Mercor + Ai-Lab

Remote Clinical Reviewer & Triage Specialist (RN/NP/PA/MD)

Posted on:

August 12, 2025

Job Type:

Contract

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

1. Role Overview Mercor is partnering with a frontier AI-lab, looking for registered nurses with advanced phone/chat assessment skills, nurse practitioners or physician assistants experienced in virtual urgent care, and physicians who are comfortable practicing remotely. You’ll use evidence-based protocols to guide patients, escalate cases appropriately, and help verify AI-generated medical guidance. This is an excellent short-term opportunity (with possible extension) to shape next-generation digital health tools while working on your own schedule. 2. Key Responsibilities Conduct real-time or asynchronous triage via phone, chat, and video using standardized clinical pathways Assess symptom acuity, provide safe self-care instructions, or route patients to higher levels of care Review and edit AI-generated medical content for clinical accuracy, tone, and regulatory compliance Document encounters clearly in the client’s tele-health platform and maintain HIPAA compliance Collaborate with the client’s clinical operations and product teams to refine triage guidelines and workflows 3. Ideal Qualifications Active, unrestricted RN, NP, PA, or MD/DO license in at least one U.S. state (multi-state highly valued) 3+ years of recent experience in urgent care, emergency, or primary care settings Prior tele-health or nurse advice-line experience with phone/chat triage protocols (e.g., Schmitt-Thompson) Strong written and verbal communication; able to translate clinical concepts for lay audiences Reliable internet connection and a private, HIPAA-compliant workspace 4. More About the Opportunity Remote and fully asynchronous options available; set your own hours Expected commitment: 10–20 hours per week (flexible) Initial contract: ~3 months with potential for renewal All clinical tools and protocol access provided by the client 5. Compensation & Contract Terms USD $100 – $150 per hour, depending on credentials and scope + potential for performance bonus Independent-contractor engagement; you control how, when, and where services are performed Payments issued weekly through Stripe Connect for services rendered 6. Application Process Submit a brief form with resume/CV and active license details Complete a short AI Interview (≤ 30 min) Complete a short assessment Final decisions and onboarding links will be provided within 7 days of initial submission 7. About Mercor Mercor is a talent marketplace connecting top experts with leading AI labs and cutting-edge tech organizations, backed by Benchmark, General Catalyst, Adam D’Angelo, Larry Summers, and Jack Dorsey. Thousands of professionals across law, healthcare, engineering, and research collaborate with Mercor on frontier projects shaping the next era of AI We consider all qualified applicants without regard to legally protected characteristics and provide reasonable accommodations upon request.

Active, unrestricted RN, NP, PA, or MD/DO license in at least one U.S. state (multi-state highly valued) 3+ years of recent experience in urgent care, emergency, or primary care settings Prior tele-health or nurse advice-line experience with phone/chat triage protocols (e.g., Schmitt-Thompson) Strong written and verbal communication; able to translate clinical concepts for lay audiences Reliable internet connection and a private, HIPAA-compliant workspace

Conduct real-time or asynchronous triage via phone, chat, and video using standardized clinical pathways Assess symptom acuity, provide safe self-care instructions, or route patients to higher levels of care Review and edit AI-generated medical content for clinical accuracy, tone, and regulatory compliance Document encounters clearly in the client’s tele-health platform and maintain HIPAA compliance Collaborate with the client’s clinical operations and product teams to refine triage guidelines and workflows

Horizon Blue Cross Blue Shield of New Jersey

Care Connect Case Manager, (REMOTE) -Oncology

Posted on:

August 7, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and committees as needed.

Education/Experience: High School Diploma/GED required. Bachelor degree preferred or relevant experience in lieu of degree. Requires a minimum of two (2) years clinical experience. Requires minimum of two (2) years’ experience with health care payer experience. Utilization Management Only(Utilization Inpatient Case Management does NOT apply to RN II role within HCS) : RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs. Additional licensing, certifications, registrations: Active Unrestricted NJ RN License or active Compact License Required. Addendum for Horizon Clinical Advocate roles: CCM certification preferred. Knowledge: Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook). Should be knowledgeable in the use of intranet and internet applications. Requires knowledge of hospital structures and payment systems. Requires working knowledge of case/care/disease management principles. Requires working knowledge of operations of utilization, case and/or disease management processes. Requires knowledge of health care contracts and benefit eligibility requirements. Requires mentoring knowledge on the operations of utilization/case/disease management. Addendum for Horizon Clinical Advocate roles: Requires ability to be an empathetic critical thinker. Requires excellent communication and organizational skills and a high tolerance for ambiguity. Ability to understand and communicate members benefits, claims and coordination focusing on advocacy principals and effective utilization. Experience in active listening and motivational interviewing strongly preferred. Requires a candidate that can work in a collaborative team environment and is a team player who possesses strong analytical, critical thinking and interpersonal skills. Requires exceptional multi-channel Communication and Interpersonal skills, including the ability to explain complex concepts clearly with compassion. Skills and Abilities: Adaptability/Flexibility Analytical Compassion Interpersonal & Client Relationship Skills Information/Knowledge Sharing Judgment Listening Planning/Priority Setting Problem Solving Team Player Time Management Written/Oral Communication & Organizational Skills Education/Experience: High School Diploma/GED required. Bachelor degree preferred or relevant experience in lieu of degree. Requires a minimum of two (2) years clinical experience. Requires minimum of two (2) years’ experience with health care payer experience. Utilization Management Only(Utilization Inpatient Case Management does NOT apply to RN II role within HCS) : RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs. Additional licensing, certifications, registrations: Active Unrestricted NJ RN License or active Compact License Required. Addendum for Horizon Clinical Advocate roles: CCM certification preferred. Knowledge: Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook). Should be knowledgeable in the use of intranet and internet applications. Requires knowledge of hospital structures and payment systems. Requires working knowledge of case/care/disease management principles. Requires working knowledge of operations of utilization, case and/or disease management processes. Requires knowledge of health care contracts and benefit eligibility requirements. Requires mentoring knowledge on the operations of utilization/case/disease management. Addendum for Horizon Clinical Advocate roles: Requires ability to be an empathetic critical thinker. Requires excellent communication and organizational skills and a high tolerance for ambiguity. Ability to understand and communicate members benefits, claims and coordination focusing on advocacy principals and effective utilization. Experience in active listening and motivational interviewing strongly preferred. Requires a candidate that can work in a collaborative team environment and is a team player who possesses strong analytical, critical thinking and interpersonal skills. Requires exceptional multi-channel Communication and Interpersonal skills, including the ability to explain complex concepts clearly with compassion. Skills and Abilities: Adaptability/Flexibility Analytical Compassion Interpersonal & Client Relationship Skills Information/Knowledge Sharing Judgment Listening Planning/Priority Setting Problem Solving Team Player Time Management Written/Oral Communication & Organizational Skills

Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. Coordinates and assists in implementation of plan for members. Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care. Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness. Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided. Encourages member participation and compliance in the case/disease management program efforts. Documents accurately and comprehensively based on the standards of practice and current organization policies. Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care. Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. Serves as mentor/trainer to new RN's and other staff as needed. Acts as subject matter expert for respective area for projects. May assume leadership type activities in team leads absence. Represent clinical teams within committee meetings Present reports required at committee meetings. Subject matter expert for user acceptance testing for medical management system. Addendum for Horizon Clinical Advocate Roles: Outreaches to members identified by Horizon as needing Clinical Advocate services. Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast-paced environment. Builds trusting relationships with members and their families utilizing Motivational Interviewing techniques. Becomes knowledgeable in ASO client employer -sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language. Advocates for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. Focuses on whole person approach, by eliminating “homework” or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well-being physical, mental, and emotional. Schedule: 8- or 10-hour workday Monday through Friday varying between 8am and 11pm. Disclaimer: This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

NR Healthcare

RN Case Manager

Posted on:

August 7, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Nurse Case Manager II Location: Remote Duration: 6 months Description: Program Overview Help us elevate our patient care to a whole new level! Join our client team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have a life-changing impact on our Dual Eligible Special Needs Plan (DSNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. Must be license in state of PA or Must Have A Compact License If the Candidate Do Not Reside In Pa.

