospitalist, ICU, Emergency) are preferred. Call Handling: You will receive about 4 after-hours calls per hour on average from Nursing Home Staff, RNs, DONs, Staff Typing Skills: Excellent typing skills are essential as you will need to enter notes live for each case If you have an active FL license, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Active Florida NP license or ability to obtain by start date. Licensure must be unencumbered, free of any open/unresolved disciplinary actions including probation or restrictions against privilege to practice Active ANCC or AANP national certification in Family, Geriatrics, Adult, Adult-Gerontology Primary Care, or Adult-Gerontology Acute Care certification, or the ability to obtain national certification and/or NP license in state of assignment by start date Current active DEA licensure or ability to obtain post-hire, per state regulations (unless prohibited in state of practice) Availability to work assigned weekends, weekdays, and pre-assigned holidays Preferred Qualifications: 2+ years of hands-on postgrad experience within Long Term Care Understanding of Geriatrics and Chronic Illness Understanding of Advanced Illness and end of life discussions Proficient computer skills, including the ability to document medical information with written and electronic medical records

Available on provided telephonic platform, both taking and placing calls to coordinate care for members between facilities, hospitals, and Optum field colleagues Utilize EMR proficiently to provide acute care to members during overnight and weekend and holiday hours Primary Care Delivery Manage both medical and behavioral, chronic, and acute conditions effectively, and in collaboration with a physician or specialty provider Responsible for ensuring encounter is documented appropriately to support the diagnosis at that visit Attend and complete all mandatory educational training requirements Care Coordination Monitor the needs of members and families while facilitating any adjustments to the plan of care as situations and conditions change Review orders and interventions for appropriateness and response to treatment to identify the most effective plan of care that aligns with the member’s needs and wishes Program Enhancement Expected Behaviors Regular and effective communication with internal and external parties including physicians, members, key decision-makers, nursing facilities, HCC staff and other provider groups Ability to meet shift scheduling requirements, and attendance expectations

UnitedHealth Group

APR-DRG CVA RN Auditor - National Remote

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Minnesota

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

In this position as a DRG CVA RN Auditor, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Associate’s degree (or higher) Unrestricted RN (Registered Nurse) license CCS/CIC or willing to obtain certification within 6 months of hire 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies 2+ years of ICD-10-CM coding experience including but not limited to expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM) 2+ years of ICD-10-PCS coding experience including but not limited to expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers Preferred Qualifications: Experience with prior DRG concurrent and/or retrospective overpayment identification audits Experience working with Utilization Management Experience with readmission reviews of claims Experience with DRG encoder tools (ex. 3M) Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry Healthcare claims experience Managed care experience Knowledge of health insurance business, industry terminology, and regulatory guidelines Soft Skills: Ability to use a Windows PC with the ability to utilize multiple applications at the same time Ability to work independently in a remote environment and deliver exceptional results Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail Excellent time management and work prioritization skills Physical Requirements and Work Environment: Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computer Have a secluded office area in which to perform job duties during the work day Have reliable high – speed internet access and a work environment free from distractions *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification Utilize expert knowledge to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements Maintain and manage daily case review assignments, with a high emphasis on quality Provide clinical support and expertise to the other investigative and analytical areas Work in a high-volume production environment that is matrix driven

CVS Health

Case Manager, Registered Nurse (Remote)

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Aetna is an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. We collaborate with members, providers, and community organizations in pursuit of quality solutions that address the full continuum of our members’ health care and social determinant needs. Dual Eligible Special Needs Plans (DSNP) members are enrolled in Medicare and Medicaid. Our Care Managers are frontline advocates for members who cannot advocate for themselves. Join us in this exciting opportunity as we grow and expand DSNP into new markets across the country.

Required Qualifications: Candidate must have active and unrestricted RN licensure in the state of Georgia or compact licensure in state of residence 3+ years of clinical experience 2+ years of case management, discharge planning and/or home healthcare coordination experience Preferred Qualifications: Certified Case Manager Excellent analytical and problem-solving skills Bilingual Effective communications, organizational, and interpersonal skills Ability to work independently Effective computer skills including navigating multiple systems and keyboarding Proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications Education: Associate's Degree in Nursing (REQUIRED) with equivalent experience Bachelor’s Degree (PREFERRED) License: Active and unrestricted RN licensure in the state of Georgia or compact licensure in state of residence

Nurse Care Manager is responsible for assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness. Develops a proactive plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness. Uses clinical tools and information/data review to conduct an evaluation of member's needs and benefits. Applies clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning. Conducts assessments that consider information from various sources, such as claims, to address all conditions including co-morbid and multiple diagnoses that impact functionality. Uses a holistic approach to assess the need for a referral to clinical resources and other interdisciplinary team members. Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

CVS Health

Transition of Care Associate, Licensed Practical Nurse, Remote

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

LPN/LVN

State License:

Texas

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

This is a full-time telework position. **This position will require 8a-5p in the assigned market time zone.** Help us elevate our member care to a whole new level! Join our Aetna Team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Dual Eligible Special Needs Plan (D-SNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand D-SNP to change lives in new markets across the country. The Transition of Care Coach is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. The TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by: Complete post-discharge questionnaire, which may be market specific. Providing comprehensive discharge planning Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications. Benefit education Provides clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports) Evaluation of health and social indicators Identifies and engages barriers to achieving optimal member health. Uses discretion to apply strategies to reduce member risk. Presents cases at case conferences for multidisciplinary focus to benefit overall member management. Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage. Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up. Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel. Updates the Care Plan for any change in condition or behavioral health status. Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality.

REQUIRED WORK EXPERIENCE: 2+ years LPN nursing experience Active and unrestricted LPN license in the state of residence Proficiency in Microsoft Word, Excel, and Outlook PREFERRED WORK EXPERIENCE: 3+ years LPN nursing experience Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses Discharge planning experience Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care. Effective verbal and written communication skills Bilingual a plus! EDUCATION: Required: H.S. or Equivalent - MUST be an LPN Preferred: Associate's Degree, Bachelor's Degree

Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines. Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions. Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community. Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions.

ChenMed

Registered Nurse, Telehealth (Fulltime)(Spanish Bilingual) - Remote

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Registered Nurse, Telehealth is responsible for providing telephonic triage directional patient care advice for general and specific illnesses, health related issues, client counseling, patient advocacy, health education and referral and resource management to ChenMed patients and their families. The incumbent in this role provides remote clinical advice and assessments within license and as possible given the technology and medium. He/She collaborates with primary caregivers and others on the interdisciplinary care plan team to provide a team approach of care. This role is a full time opportunity. Schedule: Monday - Friday 1630-0030 EST

KNOWLEDGE, SKILLS AND ABILITIES: Advanced-level business acuity In-depth knowledge and understanding of general/core Nursing-related functions, practices, processes, procedures, techniques and methods Broad nursing knowledge and understanding Ability and willingness to provide extraordinary customer service and professionalism to all customers Maintains current nursing knowledge and competency to stays abreast of budding nursing trends and best practices Excellent written and verbal communication skills through a variety of formats, tools and technologies Capable of building trust and professional relationships to deliver VIP care across the continuum Ability to demonstrate excellent clinical judgement Ability to problem solve Ability to prioritize and work under pressure Ability to provide constructive feedback Ability to effectively collaborate with physicians, patients, family members, colleagues and other team members in a courteous and professional manner Ability to effectively collaborate with a multidisciplinary team Proficient skill in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook; competent in other systems required for the position Ability and willingness to travel locally, within South Florida, to attend meetings and trainings up to 10% of the time; flexible and available to cover after-hours and to work weekends as needed Spoken and written fluency in English; bilingual (Spanish) required This job requires use and exercise of independent judgment EDUCATION AND EXPERIENCE CRITERIA: Associate Degree in Nursing required, Bachelor’s Degree in Nursing preferred Nurse Licensure Multistate Compact license required Michigan and Illinois Nurse Licensure required within 90 days of hire, ability to obtain additional licenses as requested by the organization within 90 days of hire Spanish fluency required Minimum of 2 years of Nursing experience in an ER or Emergency Triage setting required. Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required Minimum of 3 years acute clinical nursing work experience preferred Minimum of 1 year virtual care experience preferred

Connects with patients via phone or video call. Interviews and questions patients to collect health history and uses a computer system to record and store comprehensive and focused data relating to the health needs of patients and families. Provides health assessment and treatment solutions, monitors patient health and at-home care, aids in emergency scenarios and promotes patient wellness. Based on the technology available, monitors a patient’s oxygen levels, heart rate, respiration, blood glucose and other assessment measures. With the help of video chatting, identifies patient’s symptoms and conditions. Analyzes data to determine the appropriate health maintenance and identify appropriate outcome for the patient and family. Collaborates with on-call PCP as needed to support expected clinical outcomes. Implements the appropriate protocol to attain the expected outcome. Evaluates and documents progress toward the anticipated outcome. Assists in ensuring achievement of optimal patient outcomes through use of Telemedicine. Documents interventions in readable, understandable language. Aids in enhancing the quality and effectiveness of the organization’s telehealth practices and professional nursing practice through successful utilization and improvement of outcomes that demonstrate program effectiveness. Utilizes appropriate resources to plan and provide services that are safe, effective and fiscally responsible. Performs other duties as assigned and modified at manager’s discretion.