Minimum 3-5 years clinical practical experience Minimum 2-3 years CM, discharge planning and/or home health care coordination experience Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually Bilingual desired Excellent analytical and problem-solving skills. Effective computer skills including navigating multiple systems and keyboarding Demonstrates proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications Additional state licenses preferred. Certified Case Manager is preferred.

https://www.indeed.com/viewjob?cmp=NR-Healthcare&t=Registered+Nurse+Case+Manager&jk=4d101195217b450d&q=triage+nurse+remote&xpse=SoDc67I3uBEEQmSsYx0LbzkdCdPP&xfps=00b8db8c-8de6-45be-923f-782e32e1189c&xkcb=SoDq67M3uBCMXuxNYJ0MbzkdCdPP&vjs=3

CES, LLC

Medical Review Nurse III

Posted on:

August 7, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Florida

Healthcare & Medicine Other Remote Permanent / Full Time Job Description Summary: The Medical Reviewer will utilize Medicare and/or Medicaid rules, regulations, and guidelines in reviewing medical records documentation to determine if a claim meets these requirements. Primarily responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. Applies Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage. The Medical Reviewer coordinates and compiles the written Investigative Summary Report to the Program Integrity Investigator upon completion of the records review within timelines set by CMS.

Required qualifications/skills: Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN). Knowledge of, and the ability to correctly identify, Medicare coverage guidelines Excellent oral and written communication skills Proficient with Microsoft Word, Excel and Internet applications Ability to efficiently organize and manage workload and assignments A minimum of 4 years of utilization/quality assurance review and ICD-9/10-CM/CPT-4 coding experience At least 4 years' experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare coverage guidelines is required Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9/10-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, and Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required Preferred qualifications/skills: None Other: Must have and maintain a valid driver's license for the associate's state of residence Travel may be required as necessary, with prior approval. All necessary travel expenses are reimbursable via GSA standards Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program; and must have no conflict of interest (COI) as defined in § 1154(b)(1) of the Social Security Act. Work can be performed remotely (preferably within one of the following midwestern states: IL, IN, IA, KS, KY, MI, MN, MO, NE, OH and WI). Supervisory Responsibilities: None Office Equipment (if a WFH position): A locking cabinet and/or desk appropriate for storing documents and electronic media A cross-cut or micro-cut (preferred) shredder. Broadband internet connection Phone line (land line or cellular)

Review information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies Utilize extensive knowledge of medical terminology, ICD-9-CM and ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilize Medicare and Contractor guidelines for coverage determination Coordinate and compile written Investigative Summary Reports in conjunction with PI Investigators upon completion of the records review Uses leadership and communication skill to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel Provide training to staff on medical terminology, reading medical records, and policy interpretation Provide expert witness testimony as required Complete assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy Maintain chain of custody on all documents and follows all confidentiality and security guidelines Perform other duties as assigned by the Medical Review Supervisor that contribute to goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations

Cabrillo Hospice

QAPI Quality Assurance Performance Improvment Nurse

Posted on:

August 7, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

A professional who works with the Director of Clinical Services in the development and ongoing administration of the Quality Assessment/Performance Improvement (QAPI) program. QAPI - Monday - Friday 8am-5pm Must be in San Diego or Riverside County (remote work)

Graduate of an approved school of professional nursing and currently licensed in the state(s) in which practicing. A qualified health care professional. Three to five (3-5) years of hospice care experience One (1) year experience in Hospice QAPI, preferred. Knowledge of ICD10 coding, preferred Ability to exercise initiative and independent judgment. Ability to work with individuals, to enlist cooperation of many people to perform/achieve a common goal.

Understands and adheres to established Hospice policies and procedures. Understands and promotes principles of continuous QAPI. Responsible for the orientation of new staff to Hospice's QAPI program. Assists in the planning and consultative needs of staff. Assists in the preparation and implementation of policies and procedures which meet Medicare, Medicaid, accreditation standards and state and local laws. Participates in studies and other administrative functions as assigned. Serves as a role model for all colleagues by setting an example of high standards in dress, conduct, cooperation and job performance. Observes confidentiality and safeguards all patient related information. Accepts responsibility for regular attendance and punctuality; fulfills job related requirements without regard to time involved. Serves as a resource person to employees. Investigates and reports any problem relating to patient care and/or employee well-being. Immediately reports any accident, incident, lost articles or unusual occurrence to the Director/Manager of Patient Services. Attends pertinent continuing education programs other than routine inservices and shares information with staff. Responsible for review and approval of QA Manager including Start of Care and Recertification documentation Assists in the development of QAPI activities with appropriate data collection, aggregation, analysis, taking action and reporting of results according to Hospice's QAPI plan. Reviews patient medical records for compliance with federal, state and local laws, accreditation standards and Hospice policies and guidelines. Creates QAPI quarterly reports for leadership review including recommendations for improvement. Runs reports in Wellsky per request of leadership.

Planned Parenthood of Michigan

RN Care Manager

Posted on:

August 7, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Michigan

Planned Parenthood Federation of America, Inc. (PPFA) Works to protect and expand access to sexual and reproductive health care and education, and provides support to its member affiliates. Planned Parenthood affiliates are separatelty incorporated public charities that operate health centers across the U.S. as trusted sources of health care and education for people of all genders in communities across the country. Planned Parenthood (PP) America’s most trusted provider of reproductive health care. Our skilled health care professionals are dedicated to offering all people high-quality, affordable medical care. The heart of Planned Parenthood is in the local community. Our 49 unique, locally governed affiliates operate health centers nationwide, which reflect the diverse needs of their communities. These health centers provide a wide range of safe, reliable health care — and the majority is preventive care, which helps prevent unintended pregnancies through contraception, reduce the spread of sexually transmitted infections through testing and treatment, and screen for cervical and other cancers. Caring physicians, nurse practitioners, and other staff take time to talk with clients, encouraging them to ask questions in an environment that millions have grown to trust. One in five American women has chosen Planned Parenthood for health care at least once in her life.

POSITION TITLE: RN Care Manager STATUS: Full Time, Exempt ANNUAL SALARY: $88,000 per year LOCATION: Remote (Must be licensed to provide care in Michigan) BENEFITS: Medical, Dental, Vision, STD, LTD. Life & ADD, 403B, Flexible Spending Account, Generous Paid Time off Program and Free healthcare at our clinics for you and your immediate family! Planned Parenthood of Michigan has implemented a mandatory vaccination policy requiring COVID-19 vaccinations including boosters when eligible for all employees. Position Description Under the supervision of the Director of Nursing and Clinical Follow-up Manager, the RN Care Manager-Remote applies advanced skills gained through training, licensure/certification, and experience to provide care management services to patients of Planned Parenthood of Michigan throughout the state, focusing on clinical care coordination and patient advocacy.. The RN Care Manager-Remote acts as a central point of contact, connecting patients with healthcare providers, services, and resources to ensure comprehensive care and adherence to treatment plans. The RN Care Manager-Remote provides patient-centered and trauma-informed care to all patients in support of Planned Parenthood of Michigan’s “Care, No Matter What” mission. This work is conducted remotely through virtual software platforms. Weekend and holiday on-call may be required.

Registered Nurse licensure in Michigan. Two or more years of clinical case management, care management, and/or care coordination experience, preferably in an ambulatory/outpatient setting. Sexual/reproductive healthcare experience preferred. Caring, professional demeanor and excellent customer service skills. Commitment to caring for people of diverse backgrounds, cultures, and lifestyles, in a manner that engages on-going self-reflection, humility, and continual learning required. Excellent critical thinking, assessment, and problem-solving skills. Ability to work independently with minimal supervision, as well as collaborate with a care team, while demonstrating exceptional organization, attention to detail, and follow-through. Ability to effectively prioritize and manage multiple, rapidly changing priorities simultaneously with professionalism and flexibility. Demonstrate timely and accurate clinical documentation. Experience working in Electronic Medical Records, especially Epic. Ensure protection of patients’ privacy and Protected Health Information (PHI) in a home office environment. Reliable wi-fi. Key Requirements: Commitment to advancing race(+) equity in one's work: interested in expanding knowledge about the role that racial inequity plays in our society. Demonstrated ability to effectively communicate across differences, as well as hear and act on feedback related to identity and equity with an openness to learn. Commitment to Planned Parenthood's In This Together service ethos, workplace values, and service standards.

Review and interpret lab results and diagnostic imaging/studies per established protocols and provide timely treatment, thorough notification, education and care coordination for patients with abnormal results. Monitor follow-up of abnormal results and referrals. Recognize and report changes in patient conditions. Identify patients for care management. Initiate, implement, and evaluate care plans for complex and high-risk patient cases in collaboration with an interdisciplinary team, including physicians, clinicians, and other healthcare workers.. Prioritize care management tasks based on acuity and required follow-up. Assess patients’ care needs, barriers, and goals, and implement a timely, action-oriented care plan. Discuss results and treatment plans, and provide accurate, personalized health education.. Provide strengths-focused health coaching to empower patients to participate in care. Determine the care options available and suitable for patients and educate patients about the options. Identify and effectively utilize community resources. Coordinate external referrals to specialty care providers, services, and resources to ensure timely, high-quality care for patients who require specialized services outside PPMI. Evaluate the effectiveness of the care plan and revise as needed. Make medication and treatment plan adjustments per protocol and in collaboration with the clinician/provider. Document accurately and thoroughly. Utilize reports to identify data trends. Collaborate with leadership to develop strategies and solutions to address gaps in care and refine processes to improve care quality. Review medical records. Contribute to risk/quality initiatives and mandatory reporting for reportable conditions. Demonstrate commitment to living out and modeling PPMI’s In This Together Workplace Values and Service Standards. Integrate equity and inclusion best practices into all job functions and patient interactions. Perform all duties in compliance with all applicable laws, PPMI policies and insurance guidelines. Perform other duties and responsibilities as assigned.

Veritas Management Group, Inc.

Clinical Consultant

Posted on:

August 7, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

NP/APP

State License:

Colorado

Veritas Management Group (VMG) is a leading management consulting firm offering solutions to complex challenges involving public health, technology, and military domains. We serve government and commercial sector organizations, academic institutions, and non-profit organizations, domestically and globally. We are committed to transforming public health through equitable, data-driven solutions.

Position Title: Clinical Consultant – Behavioral Health, OB/GYN, or Pharmacy SME Department: Veritas Management Group Location: Remote with Travel Requirements (U.S. based) VMG is recruiting highly experienced Clinical Consultants with subject matter expertise in Behavioral Health, OB/GYN, or Pharmacy to support the Health Resources and Services Administration (HRSA), Bureau of Primary Health Care (BPHC). This role is part of the Program Management Technical Assistance and Training (PMTAT) initiative to support compliance, performance improvement, and culturally responsive technical assistance for Federally Qualified Health Centers (FQHCs), Look-Alikes (LALs), and HRSA-funded partners.

Required: Active and unrestricted U.S. clinical license (e.g., MD, DO, NP, LCSW, CNM, PharmD, PA, PsyD). Minimum of 5 years of recent clinical experience in the area of specialty (Behavioral Health, OB/GYN, or Pharmacy). Documented cultural competence and the ability to work in cross-cultural environments. Fluency in English; strong preference for bilingual (especially Spanish-speaking) candidates. Preferred: Experience with Federally Qualified Health Centers (FQHCs) or HRSA-funded programs. Knowledge of the Health Center Compliance Manual and HRSA Site Visit Protocol. Previous involvement in federal compliance reviews or clinical quality improvement initiatives. Requirements: Must reside and be licensed to practice in the U.S. or U.S. territories. Willingness to travel up to 30% of the time, including OCONUS locations. Must pass a federal background check and comply with HIPAA, data privacy, and federal reporting guidelines. Completion of all required initial and refresher trainings before and during engagement.

Clinical Consultants will: Participate in in-person and virtual Operational Site Visits (OSVs) and Technical Assistance (T/TA) engagements to assess compliance with HRSA's Health Center Program requirements. Provide specialized clinical expertise in Behavioral Health, OB/GYN, or Pharmacy during site reviews and consultative projects. Deliver guidance on credentialing, performance improvement, compliance, and quality of care related to clinical services. Lead and contribute to pre-visit preparation, conduct on-site or virtual assessments, and present findings during post-visit debriefings. Submit detailed written reports using HRSA’s STAR System and Technical Assistance Tracking System (TATS). Contribute to the development of culturally responsive TA tools, templates, policies, and resource materials. Maintain current professional licensure and complete required annual trainings and assessments. Primary Duties Include but Are Not Limited To: Offering clinical consultation to improve care delivery, health outcomes, and compliance with HRSA programmatic standards. Identifying and addressing social determinants of health and advancing health equity. Participating in consultant evaluations, quarterly performance reviews, and corrective action plans when applicable. Completing required HRSA and Veritas training protocols including Compliance Manual reviews, site visit protocol modules, and linguistic/cultural competency modules. Ensuring TA services are linguistically and culturally competent, particularly when serving limited English proficient (LEP) populations or underserved communities.

Veritas Management Group, Inc.

HIV Clinical Care Consultant

Posted on:

August 7, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Georgia

Veritas Management Group (VMG) is a leading management consulting firm offering solutions to complex challenges involving public health, technology, and military domains. We serve government and commercial sector organizations, academic institutions, and non-profit organizations, domestically and globally. We are committed to transforming public health through equitable, data-driven solutions.

VMG is seeking experienced HIV Clinical Care Consultants to support technical assistance (TA) and monitoring efforts under the HRSA Ryan White HIV/AIDS Program (RWHAP). These consultants serve as clinical subject matter experts (SMEs) during site visits or virtual TA engagements, providing guidance on outpatient HIV care models, clinical protocols, and quality management strategies. Consultants will help identify strengths and gaps in HIV clinical care and contribute to actionable recommendations and written deliverables.