Aveanna Healthcare LLC

Remote Home Health RN Assistant Clinical Manager

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Wisconsin

The Assistant Clinical Manager – Home Health, will evaluate nursing activities to ensure patient care, staff relations, and efficiency of service within the team. Act as a resource and support for clinical staff and facilitate collaborative teamwork on the unit and with ancillary departments. Oversee the Quality Program for the clinic and ensure that all standards are met, and keep procedural manuals and other necessary equipment up to date. This individual will serve as a backup to the Clinical Manager. Looking for an experienced OASIS HH RN who has a compact license to support our branches remotely with HCHB workflow, reviewing documentation, approving orders, communicating with providers, reviwing on call documentation and process improvements.

Requirements: Active RN licensure in the state of the application Bachelor’s degree required Preferred: Medicare skilled nursing experience Basic understanding of OASIS RN experience in health care (home health)

Maintains clinical record documentation according to agency policy and procedures and state/federal regulation Ensures compliance with regulations and is available for federal and state licensure surveys Participates in Performance Improvement activities including but not limited to clinical record review, quality indicator monitoring, and quality management OASIS and/or coding experience is strongly desired Acts as a Preceptor to coordinate orientation and training for all RN Clinical new hires Provides ongoing training and educational opportunities for Clinical staff Serves as a senior member to all staff regarding quality improvement and documentation Oversees clinical orientation duties including documentation and quality improvement for all new health related employee Carry a caseload of patients, understand and perform the admission process plan of care Supervise RN, LPN, and HHA field staff as indicated.

Hanger, Inc.

ACP- Nurse Clinical Ops Consultant

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

With a mantra of Empowering Human Potential, Hanger, Inc. is the world's premier provider of orthotic and prosthetic (O&P) services and products, offering the most advanced O&P solutions, clinically differentiated programs and unsurpassed customer service. Hanger's Patient Care segment is the largest owner and operator of O&P patient care clinics nationwide. Through its Products & Services segment, Hanger distributes branded and private label O&P devices, products and components, and provides rehabilitative solutions to the broader market. With 160 years of clinical excellence and innovation, Hanger's vision is to lead the orthotic and prosthetic markets by providing superior patient care, outcomes, services and value. Collectively, Hanger employees touch thousands of lives each day, helping people achieve new levels of mobility and freedom.

The Nurse Clinical Ops Consultant will achieve partner growth and retention by establishing maximum value for our clients through successful implementation of ACP clinical programs and rehab technologies. The focus of this role will emphasize nursing integration of respiratory, cardiopulmonary, and other rehab clinical programs as part of interdisciplinary ACP programs in post-acute care settings. The Nurse Clinical Ops Consultant will be part of ACP Clinical Services team and will work closely with field ops, marketing, and product development teams. The Nurse Clinical Ops Consultant will report directly to the Director of Clinical Services. Southeast Region, Georgia & Florida areas preferred

Minimum Qualifications: BSN or MSN Nursing Degree Licensed Registered Nurse 10 years of nursing experience with at least 5 years in leadership and/or operational role Deep knowledge of post-acute care (PAC) settings, healthcare systems, and regulatory environment Certifications: RAC-CT or similar certification is preferred Must have, or be eligible to obtain, a valid driver’s license and driving record within the standards outlined within Hanger’s Motor Vehicle Safety Policy and Procedures. Additional Success Factors: Extensive experience developing or implementing Clinical Programs in Post Acute Care settings including skilled nursing facilities. Strong familiarity with respiratory and pulmonary nursing care in post-acute care settings with command of the clinical, operational, and regulatory dimensions. Excellent verbal and written communication skills, with strength in dynamic presentations to influence adoption of new and innovative technologies/practices. Leadership and Management skills leading and influencing nursing teams with impact on quality of patient care. Proactive, adaptive, solutions-oriented to drive measurable results. Ability to travel up to 50% to support field implementation of ACP programs. Working knowledge of Microsoft Teams, Outlook, PowerPoint, Work, and Excel. Excellent customer service and public relations skills. Foster open collaboration and constructive dialogue with everyone around you. Continuously innovate new solutions, influencing and responding to change. Focus on superior outcomes and calibrate work processes for outstanding results. Act with integrity in all ways and at all times, remaining honest, transparent, and respectful in all relationships. Keep the patient at the center of everything that you do, building lifelong trust. Foster open collaboration and constructive dialogue with everyone around you. Continuously innovate new solutions, influencing and responding to change. Focus on superior outcomes, and calibrate work processes for outstanding results. #LI-Remote

Install ACP Respiratory/Cardiopulmonary program within ACP partner facilities where nursing team in collaboration with interdisciplinary team drive successful adoption of technology. Collaborate with members of Clinical Services, field Ops on the development of successful ACPlus Respiratory Assessment nursing workflow for respiratory assessment and treatment Promote nursing role in implementation of ACP rehab technologies and interdisciplinary clinical programs by: Collaborating with Clinical Services, Product Development, and Marketing teams to identify new opportunities. Advancing the development of ACP products and services with focused on optimal integration of nursing department/staff. Conducting webinars, training activities, and technology demonstrations for internal and external stakeholders with particular emphasis on nursing role. Contribute to nursing CE content development in collaboration with Clinical Content and Innovation team. Serve as a liaison to Remote Clinical Services addressing nursing clinical, regulatory, and operational inquiries supporting ACP core clinical programs within ACP partner facilities. Mentor ACP field team to navigate complex post-acute care settings and gain in-depth understanding of nursing role in successful technology and clinical program implementation. Be a resource for field operational leaders to support business review meetings for existing and prospective partners to strategize around business growth.

Elevance Health

LTSS Service Coordinator - RN

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

New York

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

LOCATION: This is a field designated role for the areas of Erie and Niagara Counties. New York residency is required. When you are not traveling, you will work virtually from your home. HOURS: Standard business hours, Monday through Friday. TRAVEL: Travel is required within the above areas visiting members in their homes or in a care facility. This field-based role enables associates to primarily operate in the field, traveling to client sites or designated locations as their role requires, with occasional office attendance for meetings or training. This approach ensures flexibility, responsiveness to client needs, and direct, hands-on engagement. The LTSS Svc Coordinator RN-Clinician is responsible for overall management of member's case within the scope of licensure. The RN has overall responsibility to develop the care plan for services for the member and ensures the member's access to those services.

Required Qualifications: Requires a high school diploma or equivalent. Requires current, unrestricted RN license issued by the state of New York; and 3 years of experience in working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator, Case Management, or similar role; or any combination of education and experience which would provide an equivalent background. Preferred Qualifications: You must be comfortable visiting members and providing care in their homes or in a care facility. You must be computer proficient in Microsoft Office including Word and Excel. Very strong verbal and written communication skills are needed for this position.

Responsible for performing telephonic or face-to-face clinical assessments for the identification, evaluation, coordination, and management of member's needs, including physical health, behavioral health, social services, and long term services and supports. Identifies members for high-risk complications and coordinates care in conjunction with the member and the health care team. Manages members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health benefits. Obtains a thorough and accurate member history to develop an individual care plan. Establishes short- and long-term goals in collaboration with the member, caregivers, family, natural supports, physicians; identifies members that would benefit from an alternative level of care or other waiver programs. May assist with the implementation of member care plans by facilitating authorizations/referrals for utilization of services, as appropriate, within benefits structure or through extra-contractual arrangements, as permissible. Interfaces with Medical Directors, Physician Advisors, and/or Inter-Disciplinary Teams on the development of care management treatment plans. May also assist in problem solving with providers, claims or service issues. May direct or supervise the work of any LPN, LCSW, LMSW, or other licensed professionals than an RN, in coordinating services for the member. Travels to worksite and other locations as necessary.