Required: Active U.S. license as an MD, DO, NP, PA, or RN Minimum of 3 years of recent experience in direct outpatient HIV clinical care Demonstrated knowledge of HRSA HAB clinical guidelines and HIV primary care delivery models Requirements: Familiarity with clinical quality improvement frameworks and federal HIV benchmarks Ability to synthesize clinical observations into clear, concise written deliverables Availability for short-term, task-based consultant work

The HIV Clinical Care Consultant will: Participate in site visits or virtual TA sessions as a clinical SME Review clinical practices, medical records, and care protocols for alignment with RWHAP standards and federal HIV clinical guidance Provide expert input on care retention, antiretroviral adherence, viral suppression outcomes, and clinical quality management (CQM) Contribute to the development of site visit reports, TA recommendations, and quality improvement materials Primary Duties Include but Are Not Limited To: Conduct interviews with clinical providers and staff during assessments Identify improvement opportunities in HIV service delivery systems Document clinical findings in alignment with federal reporting expectations Collaborate with multidisciplinary teams including program, fiscal, and administrative consultants

Tailored Management

Quality Review and Audit Senior Analyst

Posted on:

August 7, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Tennessee

Tailored Management is a professional staffing firm dedicated to developing strong relationships with career seekers and long-term partnerships with clients. Never content with industry norms, we are always innovating and constantly researching new ways to evolve our approach. This culture of perpetual ingenuity and inspiration is what allows us to create a more effective custom recruiting solution for you – faster than any competitor! We accomplish unparalleled success with many Fortune 500 companies within our Centralized Recruiting Hub. This approach is prime for the digital age. Even though our team is headquartered in one Columbus, Ohio office, our reach is beyond nationwide – Tailored Management is international. We can place top-notch candidates globally! Every client is assigned a dedicated Account Manager and recruiting team. This highly-trained group of staffing and recruiting experts follows the same principles that we use to guide our own business. And that’s exactly where we separate ourselves from the rest of the pack: Our team approaches the staffing process the same way we would approach our own. We act with the same urgency that you exhibit and with your best interests at heart. Your success is our success. "The people business is personal." This simple but profound phrase shapes the exact thinking that has made Tailored Management into a driving national force in the staffing industry. With unwavering passion, we are driven to finding the perfectly tailored candidate for each role we fill. Where there’s a need, there’s talent – and we will find the right person for the job!

Role: Quality Review and Audit Senior Analyst Location: 100% Remote Contract Duration: 7 Months (Potential for extension/conversion pending attendance, performance and business need) Pay Rate: $25.49-36/hour, paid weekly Tentative Start Date: 10/20/2025 Responsibilities: Annually we report Healthcare Effectiveness Data and Information Set (HEDIS), this requires a medical record retrieval process and nurses are needed to conduct abstraction of medical records.

Registered Nurse (RN) with unrestricted license in state. Licensed Practical Nurse 5+ years relevant experience. Experience in utilization review, quality assurance, and/or medical record and site review audits. Knowledge of medical terminology standard medical practices, formal quality improvement process, and federal, state, accreditation regulations and standards. PC proficiency to include Word and Excel. PREFERRED JOB REQUIREMENTS: HEDIS abstracting clinical information experience.

Apply structured auditing criteria to abstract medical records, follow defined procedures for saving approved medical record documentation and accurately enter the results of chart audits into the health plans database. Abstract medical record documentation submitted for HEDIS measures, used annually for reporting to the National Committee for Quality Assurance (NCQA). The HEDIS measures are used to assist in measuring quality of health care provided to healthplan members. Maintains productivity level with less than a 5% error rate in record abstraction and data entry on an ongoing basis. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. Maintain complete confidentiality of company related business. Maintain effective communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

ICONMA, LLC

Registered Nurse Case Manager

Posted on:

August 7, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Ohio

ICONMA is a globally recognized, Woman-Owned staff augmentation and technology consulting firm. We specialize in connecting clients with top-tier professionals and providing digital solutions, empowering organizations of all sizes to achieve their business goals. By delivering exceptional workforce talent and tailored solutions we help businesses – from startups to Fortune 500 companies – drive innovation and growth. Since 2000, we have been a trusted partner. With our headquarters in Troy, Michigan, and over 15 global locations, we are ready to support your business wherever you are.

Our Client, a Retail Pharmacy company, is looking for a Nurse Case Manager to work remotely in Central Ohio (Franklin, Delaware, Union, Pickaway or Madison County).

3 years Clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required. Healthcare and/or managed care industry experience. Case Management experience preferred Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Typical office working environment with productivity and quality expectations RN with current unrestricted state licensure. Case Management Certification CCM preferred

Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures

Healthcare Support

Remote Utilization Review – RN

Posted on:

August 7, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Florida

HealthCare Support is a national recruitment firm that has a singular focus – placing top talent in the dynamic healthcare industry. We place administrative to executive level professionals in the clinical and non-clinical healthcare arena. Launched in 2002, HealthCare Support has quickly grown to be a leader in the healthcare recruitment field and has access to a proprietary database of over 3.5 million talented candidates. Servicing local providers to national organizations, our delivery model is tailored to meet our client’s unique needs.

HealthCare Support is a nationwide staffing partner providing contract, travel, and remote opportunities for healthcare professionals. We are currently seeking experienced Remote Utilization Review RNs to assess clinical information, support authorization decisions, and ensure patients receive appropriate and timely care.

Requirements: Active and unrestricted RN license in state of residence Minimum 2 years of experience in clinical or administrative nursing roles Preferred: Prior experience with utilization review, prior authorizations, or concurrent review

Review clinical documentation to determine medical necessity and coverage eligibility Conduct telephonic or electronic utilization reviews based on established guidelines Collaborate with providers, case managers, and interdisciplinary teams

Healthcare Support

Remote RN Case Manager

Posted on:

August 7, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

South Carolina

HealthCare Support is a national recruitment firm that has a singular focus – placing top talent in the dynamic healthcare industry. We place administrative to executive level professionals in the clinical and non-clinical healthcare arena. Launched in 2002, HealthCare Support has quickly grown to be a leader in the healthcare recruitment field and has access to a proprietary database of over 3.5 million talented candidates. Servicing local providers to national organizations, our delivery model is tailored to meet our client’s unique needs.

HealthCare Support is actively seeking an RN Telephonic Case Manager to fill a remote opening for Managed Care Organization in South Carolina

Clear and active South Carolina RN license Good computer skills – experience working with computer systems, MS office – Outlook, Word, Excel, Teams and EMR's Experience using InterQual Criteria or Milliman Care Guidelines (MCG) to determine medical necessity of lower level of care to transition them to 2+ years of clinical nursing experience, preferably in case management or from hospital setting in case management, ICU or ER Experience with discharge planning (transitioning patients to a lower level of care, ie: from hospital to rehab facility or home) Graduate from accredited school of nursing Clear and active drivers license, reliable transportation and auto insurance

Transition of Care Case Management for Medicaid members, telephonic outreaches to facilities and members. Assist facility staff with discharge planning efforts for members. Outreaches to members after discharge from hospitalizations within 10 business days of discharge. Location: Remote - candidate must live in SC. May need to travel for visits about 25% of the time Shift: M-F 8-5

Med-Net Concepts, Inc.

Registered Nurse Specialist

Posted on:

August 7, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

New Jersey

Experienced Long-Term Care Registered Nurse Needed for Skilled Nursing Facility Support and Travel Remote | Willing to Travel | Full/Part-Time/Per Diem | Competitive Pay Are you looking to improve the quality of care, compliance, and operational efficiency at skilled nursing facilities?

Services This Position Will Offer to Skilled Nursing Facilities: Regulatory compliance & survey readiness (CMS/F-tag consulting) Staff education & training Clinical systems review & care plan optimization Infection control audits Risk management and incident investigation support Policy development and implementation Consultation on state and federal regulations Requirements: Current Registered Nurse’s license Extensive nursing experience in skilled nursing facility and long-term care environments In-depth knowledge of state and federal regulations Professional, collaborative approach Flexible schedule and willingness to travel to facilities Available for short-term projects, ongoing consultation, or survey preparation

Registered nurse needed to provide comprehensive support to skilled nursing facilities, long-term care centers, and residential care and assisted living communities. Need extensive experience working in a skilled nursing facility as well as a proven background in regulatory compliance, clinical quality improvement, and staff education to help facilities achieve their goals while ensuring exceptional resident care.

BCFORWARD TECHNOLOGIES PRIVATE LIMITED

Clinical UR Nurse (Prior Authorization) - Remote

Posted on:

August 7, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Founded in 1998, BCforward is a Black-owned global leader in workforce management and digital product delivery solutions, headquartered in Indianapolis, IN. With a worldwide team of over 6,000 consultants, BCforward is dedicated to empowering human potential through its core values: People-Centricity, Excellence, and Diversity. As an industry pioneer, BCforward provides a best-in-class workplace, fostering a culture of accountability, innovation, and optimism. Committed to equal opportunity employment, the company champions diversity and inclusion, striving to create a positive impact for its clients, employees, and communities.

Clinical Review Nurse - Prior Authorization - J00927 BC Forward is looking for Clinical UR Nurse (Prior Authorization) - Remote Position: Clinical UR Nurse (Prior Authorization) - Remote Location: Remote - Indiana Anticipated Start date : 09/01 Duration: 3 months Contract to Hire Shift Schedule: Monday-Friday, 8:00 AM - 5:00 PM EST | Occasional overtime (rare) | On-call rotation required Pay Rate: $42.82/hr on W2 Need: Graduate of an accredited nursing program (Diploma, ADN, or BSN) with 2-4 years of clinical experience in acute care, case management, or utilization review; current, unrestricted LPN or RN license in Indiana or a compact state. Job Description: Position Purpose The Clinical Utilization Review Nurse performs comprehensive clinical evaluations of prior authorization requests to determine medical necessity, appropriate level of care, and alignment with national standards, contractual obligations, and member benefit coverage. This role supports high-quality, cost-effective healthcare by providing evidence-based recommendations to internal medical teams and collaborating with providers to ensure timely access to care. The position operates remotely and plays a critical role in compliance with regulatory requirements, including those set forth by CMS.

Required: Graduation from an accredited School of Nursing (Diploma, Associate, or Bachelor's degree) OR Bachelor of Science in Nursing (BSN) 2-4 years of progressive clinical experience in acute care, case management, utilization review, or managed care settings Preferred Qualifications: Experience in utilization management (UM) or prior authorization processes Familiarity with InterQual or MCG guidelines Knowledge of Medicare, Medicaid, and CMS regulatory requirements Background in outpatient, ambulatory surgery, or DME review Licensure & Certification Required: Current, unrestricted LPN or RN license in the state of Indiana (or compact state) For roles supporting Health Net of California or Superior HealthPlan: RN license is required Technical & Professional Requirements ? Must-Have Competencies (Non-Negotiable): Computer Proficiency & Technical Literacy Must be highly proficient with electronic health records (EHR), case management systems, and Microsoft Office Suite Ability to troubleshoot basic technical issues independently (e.g., connectivity, system access, software navigation) Clinical Critical Thinking & Decision-Making Demonstrated ability to interpret clinical documentation, apply medical necessity criteria, and make sound, defensible judgments under time constraints Communication & Interpersonal Skills Excellent verbal communication skills; must be comfortable engaging providers over the phone in a professional, collaborative manner ?? Nice-to-Have (Preferred): Prior experience in utilization management or prior authorization in a health plan or managed care environment Working knowledge of InterQual or similar clinical decision support tools Exposure to CMS regulations, especially related to prior authorization turnaround times and transparency rules ?? Disqualifiers: Lack of basic computer literacy or inability to work independently in a remote tech environment Unexplained gaps in employment history (candidate must be prepared to provide reasonable explanation) Inability to maintain a professional, distraction-free work environment at home (e.g., lack of reliable childcare if needed, frequent background noise during calls)

Conduct thorough medical necessity and clinical reviews of prior authorization requests for outpatient, ambulatory services, procedures, and durable medical equipment (DME), using evidence-based criteria such as InterQual (preferred). Evaluate requests in accordance with federal and state regulations, payer contracts, clinical guidelines, and member-specific benefits. Collaborate directly with healthcare providers via phone (outbound and inbound) to gather clinical information, clarify documentation, and support timely decision-making. Coordinate with interdisciplinary teams, including authorization specialists and medical directors, to assess appropriateness of care and facilitate seamless care transitions. Escalate complex or non-routine cases to Medical Directors when clinical judgment or exceptions are required. Support discharge planning and patient transfers between levels of care or facilities by reviewing service requests and ensuring continuity. Accurately collect, document, and maintain member clinical data in health management systems, ensuring compliance with HIPAA, NCQA, CMS, and other regulatory standards. Assist in educating providers and internal teams on utilization management processes, policy updates, and best practices to improve quality and efficiency. Identify and provide feedback on opportunities to optimize the prior authorization process, reduce delays, and enhance member and provider experience. Participate in on-call rotations with team members to support after-hours coverage as needed. Perform other duties as assigned. Maintain strict adherence to company policies, procedures, and ethical standards.

Daymark Recovery Services Inc

FBC Centralized Nurse-RN

Posted on:

August 6, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

North Carolina

Our mission is to inspire and empower people to seek and maintain recovery and health. Daymark Recovery Services, Inc. is a mission driven, comprehensive community provider of culturally sensitive mental health and substance abuse services.

Daymark Recovery Services operates 5 adult and 2 child/adolescent Facility-Based Crisis Centers, providing 5-7 days of crisis stabilization for substance abuse and mental health in a residential setting. This remote position provides referral coordination to the medical units and supervision for non-licensed staff providing medication administration.

Qualification Requirements: 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 accommodation may be made to enable individuals with disabilities to perform the essential functions. Education and/or Experience: Must be licensed with NC Board of Nursing, RN minimum of Associate Degree in Nursing. A four-year BS degree in nursing is preferred. Prefer four years of experience in psychiatric nursing with minimum of 1-year supervisor/management experience. Actual work experience will be considered in addition to other requirements. Prefer experience with both adult and child/adolescent populations.

Provides coordination of referrals for FBC- provide support/guidance for onsite staff with walk-in referrals. Provides assessment / screening for admission, obtain physician orders, medication administration, and medication education. Provides oversight/ supervision for non-licensed staff providing medication administration coverage. Assesses patient needs and delegates tasks. Reviews UDS, VS, COVID-19 & breathalyzer results. Enters medication orders into software, ensures discharge medications are managed and routed to appropriate pharmacy, Monitors for transcription and medication errors, delegates monitoring of pharmacy stock and medical supplies to medication assistant. Participates in daily shift reports through in-person, virtual, or telephonic for each center. Reviews all shift reports for each center. Delegates care to unlicensed assistive personnel (UAP). Provides crisis intervention consultation to all members of the team All other duties as assigned by center/regional directors.