Elevance Health

Care Management Manager, Foster Care (Rutherford Co.)

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

North Carolina

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

North Carolina residency is required! LOCATION: This is field position. When you are not in the field, you will work remotely from your home. You must reside within 20 miles of Rutherford County. HOURS: General business hours, Monday through Friday. TRAVEL: Some travel within your assigned area or region is required. The CFSP Care Management Manager (Manager I GBD Special Programs) is responsible for managing and overseeing assigned care managers and ensuring fidelity to the CFSP Care Management model which includes physical health, behavioral health, and social services.

For the State of North Carolina, in accordance with federal/state law, scope of practice regulations or contract, the requirements are: Requires an active and current license as an LCSW, LCMHC, LPA, LMFT, or RN issued by the state of North Carolina. Requires a MS/MA in social work, counseling, or a related behavioral health field, or a degree in nursing. Requires three (3) years of experience providing care management, case management, or care coordination to individuals served by the child welfare system. Preferred Qualifications: Knowledge of resources, supports, services and opportunities required for safe community living for populations receiving in-reach and transition services, including LTSS, Behavioral Health, therapeutic, and physical health services. Experience working with Children, Youth, and Families who are being served by Local Departments of Social Services through Foster Care and Adoptive Assistance programs is very strongly preferred. At least 2 years of management/supervisor experience (with direct reports) is needed for this position. Service delivery coordination, discharge planning or behavioral health experience in a managed care setting preferred. We are unable to accommodate LCSW-A, LCMHC-A or any other associate level licenses.

Manages resource utilization to ensure appropriate delivery of care to members, adequate coverage for all tasks and job responsibilities. Review all Care Plans and ISPs for quality control and provide guidance to care managers on how to address Members’ complex health and social needs. Ensure care managers provide Trauma-Informed Care and recognize the impact of ACEs on the CFSP population. Coordinates service delivery to include member assessment of physical and psychological factors. Participates in cross-functional workgroups created to maintain and develop program. Evaluates current processes of Special Program's support functions; recommends changes for increased efficiencies and improved outcomes. Develops and conducts training programs for staff involved in the program. Extracts and manipulates analytical data to present findings to relevant markets and stakeholders. Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Pope's Place

Nurse Case Manager-RN

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Washington

Pope's Kids Place is a nonprofit providing services and assistance in the Pacific Northwest for medically complex and fragile children. We offer individualized care for children and young adults with exceptional medical and behavioral needs, strengthening them, their families, and the community. Our dedicated and loyal staff provide skilled nursing care to our residents. We are located in Centralia, Washington.

This is a full-time remote role for a Nurse Case Manager-RN.

Experience in special needs/ complex care Nursing Skills in authorizations and appealing Excellence in Case Management Excellent communication and organizational skills Ability to work independently and remotely Experience in working with medically complex and fragile children is a plus Bachelor's degree in Nursing (BSN) and an active RN license CCM

The Nurse Case Manager-RN will be responsible for coordinating and managing patient care, including admissions, discharge planning, utilization management, and case management. Daily tasks will involve assessing patient needs, developing care plans, coordinating with healthcare providers, and ensuring patients receive appropriate medical and nursing care.

IntellaTriage

Remote Hospice Triage RN- PT 2 shift 3:30p-12a + rotating Sat & Sun 7:30-4p

Posted on:

May 5, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Built around a mission to improve the lives of nurses and patients, IntellaTriage has been providing after-hours nurse triage for hospice and home health providers since 2008. Utilizing best-in-class technology, IntellaTriage provides round-the-clock direct access to licensed, registered nurses using client-customized protocols for patient-centered, compassionate care. We are growing rapidly and excited to support our clients’ nursing staff in the field by leveraging our outsourced team of nurses to manage after-hours care delivery. Our triage nurses become an extension of our clients’ care team, and they trust us to support them and their patients during their non-core hours. Learn more at www.intellatriage.com.

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

MUST have or be willing to obtain a Compact RN license (states with pending or future implementation dates are not considered current compact states until the implementation date) You must remain in good standing and ensure your home state license remains active. IntellaTriage will cover the cost of non-compact state licensure if necessary for client support. Hospice, palliative, end-of-life care is strongly preferred Experience in a fast-paced environment: ED, surgical services, or critical care, etc. Must be comfortable accessing multiple technology applications to document during calls Ability and comfort with typing in a fast-paced environment Fluency in English is required, additional languages are a bonus Must physically reside in the U.S. and be legally eligible to work for any employer Must be able to complete three weeks of remote paid training that is conducted during days and evenings Must be available to work every other Saturday & Sunday Must be available to work some Holidays as required Must be able to handle stress and multitask when receiving calls (minimum of 5 calls per hour on weekdays, and up to 8 per hour on weekends) Must be able to communicate empathically with patients while adhering to protocols Must maintain CEU’s as designated by the states in which you are answering calls Must attend any in-services, and additional training on an as needed basis Must pass background check and nurse licensing check

Our Hospice Triage Nurses: Have experience in hospice, palliative, end-of-life care and in fast-paced environments: ED, critical care, surgical services, etc. Part-time nurses work a minimum of 1 week day shift & every other weekend both Saturday & Sunday Receive three weeks of remote paid training. The training schedule varies based on availability You can pick up additional shifts, if available, for the clients’ you are trained to support. We will provide you with a laptop and headset. You’re required to use your own high-speed internet You’ll need a quiet space, away from noise and distraction, while you work (privacy/HIPAA compliant space is required). You’ll access EMRs for charting and utilize our internal applications to perform job functions You MUST be able to follow instructions, read directions, and be confident using technology A minimum of 30 minutes paid shift prep is required prior to taking calls You’ll spend 30 minutes to 2 hours, at the end of your shift, completing remaining charting before clocking out

Molina Healthcare

Manager, Clinical Quality Interventions - RN Required (Remote)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Nebraska

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Molina's Quality Improvement function oversees, plans, and implements new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs for members in accordance with prescribed quality standards; conducts data collection, reporting and monitoring for key performance measurement activities; and provides direction and implementation of NCQA accreditation surveys and federal/state QI compliance activities.

KNOWLEDGE/SKILLS/ABILITIES: The Manager, Health Plan Quality Interventions is responsible for developing, implementing, and monitoring the success of quality improvement interventions. The Manager works to coordinate resources and training within the health plan and identify barriers to established goals and timelines. Key activities include implementing, monitoring, and analyzing the effectiveness of a comprehensive intervention strategy; and facilitating stakeholder input and strategic direction from the interventions Joint Operations Committee that includes leadership from multi-functional areas. The Manager serves as the primary contact for health plan interventions and leads the interventions Joint Operations Committee representing the Molina Plan Senior Leadership Team. In all activities, the Manager works with the national and regional collaborative analytics and strategic team to present and evaluate intervention strategies. Required Education: Active, unrestricted RN License. Required Experience: 5+ years' experience in managed healthcare, including at least 2 years in health plan quality improvement or equivalent/related experience. 2+ years' management experience leading a healthcare quality team. Operational knowledge and experience with Excel and Visio (flow chart equivalent). Preferred Education: Master's Degree or higher in a clinical field, Public Health or Healthcare. Preferred Experience: 3+ years' experience with member/ provider (HEDIS) outreach and/or quality intervention or improvement studies (development, implementation, evaluation). Supervisory experience. Project management and team building experience. Experience developing performance measures that support business objectives. Preferred License, Certification, Association Certified Professional in Health Quality (CPHQ) Certified HEDIS Compliance Auditor (CHCA)

Plans and/or implements Quality interventions that meet state and federal intervention rules and are aligned with effective practices as identified in the healthcare quality improvement literature and within Molina plans. Develops and implements targeted interventions related to performance improvement, including member and provider outreach to improve care and service. Serves as operations and implementation lead for Molina Plan quality improvement interventions using a defined roadmap, timeline, and key performance indicators. Collaborates with the national intervention collaborative analytics and strategic teams to deliver proposed interventions for review and evaluation. Communicates with the Molina Plan Senior Leadership Team, including the Plan President, Chief Medical Officer, national intervention collaborative analytics and strategic teams about key deliverables, timelines, barriers, and escalated issues that need immediate attention. Presents concise summaries, key takeaways, and action steps about Molina plan intervention strategy to national, regional and plan meetings. Demonstrates ability to lead and influence cross-functional teams that oversee implementation of quality interventions. Possesses a strong knowledge in quality to implement effective interventions that drive change. Functions as key lead for interventions including qualitative analysis, reporting and development of program materials, templates, or policies. Provides on-going support to manage and maintain the integrity of established programs/processes and member/provider outreach initiatives. Supports provision of high-quality clinical care and services by facilitating/building strategic relationships with health care providers.

CareFirst BlueCross BlueShield

Clinical Advisor - (Registered Nurse) - (Remote)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Must live in MD, DC, VA PURPOSE: The Clinical Advisor's role is multifaceted from data analytics, client facing presentations, and solutions optimization. The Clinical Advisor will extract clinical and relevant data to educate clients, brokers, consultants, and internal stakeholders, showcasing the value of the organization's approach to managing care delivery. The Clinical Advisor will synthesize data and make individualized recommendations related to population health with a goal of improving outcomes and driving down cost in populations. The Clinical Advisor serves as key subject matter expert and strategic partner for the Sales team and will regularly attend onsite and virtual client meetings to review health outcomes and cost information.

QUALIFICATIONS: Education Level: Bachelor's Degree in Nursing, Pharmacy, Psychology, Behavioral Health, Social Work or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience Licenses/Certifications: RN - Registered Nurse - State Licensure And/or Compact State Licensure. Experience: 4 years experience working in a clinical setting. 2 years demonstrated experience with healthcare data analysis. Preferred Qualifications: Graduate degree such as MSN, MBA, MPH. Knowledge of health plan sales or account management. Experience working in a health plan environment in a business role. Knowledge, Skills and Abilities (KSAs): Ability to present onsite and virtually to both small and large audiences. An in-depth knowledge of current and emerging trends in care management. Ability to work closely with and influence people at all levels, including C-suite executives, vice presidents, directors, managers, and associates. Critical thinking and judgment with the ability to connect the dots, put the story together and then deliver to the client in a professional manner. Demonstrated ability to analyze and interpret data. Ability to lead/coordinate projects and function as a resource to other CareFirst departments. Ability to communicate effectively, both verbally and in writing. Ability to present and communicate in group settings in a professional manner. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for extended periods of time. Must be able to meet established deadlines and manage multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Analyzes population health data as well as clinical and financial trends, for existing and prospect customer accounts. Develops business case studies and next generation reports to demonstrate the value of care management and wellness approaches. Makes strategic recommendations for key accounts and their consultants/brokers to retain and grow business. Delivers presentations and demonstrates to external clients, customers and prospects the value proposition and return on investment of assigned solutions. Consults with key stakeholders regarding cost containment and quality improvement for their employee populations. Identifies gaps in care and make referrals to appropriate programs. As a clinical subject matter expert, reviews and analyzes member data to show value of care management programs. Collaborates with internal teams including wellness, pharmacy, and care management. Creates and executes upon a sales strategy for the assigned solutions to help customers meet their clinical goals. Present and demonstrate to external clients, customers and prospects the value proposition and return on investment of assigned solutions in a consultative approach. Consult about how to best control cost and improve quality for their employee populations. Using clinical knowledge, review and analyze member data to show the value of the organizations care management efforts; identify gaps in care and make referrals to appropriate programs.

Providence Service

Hospital at Home Command Center RN *Remote, .6 Day Shift*

Posted on:

May 4, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

Texas

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits.

**Hospital at Home Command Center RN *Remote, . 6 Day Shift Candidates residing in AK, WA, MT, OR, CA, TX or NM are encouraged to apply.** Interested in being on the cutting edge of innovation within nursing? Passionate about caring for patients but no longer want to work in the traditional Hospital setting? Enjoy working in a fast-paced and challenging environment? If so, then come join our team! Hospital At Home is a very dynamic model of care, where appropriate patients transfer to the virtual unit to complete their hospitalization. This program runs like a regular inpatient unit, it just happens to be set up in the patient’s home. The program provides medical equipment, meals, and diagnostics in the home setting. The Field RN will provide the ‘hands on’ care and be part of a team of clinicians which includes Command Center RNs, MDs, plus Field Therapists such as PT and OT. This role is very dynamic as, the Field RN will work closely with their virtual colleagues throughout the day to provide clinical care for our patients. Hospital at Home is a model of care where patients who meet inpatient criteria are clinically managed in their home. Data shows that patients cared for in a Hospital at Home model have better outcomes, higher patient/family satisfaction, fewer complications, and shorter lengths of stay. Staff who care for these patients virtually and in the home also report higher job satisfaction. The Field RN is an integral part of providing the best care possible for a subset of the patient population. The acuity of patients in our program are the same as a standard medical floor. And, while this care model isn’t appropriate for everyone, it is appropriate for those patients who meet specific, established criteria, and are deemed safe and appropriate to be hospitalized in their home versus the traditional setting. Strong candidates will have excellent clinical and communication skills, be comfortable with technology, and a willingness to flex as the day progresses. You will be joining a team of very supportive colleagues! Those hired into this role will be required to obtain nursing licenses for the balance of the states the department supports. Providence nurses are not simply valued – they’re invaluable. You will thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best nurses, we must empower them. Learn why nurses choose to work at Providence by visiting our Nursing Institute page. Join our team at Providence Strategic And Management Services as a Providence caregiver, you’ll apply your specialized training to deliver world-class health with human connection and make a difference every day through your extraordinary care.

Graduation from an accredited nursing program. Registered Nurse License from the state in which you reside, specifically one of our footprint states where we can hire: Texas Registered Nurse License upon hire, Or Washington Registered Nurse License (Vendor Managed) Or Alaska Registered Nurse License (Vendor Managed) Or California Registered Nurse License (Vendor Managed) Or Montana Registered Nurse License (Vendor Managed) Or Oregon Registered Nurse License (Vendor Managed) Or New Mexico Registered Nurse License (Vendor Managed) Or Texas Registered Nurse License (Vendor Managed) 1 year - Nursing experience.

UnitedHealth Group,

Behavioral Health Senior Clinical Admin RN - Remote

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

The Senior Clinical Admin Nurse will be responsible for providing individualized attention to UMR membership and covered families and serves to assist with navigation of the health care system. The purpose of the clinical liaison nurse is to help individuals live their lives to the fullest by supporting coordination and collaboration with multiple and external partners including consumers and their families/caregivers, medical, and other clinical teams. You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Hours: Monday – Friday 8:00 am – 5:00 pm.

Required Qualifications: Current and unrestricted RN compact license 2+ years of acute nursing experience 2+ years of behavioral health nursing experience Basic computer proficiency (i.e. MS Word, Outlook) Proven ability to function independently and responsibly with minimal supervision Preferred Qualifications: Bachelor’s degree in nursing CCM 2+ years managed care experience Critical care, pediatric, med-surg and/or telemetry experience Utilization management experience Adverse Determination experience Telecommute experience Soft Skills: Demonstrated excellent verbal and written communication skills Excellent customer service orientation Proven team player and team building skills Ability and flexibility to assume responsibilities and tasks in a constantly changing work environment

Provide members with tools and educational support needed to navigate the health care system and manage their health concerns effectively and cost efficiently Assist members with adverse determinations, including the appeal process Teach members how to navigate UMR internet-based wellness tools and resources Outreach to membership providing pre-admission counseling to membership Outreach to membership providing discharge planning to membership and caretakers Track all activities and provide complete documentation to generate customer reporting Accept referrals via designated processes, collaborate in evaluating available services, and coordinate necessary medical care and community referrals as needed Comply with all policies, procedures and documentation standards in appropriate systems, tracking mechanisms and databases Contribute to treatment plan discussions Other duties as assigned

SSM Health

RN - Clinical Documentation Specialist, First Reviewer | Remote

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Missouri

Must have prior and direct Clinical Documentation experience Job Summary: Performs concurrent analytical reviews of clinical and coding data to improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners. Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.