MPF Federal

Night and Weekend Call Center Nurse (RN-BSN) - Remote

Posted on:

August 6, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Ready to Bring Your Acute Care Skills Home? Join Our Remote RN Team Supporting Our Military Communities! Are you a seasoned ER or Med-Surg nurse looking for a meaningful, mission-driven role that lets you care for others without the scrubs and long drives to the hospital? MPF Federal is hiring Remote Telehealth Triage Nurses (RNs) to join our 24/7 Nurse Advice Line—supporting veterans and their families—all from the comfort of your home. This isn’t just a job; it’s your chance to use your clinical expertise, empathy, and critical thinking skills to guide patients through their toughest moments—all while achieving better work-life balance. Pay & Perks $35.00/hr base rate Evening, night, and weekend differentials may apply 100% Remote – Work From Home Most schedules include Saturday and Sunday and do not rotate ONLY FULL TIME SHIFTS AVAILABLE EVENINGS / NIGHTS / WEEKENDS INCLUDED (= means day off; R means Thursday; and Y means Saturday) SM==RFY 1530-0000(3:30PM-MIDNIGHT) 8HR S=TWR=Y 1530-0000 (3:30PM -MIDNIGHT) 8HR ==TWRFY 1530-0000 (3:30PM - MIDNIGHT) 8HR S===RFY 1500-0130 (3PM-1:30AM) 10HR SMTWR== 1330-2200 (1:30PM-10PM) 8HR SM==RFY 0000-0830 (MIDNIGHT - 8:30AM) 8HR =MT==FY 0000-1030 (MIDNIGHT TO 10:30AM) 10HR =MT==FY 1830-0500 (6:30PM-5AM) 10HR Training Approximately 6 Weeks Paid Training | Monday–Friday, 8:00 AM – 4:30 PM Start Date: September 15, 2025

You’re a Great Fit If You Have: 5+ Years of Recent Hands-On Acute Care RN Experience ER or Med-Surg strongly preferred Current Compact RN License in good standing from the state you are physically in BSN Degree from an accredited American university Confidence with phone-based care and multi-screen computer systems Strong clinical judgment, emotional intelligence, and documentation skills A mission-first mindset and passion for serving military-connected communities Bonus Points If You Also Have: Experience with behavioral health, mother-baby, and/or peds Past work in telehealth, triage, or call center nursing Familiarity with military healthcare systems or VA patients Tech & Work Environment: Must have a hard-wired Ethernet internet connection (Wi-Fi only, satellite, or radio internet is not acceptable) Quiet, distraction-free home office space with a door for HIPAA compliance Metrics-driven environment – you’ll need to meet quality, handle time, and documentation goals Federal Requirements: Must be a U.S. Citizen Ability to pass a Public Trust Background Check & Drug Screening per federal guidelines Must be willing and able to obtain licenses in all 50 states (we support you here!)

Triage Symptoms: Assess callers using evidence-based protocols Deliver Immediate Care Advice: Recommend next steps, from self-care to urgent care, calmly and confidently Offer Health Education: Counsel patients on medications, test results, and chronic condition management Crisis Triage: Handle behavioral health, emergency, and complex calls with empathy and grace Document Interactions: Accurately chart calls in our EHR and follow compliance protocols Team Collaboration: Work closely with a supportive leadership team and fellow remote RNs If you're an experienced nurse with a calm voice, a critical mind, and a heart for service—this is your moment to make a real difference. Apply now and be the steady hand guiding military families when they need it most—right from your home.

Frontpoint Health, LLC

Home Health - Medical Reviewer (Remote)

Posted on:

August 6, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Education: Graduate of an accredited school of vocational/practical nursing. Licensure: Active, state license as a licensed vocational/practical nurse, or a multi-state license issued by a Nurse Licensure Compact (NLC) member state. Current driver’s license. Experience and Skills: One year of experience as a licensed vocational/practical nurse; home health experience preferred. Transportation: Reliable transportation and valid auto liability insurance. Environmental and Working Conditions: This is a remote position, requiring access to a reliable internet connection and a quiet, professional workspace. The role involves frequent use of a computer and communication tools (phone, email, virtual meetings). Candidates must be able to work independently, stay organized, and collaborate effectively with team members in a virtual environment.

The Medical Reviewer – Home Health plays a key role in ensuring quality and timely care delivery by reviewing incoming patient referrals, verifying clinical documentation, and coordinating with the interdisciplinary care team. This position ensures that all home health services are properly authorized, documented, and aligned with regulatory and organizational standards.

Adherehealth Solutions Llc

PRN Medication Case Manager

Posted on:

August 6, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Tennessee

The role of the Medication Case Manager is to facilitate HEDIs compliant patient care by working with physician offices, pharmacies and patients. The overall goal for case managers is to improve clinical outcomes, increase patient satisfaction, and promote cost-effectiveness. The MCM will work to improve population health through the resolution of drug therapy problems and facilitation of preventative screenings.

Education & Experience: Must possess an Associate’s or bachelor’s degree in nursing from an accredited school of nursing Current unrestricted state LPN/LVN or RN licensure from state of residence. LPN/LVN with 10+ years of medical office experience or RN with 5+ years of experience or 3 years of case management, utilization review or employer health benefits experience or equivalent combination of education and experience preferred. Minimum Physical Requirement: The MCM will perform his or her work in a general office environment using standard office equipment. The following demands are representative of those that must be met by an employee to successfully perform the essential functions of this job: Regularly lift and/or move up to 10 pounds Bend, twist or stoop on a repetitive and continuous basis Stand and remain on feet for extended periods of time Operate various business instruments, including computers, printers/scanners/fax machines, requiring manual dexterity Sit and concentrate for long periods of time to compute, examine, and interpret data Read paperwork and computer monitors, requiring visual acuity Skills: Proficient in Microsoft Word, Excel, Outlook and Google and ability to learn new software as needed Strong working knowledge of web-based applications Strong written and oral communication skills including ability to communicate effectively with all levels of healthcare personnel. Strong time-management skills and keen eye to detail Ability to deal with all situations in a calm and positive manner Ability to learn new processes quickly in a fast paced environment Strong interpersonal and persuasion skills Using critical thinking skills that involve analysis, research, and problem-solving to obtain resolution. Demonstrated ability to think critically and make decisions within individual role and responsibility

Telephonic outreach to provider’s offices to inform of Drug Therapy Problems (DTPs) that have been identified from Medical and Pharmacy claims. DTPs include but are not limited to potential medication adverse reactions, potential cost saving alternatives and/or GAPs in medical care as indicated from AdhereHealth’s clinical rules platform. Make outbound calls to patients to facilitate and coordinate medical care, including medications and preventative care. Work directly with patients to assess their needs (medical and SDOH) and connect them with essential services. Maintain confidentiality as related to patient information. Any disclosures of confidential information made unlawfully outside the proper course of duty will be treated as a serious disciplinary offense. Maintain accurate and timely documentation Other Duties & Responsibilities: Applying sound judgment required to develop, modify and adapt procedures in order to most effectively meet demands in atypical situations. Participate in proactive team efforts to achieve departmental and company goals Provide leadership to others through example and sharing of knowledge/skill Other duties as required and assigned

For The People of Georgia, LLC

Clinical Case Manager-RN

Posted on:

August 6, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Georgia

We are seeking a dedicated Case Manager to join our team. The ideal candidate will be responsible for coordinating patient care and providing support to individuals in need.