Preferred Qualifications: CCDS certification Proficiency with MS Office Tool - especially Excel. Prior experience reviewing PSI (patient safety indicator) or experience with Vizient specialized mortality reviews. Required Qualifications: 12 months of experience as a Clinical Documentation Specialist Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS) Two years' in an acute care setting or relevant experience Eligible Remote States Candidates are required to reside on one of SSM's approved States: Alabama, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, and Wisconsin. EDUCATION: Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS) Experience: Two years' in an acute care setting or relevant experience Physical Requirements: Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. Frequent keyboard use/data entry. Occasional bending, stooping, kneeling, squatting, twisting and gripping. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Rare climbing. Required Professional License And/Or Certifications State of Work Location: Illinois Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) Or Physician Assistant in Medicine, Licensed - Illinois Department of Financial and Professional Regulation (IDFPR) Or Physician - Regional MSO Credentialing Or Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Or Advanced Practice Nurse (APN) - Illinois Department of Financial and Professional Regulation (IDFPR) Or APN Controlled Substance - Illinois Department of Financial and Professional Regulation (IDFPR) Or Full Practice Authority APRN Control Substance - Illinois Department of Financial and Professional Regulation (IDFPR) Or Full Practice Authority APRN - Illinois Department of Financial and Professional Regulation (IDFPR) State of Work Location: Missouri Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) Or Physician Assistant - Missouri Division of Professional Registration Or Physician - Regional MSO Credentialing Or Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration Or Nurse Practitioner - Missouri Division of Professional Registration Or Registered Nurse Practitioner - Missouri Division of Professional Registration State of Work Location: Oklahoma Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) Or Acknowledgement of Receipt of Application for Physician Assistant - Oklahoma Medical Board Or Physician Assistant - Oklahoma Medical Board Or Physician - Regional MSO Credentialing Or Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) Or Advanced Practice Registered Nurse (APRN) - Oklahoma Board of Nursing (OBN) Or Certified Family Nurse Practitioner (FNP-C) - American Academy of Nurse Practitioners (AANP) State of Work Location: Wisconsin Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) Or Physician Assistant - Wisconsin Department of Safety and Professional Services Or Physician - Regional MSO Credentialing Or Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services Or Advanced Practice Nurse Prescriber (APNP) - Wisconsin Department of Safety and Professional Services

Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate diagnosis review group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI). Maintains appropriate productivity level. Conducts follow-up reviews of patients every to support and assign a working or final DRG assignment upon patient discharge, as necessary. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Identifies issues with reporting of diagnostic testing proactively. Enhances expertise in query development, presentation, and standards including understanding of published query guidelines and practice expectations for compliance. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. Attends department meetings to review documentation related issues. Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics. Collaborates with coding to reconcile the DRG and resolves mismatches utilizing the escalation policy. Troubleshoots documentation or communication problems proactively and appropriately escalates. Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurateDRGassignment, SOI, and/or ROM.Assists in the mortality review and risk adjustment process utilizing third-party models. Demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record. Impartsknowledge to providers and other members of the healthcare team. Maintains a level of expertise by attending continuing education programs. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service. Works in a constant state of alertness and safe manner. Performs other duties as assigned.

IntellaTriage

Remote Hospice Triage RN- PT 2 shifts 3:30p-9:30p + rotating Sat & Sun 7:30-4p

Posted on:

May 4, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Built around a mission to improve the lives of nurses and patients, IntellaTriage has been providing after-hours nurse triage for hospice and home health providers since 2008. Utilizing best-in-class technology, IntellaTriage provides round-the-clock direct access to licensed, registered nurses using client-customized protocols for patient-centered, compassionate care. We are growing rapidly and excited to support our clients’ nursing staff in the field by leveraging our outsourced team of nurses to manage after-hours care delivery. Our triage nurses become an extension of our clients’ care team, and they trust us to support them and their patients during their non-core hours. Learn more at www.intellatriage.com.

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-9:30p CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

MUST have or be willing to obtain a Compact RN license (states with pending or future implementation dates are not considered current compact states until the implementation date) You must remain in good standing and ensure your home state license remains active. IntellaTriage will cover the cost of non-compact state licensure if necessary for client support. Hospice, palliative, end-of-life care is strongly preferred Experience in a fast-paced environment: ED, surgical services, or critical care, etc. Must be comfortable accessing multiple technology applications to document during calls Ability and comfort with typing in a fast-paced environment Fluency in English is required, additional languages are a bonus Must physically reside in the U.S. and be legally eligible to work for any employer Must be able to complete three weeks of remote paid training that is conducted during days and evenings Must be available to work every other Saturday & Sunday Must be available to work some Holidays as required Must be able to handle stress and multitask when receiving calls (minimum of 5 calls per hour on weekdays, and up to 8 per hour on weekends) Must be able to communicate empathically with patients while adhering to protocols Must maintain CEU’s as designated by the states in which you are answering calls Must attend any in-services, and additional training on an as needed basis Must pass background check and nurse licensing check

Our Hospice Triage Nurses: Have experience in hospice, palliative, end-of-life care and in fast-paced environments: ED, critical care, surgical services, etc. Part-time nurses work a minimum of 1 week day shift & every other weekend both Saturday & Sunday Receive three weeks of remote paid training. The training schedule varies based on availability You can pick up additional shifts, if available, for the clients’ you are trained to support. We will provide you with a laptop and headset. You’re required to use your own high-speed internet You’ll need a quiet space, away from noise and distraction, while you work (privacy/HIPAA compliant space is required). You’ll access EMRs for charting and utilize our internal applications to perform job functions You MUST be able to follow instructions, read directions, and be confident using technology A minimum of 30 minutes paid shift prep is required prior to taking calls You’ll spend 30 minutes to 2 hours, at the end of your shift, completing remaining charting before clocking out

CVS Health

Case Manager Registered Nurse (Remote)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Florida

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

CVS Health Aetna has an opportunity for a full-time Case Manager, Registered Nurse (RN). Case Managers serve as dedicated advocates for members who are unable to advocate for themselves. In this role, you will assess, plan, implement, and coordinate comprehensive case management activities. Your focus will be to evaluate members’ medical needs and facilitate services that support their overall health and well-being. Schedule: Monday–Friday, 8:00 AM–5:00 PM EST No nights, weekends, or holidays required.

Required Qualifications: Must be a Registered Nurse with an active state license in good standing, valid in the region where duties are performed. Compact RN License or license in multiple states or willing to obtain within 3-6 months. 3–5 years of clinical practice experience. 2–3 years of experience in case management, discharge planning, or home health care coordination. Comfortable working remotely and independently using collaboration tools and virtual communication platforms. Willingness and ability to travel within a designated geographic area for in-person case management activities as needed. Preferred Qualifications: Bilingual proficiency in Arabic, Korean, or Spanish preferred. Compact RN license or licensure in multiple states. Strong analytical and problem-solving skills. Excellent communication, organizational, and interpersonal skills. Self-motivated and able to work independently. Proficient in navigating multiple systems and applications; skilled in typing and keyboard use. Familiarity with corporate software tools such as Microsoft Word, Excel, Outlook, PowerPoint, and proprietary applications. New Education: Associate’s Degree in Nursing. BSN preferred.

Conduct comprehensive assessments of members’ physical, emotional, and social needs. Develop and implement individualized care plans based on clinical findings and member goals. Coordinate services across healthcare providers, specialists, and community resources. Monitor and evaluate care plans regularly, adjusting as needed to improve outcomes. Advocate for timely and appropriate healthcare services to support member well-being. Document case activities, interventions, and communications accurately and in compliance with regulatory requirements. Collaborate with interdisciplinary teams to ensure continuity of care. Participate in team meetings, training sessions, and quality improvement initiatives. Travel locally for in-person case management activities, as directed by leadership or business needs.

CareHarmony

Remote - Licensed Practical Nurse (LPN) - Intake Coordinator

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

License:

LPN/LVN

State License:

Virginia

CareHarmony’s Care Coordinators (LPN) (NLC) (LVN) work comprehensively with providers to deliver value-based care management initiatives for their patients CareHarmony is seeking an experienced Licensed Practical Nurse – LPN Nurse (LPN) (NLC) (LVN) with at least 3 years of direct patient-facing work experience; that thrives in a fast-paced environment, is self-motivated, has impeccable attention to detail, and values the impact they can have on a patient’s healthcare journey. You will have experience identifying resources and coordinating needs for chronic care management patients. What's in it for you? Fully remote position - Work from the comfort of your own home in cozy clothes without a commute. Score! Consistent schedule - Full-Time Monday – Friday, no weekends, rotational on-call-once per year on average. Flexible hours - Have an appointment you need to attend? We will work with you to make up the hours at another time. Career growth - Many of our team members move up in the company at a faster-than-average rate. We love to see our people succeed!

Additional Requirements: Active Washington D.C. License & active Compact/Multistate License (LPN) Technical aptitude – Microsoft Office Suite Excellent written and verbal communication skills Plusses: Epic Experience Bilingual Additional state licensures (LPN) Remote Requirements: Must have active high-speed Wi-Fi Must have a home office or HIPAA-compliant workspace Physical Requirements: This position is sedentary and will require sitting for long periods of time This position will require the ability to speak clearly and listen attentively, often by telephone, for an extended period of time The position will require the ability to understand, process, and take thorough notes in real-time on telephone conversations

Manage patient census with a resolution-driven approach to close gaps in clinical and non-clinical patient care. Identify and coordinate community resources with patients that would benefit their care. Provide patient education and health literacy on the management of chronic conditions. Perform medication management, including identifying potential medication concerns, reconciliation, adherence, and coordinating refills. Assist in ensuring timely delivery of services to your patients; Home Health, DME, Home Infusion, and other critical needs. Resolve patients' questions and create an open dialogue to understand needs. Assist/Manage referrals and appointment scheduling.

CVS Health

Utilization Management Nurse Consultant (Weekends - CST)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Florida

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Hours of operation/Work schedule Friday/Saturday/Sunday/Monday 10 hour shifts. First 6 months of training will be M-F 8-5 CST.

Required Qualifications: Registered Nurse in state of residence. 3+ years of Nursing experience. Preferred Qualifications: Prior authorization utilization management/review experience preferred Outpatient Clinical experience. Knowledge of Medicare/Medicaid Managed care experience Education: Associates Degree in Nursing BSN preferred

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Molina Healthcare

Sr. Specialist, Provider Engagement (RN Preferred / Remote)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Mississippi

Remote and must live in Mississippi Job Summary: The Sr Specialist, Provider Engagement role implements Health Plan provider engagement strategy to achieve positive quality and risk adjustment outcomes through effective provider engagement activities. Ensures the core set of Tier 2 providers in the Health Plan have engagement plans to meet annual quality and risk adjustment goals. Drives coaching and collaboration with providers to improve performance through regular meetings and action plans. Addresses practice environment challenges to achieve program goals and improve health outcomes. Tracks engagement activities using standard tools, facilitates data exchanges, and supports training and problem resolution for the Provider Engagement team. Communicates effectively with healthcare professionals and maintains compliance with policies.

Bachelor's degree in Business, Healthcare, Nursing or related field or equivalent combination of education and relevant experience Min 3 years experience experience improving provider Quality performance through provider engagement, practice transformation, managed care quality improvement, or equivalent experience. Experience with various managed healthcare provider compensation methodologies including but not limited to: fee-for service, value-based care, and capitation Strong working knowledge of Quality metrics and risk adjustment practices across all business lines Demonstrates data analytic skills Operational knowledge and experience with PowerPoint, Excel, Visio Effective communication skills Strong leadership skills Preferred Qualifications: Min 3 years experience improving Quality performance for Medicaid, Medicare, and/or ACA Marketplace programs To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Ensures assigned Tier 2 & Tier 3 providers have a Provider Engagement plan to meet annual quality & risk adjustment performance goals. Drives provider partner coaching and collaboration to improve quality performance and risk adjustment accuracy through consistent provider meetings, action item development and execution. Addresses challenges/barriers in the practice environment impeding successful attainment of program goals and understands solutions required to improve health outcomes. Drives provider participation in Molina risk adjustment and quality efforts (e.g. Supplemental data, EMR connection, Clinical Profiles programs) and use of the Molina Provider Collaboration Portal. Tracks all engagement and training activities using standard Molina Provider Engagement tools to measure effectiveness both within and across Molina Health Plans. Serves as a Provider Engagement subject matter expert; works collaboratively within the Health Plan and with shared service partners to ensure alignment to business goals. Assist Provider Engagement Specialists with training and problem escalation. Accountable for use of standard Molina Provider Engagement reports and training materials. Facilitates connectivity to internal partners to support appropriate data exchanges, documentation education and patient engagement activities. Develops, organizes, analyzes, documents and implements processes and procedures as prescribed by Plan and Corporate policies. Communicates comfortably and effectively with Physician Leaders, Providers, Practice Managers, Medical Assistants within assigned provider practices. Maintains the highest level of compliance. This position may require same day out of office travel approximately 0 - 80% of the time, depending upon location.

Aarorn Technologies Inc

REMOTE F/T OVERNIGHT RN TELEPHONE TRIAGE (NYS LICENSED)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

New York

MUST LIVE WITHIN A 2 HOUR DRIVE TO THE WNY AREA**** We are looking for qualified Registered Nurse's to join our team. We are a fully remote 24-hour triage center where we receive incoming calls for our clients/individuals in need of immediate medical attention. We provide assessment, guidance, and disposition to the appropriate level of care. We work closely with our team of RN's and providers to determine Right Care, Right Place and Right Time disposition, which may be care instructions, tele medicine visit with a provider or advise, Urgent Care, ER or 911 level of care required MUST BE WITHIN A 2 HOUR DRIVE TO THE WNY AREA**** Rotating (4) 10 hour shifts with 3-12's including rotating weekends, premium shift differential. Salary range: $68,000-$71,500 (excellent medical benefits package and more)

New York State Registered Nurse Licensure Only Unrestricted New York State Licensed RN with a minimum of two years of experience as a clinical hospital nurse in an emergency room, critical care or med/surg, OR a minimum of two years’ experience in RN telephone triage in a primary care setting required AAS in Nursing, Bachelor’s Degree in Nursing or related fields preferred, not required Knowledge of OPWDD regulations recommended, not required Previous Chronic Care Management / Case Management required Previous Chronic Disease Management and Education required Current CPR/BLS required Current Infection Control Certificate required Must be proficient with advanced computer technology and in using multiple computer applications and internet at one time

Receives incoming calls from contracted clients Assess patient's current health status and recommends appropriate level of care based on clinical judgment, evidenced based guidelines and clinical protocols Develops plan(s) of nursing service appropriate to the patients’ health care needs Demonstrates knowledge of medications. Telephone communication skills with appropriate phone etiquette necessary Must have the ability to make critical independent decisions and prioritize appropriately. Document all calls and actions taken into the patient’s medical record Utilizes technology as appropriate to meet the requirements of the job functions. Communicates to the health care team members the outcome of the assessment/reassessment to ensure appropriate follow up occurs based on the needs of the patient care. Displays an exemplary level of patience, courtesy, and flexibility. Interacts with patients, physicians, and staff in a manner conducive to maintain positive relationships and to meet the goals and objectives of the agency. Adheres to ethical, legal/regulatory and accreditation standards Assumes responsibility for his/her own education, using formal and informal resources that contribute to professional self‐growth. Consult with administrator for issues or requested services outside scope of practice or requiring assistance in performing Must be detail oriented and able to multitask Performs other duties as assigned

Inizio Engage

Remote RN- Call Center Experience Only

Posted on:

May 3, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Pennsylvania

Inizio Engage is a strategic, commercial, and creative engagement partner specializing in healthcare. Our passionate, global workforce combines local expertise with a diverse mix of skills, data, science, and technology to deliver bespoke engagement solutions. Our mission is to help healthcare professionals and patients get the medicines, knowledge, and support they need to improve treatment outcomes. We believe in our values: We empower everyone We rise to the challenge We work as one We ask what if We do the right thing To learn more about Inizio Engage, visit us at: https://inizio.health/

In this position, you’ll be able to leverage your healthcare knowledge and skills in a supportive, non-clinical setting. This role is remote, meaning you'll need to be self-motivated and comfortable working independently without the typical face-to-face interactions of clinical settings. The primary focus of this role is to deliver inbound or outbound telephonic educational support to identified patients, caregivers, Healthcare Professionals, and their staff within primary care or specialist facilities. The goal is to support education and engagement related to a designated disease state, meeting all relevant standards as set by the company and Clinical Manager.