Previous experience in a healthcare setting, preferably in acute care or trauma centers Knowledge of vital signs monitoring and patient care techniques Familiarity with medical terminology and procedures Ability to work with diverse patient populations, including geriatrics Strong communication and interpersonal skills Proficiency in utilizing electronic health records systems Bachelor's degree in Nursing, Social Work, or related field preferred This is an excellent opportunity for a compassionate individual with a passion for patient advocacy and healthcare coordination. If you meet the requirements and are ready to make a difference in the lives of others, we encourage you to apply for this rewarding position.

Collaborate with healthcare providers to ensure quality patient care Conduct assessments to determine patient needs and develop care plans Monitor and evaluate the effectiveness of treatment plans Assist patients in navigating the healthcare system and accessing necessary resources Maintain accurate and up-to-date medical records Provide emotional support and guidance to patients and their families

Veear Projects Inc.

Registered Nurse – ED Case Manager

Posted on:

August 6, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

California

Certification Requirements: California RN License – Required Certified Case Manager (CCM) or Accredited Case Manager (ACM) – Preferred Experience Requirements: Minimum 3 years acute clinical nursing experience – Required Minimum 2 years case management experience – Preferred Emergency Department experience – Preferred Experience with MCG and Cerner – Preferred Education Requirements: Graduate of an accredited nursing school – Required BSN – Required MSN – Preferred

The Emergency Department Case Manager (EDCM) is responsible for assessing, planning, implementing, monitoring, and evaluating individualized care plans for patients in the Emergency Department (ED). Ensures timely transitions to the appropriate level of care and coordinates post-ED care in collaboration with patients, families, and interdisciplinary teams. Applies clinical knowledge, MCG criteria, and strong documentation skills in Cerner to drive patient outcomes and ensure medical necessity. Acts as a liaison between the hospital and external resources, including health plans and outpatient services. Supports departmental policies, provides case handoffs using SBARQ, and reports to the Inpatient Case Management Supervisor.

CardioOne

Virtual Care Manager

Posted on:

August 6, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Colorado

CardioOne partners with independent cardiologists to provide innovative solutions that improve patient outcomes and reduce costs. Our platform helps our physician partners thrive in today’s fee-for-service environment and prepare for success in value-based care. In February 2024, we partnered with WindRose Health Investors as well as top physician services and payor executives to grow our team and invest in our next phase of growth. CardioOne offers a magnificent work environment, good working conditions, and competitive pay. We offer medical, dental, vision, and a 401k plan with a match to benefit eligible employees. We offer PTO (Personal Time Off) and sick time to full-time employees. We take pride in creating a culture of employee engagement that translates into an exemplary patient experience. Join us in our mission to positively impact US cardiology.

CardioOne is hiring a Virtual Care Manager. You will play a critical role in helping to stand up virtual care services at CardioOne. This role will be responsible for providing critical remote support to patients in-between office visits with the goal of keeping them healthy, optimizing our ability to intervene quickly when they're not and encouraging patients to take more control of their personal healthcare goals. You will work remotely and report directly to the Director of Virtual Care Management. Work Location: Remote: Colorado, Florida, New Hampshire, New Jersey, New York, Pennsylvania, Texas.

Graduate from an accredited program for professional nursing education, BSN preferred. Minimum of 3 years nursing experience needed. Current RN state license with the applicable State Board of Nursing. Current CPR certification required. Cardiology experience Strong communication & documentation skills Patient assessment skills that will allow effective care management support from a remote location utilizing video, phone and/or texting tools Ability to develop meaningful relationships with patients who would benefit from additional healthcare support at home

Provide remote care management support for all of CardioOne’s virtual care services Remote patient support includes disease specific care plan development & ongoing management, medication reconciliation, education & coaching, appropriate documentation and communication with clinicians Support the development of additional virtual care services

Zócalo Health

RN Care Coordinator

Posted on:

August 6, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Zócalo Health is the first tech-driven provider built specifically for Latinos, by Latinos. We are developing a new approach to care that is designed around our very own shared and lived experiences and brings care to our gente. Founded in 2021 on the idea that our communities deserve more than just safety nets, we are backed by leading healthcare and social impact investors in the country to bring our vision to life. Our mission is to improve the lives of our communities—communities that have dealt with generations of poor experiences. These experiences include waiting hours in waiting rooms, spending mere minutes with doctors who don’t speak their language, and depending on their youngest kids to help them navigate our complex healthcare system. At Zócalo Health, we meet our members where they are, bringing care into their homes and neighborhoods through our team of community-based care providers and virtual care offerings. We partner with community-based organizations, local healthcare providers, and health plans that recognize the value of culturally aligned care, which are not limited to brief interactions in an exam room. Together, we are building a new experience that revolves around the use of modern technology, culturally competent primary care, behavioral health, and social services to provide a radically better experience of care for every member, their family, and the communities we serve. We are committed to expanding our reach to serve more members and their communities. We are looking for passionate individuals who share our belief that healthcare should be accessible, personalized, and rooted in the community. Join us in our mission to ensure that no one has to navigate the complexities of the healthcare system alone and that everyone receives the local, culturally competent care they deserve.

Zócalo Health is seeking a skilled and empathetic RN Care Coordinator to provide clinical care coordination for patients receiving services from our interdisciplinary team of board-certified physicians, nurse practitioners, and licensed behavioral health therapists. The RN Care Coordinator will play a critical role in supporting the implementation, monitoring, and continuous improvement of Zócalo Health’s suite of clinical programs, including the Enhanced Care Management (ECM) program. This role will provide clinical oversight, ensure compliance with regulatory requirements, and help optimize care coordination and documentation processes. The RN Care Coordinator will work closely with the VP, Clinical Operations and serve as a clinical advisor and reviewer for the Community Health Worker (CHW) team. This role will initially report to the VP, Clinical Operations..

Education: Active, unrestricted RN license in the state of California. Added benefit: Multi state RN license Experience: Minimum 3 years of clinical experience in community-based care, case management, care coordination, or population health. Familiarity with Medi-Cal, ECM, and population-based care models. Experience working alongside interdisciplinary teams including CHWs, social workers, and behavioral health clinicians. Skills: Familiarity with health plan portals, reporting systems, and EHRs (e.g., Athena). Strong attention to detail with ability to review and validate documentation for clinical and compliance accuracy.

Clinical Oversight & Documentation: Review and provide clinical sign-off on ECM care plans developed by CHWs, ensuring alignment with clinical best practices, DHCS requirements, and plan-specific documentation standards. Oversee and support accurate medication reconciliation for ECM-enrolled patients and other assigned populations. Serve as a clinical escalation resource for CHWs and other non-licensed staff as needed. Clinical Care Coordination: Serve as the primary clinical point of contact for patients, ensuring seamless coordination of care across medical and behavioral health services, both internally with Zócalo Health providers and externally with specialists and other providers. Facilitate timely referrals to specialty care, diagnostic tests, or community resources as needed. Work collaboratively with Zócalo Health physicians and nurse practitioners to support implementation of care. Promote health literacy by using culturally and linguistically appropriate materials and communication strategies. Quality Improvement & Compliance: Participate in audits of documentation and care plans to identify gaps in care or inconsistencies in reporting and ensure high standards of care delivery. Monitor performance against clinical compliance benchmarks (e.g., care plan completion, medication reconciliation, and gap closure activities). Training & Collaboration: Collaborate with the Learning & Development and CHW leadership teams to support training related to clinical components of the ECM program and other care delivery models. Stay current with relevant regulatory, Medi-Cal, and health plan-specific guidelines to ensure that documentation and clinical workflows remain compliant. Participate in regular interdisciplinary care team huddles and case conferences to support comprehensive care planning and real-time collaboration.