Current US healthcare professional license (RN) Associate’s Degree/Bachelor’s/BSN or equivalent work-related experience 3+ years’ experience working in a specific disease state or related field (preferred) Effective communication skills with a strong focus on outbound calling and follow-up Ability to manage multiple calls and priorities simultaneously with minimal disruption Proficiency with call center telephone technology Organizational skills to track and document interactions and follow-up activities A self-starter attitude with high personal motivation to achieve goals and meet objectives Evidence of ongoing professional development and commitment to lifelong learning

Conducting outbound calls to provide non-promotional disease-state-related educational support to identified customers as directed by the client company Providing outbound/inbound support for therapy and/or medical device product education, including but not limited to supplemental injection/infusion/inhalation training support or technique Proactively reaching out to Healthcare Professionals/Patients/Caregivers to present virtual educational programs in accordance with client procedures Conducting outbound medication adherence support to patients and caregivers, ensuring consistent follow-ups to support positive health outcomes Scheduling and enrolling patients and caregivers into educational seminars or providing resources to assist them with finding local community resources or centers of care for their specialty or primary care disease Collecting and managing demographic data and disposition for product, sample, reimbursement services, and literature fulfillment Maintaining high standards of customer service by adhering to program talking points or scripts and leveraging live video conferencing software as applicable Ensuring compliance by using only approved materials provided by Inizio or by the client, without changes, copying, or distribution Participating in training by attending and completing all required courses and competency assessments, maintaining a high standard of performance Building and nurturing relationships with key customers, acting as a trusted resource for disease-related education Collaborating across healthcare sectors to develop and provision services that benefit customers and support the client’s goals Driving innovation by considering new approaches that could create new partnership opportunities Completing administrative responsibilities such as daily computer updates, weekly activity summaries, emails, and time reporting in a timely and accurate manner Maintaining equipment and materials according to company standards and instructions Adhering to all policies and procedures set by Inizio and the client, ensuring compliance at all times

IntellaTriage

Remote Hospice Triage RN- PT 2 shifts 3:30p-8:30p rotating Sat & Sun 7:30-4p

Posted on:

May 3, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Built around a mission to improve the lives of nurses and patients, IntellaTriage has been providing after-hours nurse triage for hospice and home health providers since 2008. Utilizing best-in-class technology, IntellaTriage provides round-the-clock direct access to licensed, registered nurses using client-customized protocols for patient-centered, compassionate care. We are growing rapidly and excited to support our clients’ nursing staff in the field by leveraging our outsourced team of nurses to manage after-hours care delivery. Our triage nurses become an extension of our clients’ care team, and they trust us to support them and their patients during their non-core hours. Learn more at www.intellatriage.com.

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-8:30p CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

MUST have or be willing to obtain a Compact RN license (states with pending or future implementation dates are not considered current compact states until the implementation date) You must remain in good standing and ensure your home state license remains active. IntellaTriage will cover the cost of non-compact state licensure if necessary for client support. Hospice, palliative, end-of-life care is strongly preferred Experience in a fast-paced environment: ED, surgical services, or critical care, etc. Must be comfortable accessing multiple technology applications to document during calls Ability and comfort with typing in a fast-paced environment Fluency in English is required, additional languages are a bonus Must physically reside in the U.S. and be legally eligible to work for any employer Must be able to complete three weeks of remote paid training that is conducted during days and evenings Must be available to work every other Saturday & Sunday Must be available to work some Holidays as required Must be able to handle stress and multitask when receiving calls (minimum of 5 calls per hour on weekdays, and up to 8 per hour on weekends) Must be able to communicate empathically with patients while adhering to protocols Must maintain CEU’s as designated by the states in which you are answering calls Must attend any in-services, and additional training on an as needed basis Must pass background check and nurse licensing check

Our Hospice Triage Nurses: Have experience in hospice, palliative, end-of-life care and in fast-paced environments: ED, critical care, surgical services, etc. Part-time nurses work a minimum of 1 week day shift & every other weekend both Saturday & Sunday Receive three weeks of remote paid training. The training schedule varies based on availability You can pick up additional shifts, if available, for the clients’ you are trained to support. We will provide you with a laptop and headset. You’re required to use your own high-speed internet You’ll need a quiet space, away from noise and distraction, while you work (privacy/HIPAA compliant space is required). You’ll access EMRs for charting and utilize our internal applications to perform job functions You MUST be able to follow instructions, read directions, and be confident using technology A minimum of 30 minutes paid shift prep is required prior to taking calls You’ll spend 30 minutes to 2 hours, at the end of your shift, completing remaining charting before clocking out

Synergy Healthcare USA, LLC

Nurse Advocate - Greater Charlotte Area

Posted on:

May 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

North Carolina

We are seeking an experienced Case Manager to join our growing team and serve as a Nurse Advocate for our new clients and their employees. The ideal candidate will be located in the greater Charlotte area, with the ability to travel on occasion to visit clients in NC/SC. He/she will have a thorough understanding of the healthcare system, and will be responsible for providing guidance and support to members in navigating the complex healthcare landscape. As a dedicated Nurse Advocate, you will be responsible for resolving a myriad of issues for their members and allow you the flexibility to “think outside the box”. With your clinical experience and background, you will help members better understand their health status and available treatment options. You will have a unique opportunity to develop valued relationships with members and executive teams with your specific employer clients. This opportunity allows for remote work so can be flexible on location. Minimal travel within the States of NC/SC for periodic client visits (open enrollment meeting, annual activity reviews etc) may be required. Most if not all work will be done virtually out of the convenience of your own home office. The key to your success will rely on your ability to cultivate trusted relationships with stakeholders, members, and their families. Our growing Synergy team is passionate about delivering an exceptional healthcare experience that is personal, data driven, and value based to help every person live their healthiest life.

Active nursing license with a Bachelor of Science in Nursing (BSN) degree preferred. Minimum of 3 years of experience as a nurse case manager or in a related healthcare field. CCM certification or CCM eligible. Commit to CCM exam within the first year. In-depth knowledge of the healthcare and insurance systems. Strong analytical and problem-solving skills with the ability to identify and resolve complex healthcare issues. Excellent communication and interpersonal skills with the ability to interact effectively with employees and healthcare professionals. Ability to work remotely, independently, and as part of a team in a fast-paced, dynamic environment. Strong organizational skills with the ability to manage multiple tasks and priorities simultaneously. Proficient in the use of electronic health records (EHRs), Outlook, Excel, and other healthcare-related software.

Serve as the primary point of contact for members seeking assistance with navigating the healthcare system. Work with members to identify their healthcare needs and provide clinical support. Liaison with TPAs and insurance companies to resolve claim and billing issues. Educate members on their healthcare benefits and how to effectively utilize them. Advocate for members so they can receive improved healthcare outcomes, including referrals to specialists and timely access to care. Collaborate with other healthcare professionals, including physicians and nurses to ensure seamless coordination of care. Monitor member health status and progress towards achieving their healthcare goals. Maintain accurate and up-to-date records of member interactions and healthcare interventions. Client facing reporting with the potential for limited travel to client worksites. Health Risk Assessment review to encourage lifestyle modification and improve overall wellness.

Humana

SNF Utilization Management RN

Posted on:

May 3, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

The Utilization Management Nurse utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Compact licensure Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action. 2-3 years Skilled nursing facility experience and /or skilled nursing facility utilization management review experience. Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting Comprehensive knowledge of Microsoft Word, Outlook and Excel Ability to work independently under general instructions and with a team Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 25 x10 (25mbs download x 10mbs upload) is required Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications: Education: BSN or Bachelor's degree in a related field Health Plan experience Previous Medicare/Medicaid Experience a plus Bilingual is a plus Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

The SNF Utilization Management Nurse uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Conifer Health Solutions

Healthcare Appeals Clinician RN - Remote $10K sign on bonus

Posted on:

May 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost, and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

The Revenue Cycle Clinician for the Appellate Solution is responsible for: Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review Preparing and documenting appeal based on industry accepted criteria.

KNOWLEDGE, SKILLS, ABILITIES: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Demonstrates proficiency in the application of medical necessity criteria, currently InterQual® Possesses excellent written, verbal and professional letter writing skills Critical thinker, able to make decisions regarding medical necessity independently Ability to interact intelligently and professionally with other clinical and non-clinical partners Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms Ability to multi-task Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process. Ability to conduct research regarding off-label use of medications. Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings. EDUCATION / EXPERIENCE: Include minimum education, technical training, and/or experience required to perform the job. Must possess a valid RN nursing license (Registered Nurse) Minimum of 3 years acute care experience in a facility environment Medical-surgical/critical care experience preferred Minimum of 2 years UR/Case Management preferred Managed care payor experience a plus either in Utilization Review, Case Management or Appeals Patient Accounting experience a plus Previous classroom led instruction on InterQual® or MCG products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred CERTIFICATES, LICENSES, REGISTRATIONS: Current, valid RN licensure Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to lift 15-20lbs Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sites Ability to sit and work at a computer for a prolonged period of time conducting medical necessity reviews WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc. OTHER: May require travel – approximately 10% Interaction with facility Case Management, Physician Advisor is a requirement.

Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review. Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual® or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization. Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process. Adheres to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines. Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office. Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc. Additional responsibilities: Serves as a resource to non-clinical personnel. Provides CRC leadership with sound solutions related to process improvement Assist in development of policy and procedures as business needs dictate. Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.

CorVel Corporation

CA UR Case Manager II

Posted on:

May 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

CorVel, a certified Great Place to Work® Company, is a national provider of industry-leading risk management solutions for the workers’ compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 4,000 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

The Utilization Review Case Manager gathers demographic and clinical information on prospective, concurrent and retrospective in-patient admissions and out-patient treatment, certifies the medical necessity and assigns an appropriate length of stay; supporting the goals of the Case Management department, and of CorVel. This is a remote position.

KNOWLEDGE & SKILLS: Must have a thorough knowledge of both CPT and ICD coding. Effective multi-tasking skills in a high-volume, fast-paced, team-oriented environment. Ability to interface with claims staff, attorneys, physicians and their representatives, and advisors/clients and coworkers. Ability to promote and market utilization review products with attorneys and claims staff. Strong ability to negotiate provider fees effectively. Excellent written and verbal communication skills. Ability to meet designated deadlines Computer proficiency and technical aptitude with the ability to utilize MS Office including Excel spreadsheets Strong interpersonal, time management and organizational skills. Ability to work both independently and within a team environment. EDUCATION/EXPERIENCE: Graduate of accredited school of nursing with a diploma/Associates degree (Bachelor of Science degree or Bachelor of Science in Nursing preferred) Current Nursing licensure in the state of operation required. RN is required unless local state regulations permit LVN/LPN. 4 or more years of recent clinical experience. Previous experience in the following areas, preferred: Prospective, concurrent and retrospective utilization review Experience in the clinical areas of O.R., I.C.U., C.C.U., E.R., orthopedics Knowledge of the workers’ compensation claims process Outpatient utilization review

Identifies the necessity of the review process and communicates any specific issues of concern to the appropriate claims staff/customer. Collects data and analyzes information to make decisions regarding certification or denial of treatment. Documenting all work in the appropriate manner. Requires regular and consistent attendance. Complies with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP). Additional duties as required.

CorVel Corporation

Itemization Review Nurse II

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Texas

CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

The Itemization Review Manager is responsible for the overall aspects of the medical review team including personnel hiring, quality assurance of product, workflow, maintaining the tracking of and accountability of staff regarding production standards and turn-around expectations. This is a remote position.

KNOWLEDGE & SKILLS: Understanding of audit guidelines including CMS and payor policies Extreme attention to detail Must possess problem solving, critical thinking skills Must be team oriented Effective and professional communication skills, both verbal and written Ability to act in a professional manner with both internal and external customers Ability to think and work independently Ability to work in a fast-paced production environment Proficient in Microsoft Office Suite EDUCATION & EXPERIENCE: Associate degree and current RN license required. Bachelor’s or master’s degree in nursing or other healthcare related field preferred Previous supervisory experience required Previous nurse audit or payment integrity experience preferred

Responsible for managing the daily file flow coming into Medical Review while maintaining awareness of potential file flow from other departments to track rush or special files, test files, pilot studies for prospective clients Writing performance evaluations for direct report staff on annual basis as per CorVel/CERIS guidelines Responsible for meeting client specific turnaround times and metrics Responsible for quality of review results and an error rate of less than 2% on all completed files per month Responsible for human resources matters directly related to department staff under direct supervision including documentation of events or occurrences and verbal counseling direct report staff when attendance or performance deficiencies are discovered Requires regular and consistent attendance and the tracking of attendance of staff under direct supervision, in addition to ensuring adequate staffing levels to meet business needs and productivity standards Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP) Responsible for implementing new procedures/protocols as necessary Responsible for identifying process improvement opportunities and reporting these to the director of audit Responsible for maintaining and updating department protocol library Responsible for monitoring various reports daily to ensure productivity metrics and client goals are met Assist with additional projects as requested Participate in provider and client calls as needed Participate in leadership calls as needed May be required to travel overnight to attend meetings and/or training Additional duties as assigned by director of audit and/or SVP of operations

Green Key Resources

Nurse Case Manager

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Serve as a team member on a multidisciplinary team, coordinating care, resources and/or services for members to achieve optimal clinical and resource outcomes.

RN with 3 years of clinical and/or case management experience required. Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties. For some roles, additional specialty certification (i.e. CCM, CDCES) may be required. If so, incumbents must obtain relevant certification within 2 years of employment.

Utilize applicable clinical skillset and perform comprehensive assessments to determine how to best collaborate with members, family, internal partners and external services/providers on plans for treatment, appropriate intervention and/or discharge planning. Develop a member-centric plan tailored to members’ needs, health status, educational status and level of support needs; identify barriers to meeting goals or plan of care Utilize community resources and funding sources as needed in the development of the plan of care. Perform ongoing monitoring and management of member which may include scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation, assessment of progress towards goals, modification of plan/goals as needed, with contact frequency appropriate to member acuity. Evaluate and facilitate care provided to members through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care, etc). Educate members and encourage pro-active intervention to limit expense and encourage positive outcomes Effectively document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome. May outreach directly to members identified as high risk, high cost, or high utilization cases. May review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options, where eligible. May evaluate medical necessity and appropriateness of services as defined by department. As needed, develop relevant policies/procedures, education or training for use both internally and externally.

Optimize Health

Care Navigator- LPN/LVN - Remote - EST Time Zone - CT, MA, or NY AND Compact License Required

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

At Optimize Health, we believe that it's time to rethink brick-and-mortar-only healthcare visits. With our powerful combination of the leading platform technology, patient-friendly devices, and trusted support, we are pioneering how medical groups use technology and real-time data to treat patients' health outside the practice walls. As the most trusted and experienced remote care vendor in the industry, we simplify the complexities of delivering effective, high-quality remote patient monitoring and optimize our clients’ clinical and financial performance.

As a care team member, you love building relationships with patients based on trust, utilizing motivational communication techniques , to help drive positive health behavior change and improved patient outcomes. This program is based around triaging vital signs and using this data to promote positive lifestyle and health behavior changes. This is accomplished through collaboration with the patients care team to provide wellness calls with patients to outline patient-centric goals and the development of associated action plans to improve their health and well-being. Our ideal candidate has clinical background working with the adult and geriatric patient population ideally with experience in phone triage. Has a strong working knowledge of remote-patient monitoring (RPM) preferred and/or Chronic Care Management (CCM), Behavioral Health, Care Coordination or Utilization Management principles. Experienced in remote working technologies, being a strong team player and a desire to clinically and emotionally support our patients while keeping a keen eye on reimbursement requirements are valued in this role. Being a Care Team Member at Optimize Health provides the chance to serve patients by proactively monitoring vital signs, educating, and coaching patients on a plan for better health. Early intervention through RPM, reduces risk for emergent care and/or hospital admission/re-admissions. Encounters with patients will be performed via phone through a Remote Care Platform that receives electronically transmitted physiological markers like blood pressure/weight/blood glucose . The care team member will perform monitoring as well as synchronous and asynchronous communication with the patient within Optimize Health’s industry-leading platform.

Unrestricted LPN/LVN license in a compact state and CT, MA, or NY Ability to work EST zone between 8:00a - 5:00pm Spanish speaking a plus 1-3 years of clinical experience, patient management, or disease management desired Experience working with different provider practices and workflows Fast learners Ability to work independently with minimal direction Experience with Medicare patients Experience performing virtual visits with patients and telephonic care management Interest in professional leadership growth and development opportunities with a growing organization Interest in operating in a new, exciting clinical program and become an integral player in the development of processes and best practices in caring for RPM patients Motivational Interviewing/Health Behavior Change experience a plus Health Coach certification a plus.

Manage physiological markers like blood pressure/weight/blood glucose with clinical appropriateness Meet team goals and standards outlined metrics Significantly impact longitudinal patient engagement in RPM program(s) Provide preventive health and disease management education and coaching Perform monthly wellness calls with assigned patients Lead collaborative wellness calls with the patients to define health goals outlined by their Care Team Manage patient messaging and alerts Direct patients to treating physician for routine questions Meet patient engagement program goals Follow appropriate escalation pathways for any urgent care needs