StationMD

Nurse

Posted on:

August 6, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

StationMD is a telehealth company dedicated to serving individuals with intellectual and/or developmental disabilities (I/DD). All StationMD clinicians are board-certified and specially trained to treat individuals with I/DD. Clinicians are available 24/7 via telemedicine for urgent and non-urgent medical matters. StationMD also offers scheduled behavioral health telemedicine to individuals with I/DD. In providing this suite of services, StationMD enables individuals with I/DD faster access to high-quality care and substantially reduces unnecessary medical costs.

RN degree is required Compact nursing license is preferred Specialized training in intellectual and developmental disabilities is preferred At least 2 years of clinical experience with either geriatric patients or people with intellectual or developmental disabilities Ability to understand basic laboratory and radiology tests Unrestricted registered nurse license in at least one state Excellent communication skills Access to internet Ability to work with Microsoft office platforms MS excel, outlook, and word proficiency are a must Ability to use common telehealth platforms Experience using electronic medical records Basic computer/mobile device competency and comfortability Ability to use secure text messages Comfortable learning multiple electronic medical records Must provide care from the United States

Coordinate care for our patients after they are seen by our physicians. This will include: Follow up on diagnostic tests ordered and ensure patients have received orders and instructions Make follow up calls to patients to ensure care plans are followed Document encounters in our medical record Communicate with insurance companies/pharmacies for pre-authorizations Communicate with our patients and their caregivers should they have questions or concerns Monitor the incoming labs and radiology results and review results with physicians to determine further actions Assist in providing and collecting data for QA activities Help onboard new nurses and staff Participate in the development of processes and standard operating procedures for the service line Participate in clinical work groups to help improve technology, clinical care delivery, and documentation Other activities as deemed fit for the role from time to time as needed by the organization

Inizio Engage

Remote Call Center Registered Nurse

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Oregon

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

BlueCross BlueShield of South Carolina

RN Medical Reviewer III (W@H South Carolina)

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

We are currently hiring for a Medical Reviewer III to join BlueCross BlueShield of South Carolina. In this role as a Medical Reviewer III, you will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines, document decisions using indicated protocol sets or clinical guidelines, and provide support and review of medical claims and utilization practices. Location: This position is full-time (40 hours/week) Monday-Friday with an 8-hour shift from 6:00am-5:00pm EST and will be fully remote . Candidates may be asked to report on-site occasionally for trainings, meetings, or other business needs.

Required Education: Associates in a job-related field Degree Equivalency: Graduate of Accredited School of Nursing Required Experience: 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience. Required Skills and Abilities: Working knowledge of managed care and various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same. Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools: Microsoft Office. Required Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area. What We Prefer You to Have: Preferred Education: Bachelor's Degree-Nursing or Graduate of accredited School of Nursing. Preferred Work Experience: Must have well rounded clinical experience. Preferred Work Experience: 3 years’ utilization/medical review, quality assurance, or home health, plus 5 years clinical experience. Preferred Skills and Abilities: Knowledge of spreadsheet and database software. Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review. Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet database software.

Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies. Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management.

Northside Hospital

Clinical Denials Supervisor, RN

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Georgia

Our team members report that our state-of-the-art environment, work/life balance, reputation as a leader both locally and nationally, continuing education offerings, growth opportunities, and pay/benefits/pension plan are why they chose — and chose to stay with — Northside Hospital.

This is a fully remote position with work in the office responsibilities for new hire training once fully orientated. Must be willing to train in Sandy Springs Interchange location.

REQUIRED: Nursing degree and three (3) years previous experience as hospital care coordinator or insurance case management. Current Standards of Care & Criteria, working knowledge of Intequal and/or Milliman. Ability to train and direct employees. PREFERRED: Bachelor’s degree in nursing. Five years of experience in care coordination or related field. Leadership experience preferred. Certification as Certified Case Manager (CCM), or Accredited Case Manager (ACM).

The UM/Appeals Supervisor Care Coordination RN is responsible for an appeals caseload and responsible for the Care Coordination staff for case reviews and UR appeals. Works with Appeals and Case review staff on a daily basis to resolve cases and provide guidance. Coordinates worklists.

Northside Hospital

Clinical Denial Specialist, RN

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Georgia

Northside Hospital is award-winning, state-of-the-art, and continually growing. Constantly expanding the quality and reach of our care to our patients and communities creates even more opportunity for the best healthcare professionals in Atlanta and beyond. Discover all the possibilities of a career at Northside today.

Fully remote once successful completion of orientation. Must have basic computer knowledge.

Case Management: Graduate of an accredited school of nursing, with strong clinical case management experience Three (3) years experience in Utilization Management/Case Management or related field, with specific experience in the following areas: the application of industry prevalent guideline criteria; knowledge of coding, billing, audit and reimbursement payer methodologies and guidelines. Experience in the collection, interpretation, and presentation of data to medical staff members; and, interaction with managed care companies, including appealing denials. General: Excellent written and verbal communication skills. Ability to communicate effectively with business office, physicians, clinical care team and case management team. Ability to type accurately at an approximate rate of 30 words per minute.

Processes, tracks and appeals clinical denials. Supports and facilitates the design, development and implementation of Utilization Management data collection methodologies and studies in the respective functional areas. Displays and analyzes data to identify trends. Works collaboratively to develop plan of action. Must be willing to orient in person in the Sandy Springs Interchange location.

PeaceHealth

RN Clinical Data Abstractor - Remote

Posted on:

August 5, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Oregon

PeaceHealth is seeking a RN Clinical Data Abstractor - Quality Outcomes for a Full Time, 1.00 FTE, Day position. This remote role requires the incumbent work and reside in OR, WA or AK by date of hire. The salary range for this job opening at PeaceHealth is $45.14 – $67.70. The hiring rate is dependent upon several factors, including but not limited to education, training, work experience, terms of any applicable collective bargaining agreement, seniority, etc. Job Summary: Responsible for abstracting and/or auditing a large volume of clinical case records, data, or other information within established deadlines in support of PeaceHealth's quality assessment and performance improvement program and compliance with regulatory and accreditation requirements. Applies clinical training, knowledge and clinical experience in the review of moderate to highly complex clinical information from individual patient records and other sources to abstract data elements for clinical registries and to ensure compliance with standards of care, policies and procedures, regulations or accreditation requirements. Produce reports addressing variances from established standards, and identify significant data trends, outlier values or unusual data for additional review by physicians, clinical value improvement staff and/or leadership. Responsible for the integrity of the reported data.

Education: Associate Degree Required: Nursing. And Bachelor's Degree Preferred: Nursing. Experience: Minimum of 3 years Required: Clinical experience in an acute care hospital with preferred experience in surgery, inpatient care, and emergency services. Clinical experience must be recent enough to demonstrate knowledge of current clinical practice standards or demonstration of adequate continuing education. An Advanced Nurse Practitioner degree may be substituted for preferred experience and Required: Care management and/or hospital insurance case management experience may be substituted for clinical experience. However, either must reflect competence in current clinical practice and Preferred: Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity Credentials Required : Registered Nurse and Preferred : Certified Professional in Healthcare Quality Skills: Advanced knowledge of medical terminology, anatomy and physiology and understanding of disease processes, pharmaceuticals, and diagnostic studies. (Required) Strong organization, analysis, software aptitude, and communication skills (both written & verbal). (Required) Proficient skills in database management, spreadsheets, word processing, graphs and presentations. (Required) Proficient with MS Office applications. (Required) Demonstrated experience working successfully with physicians and clinicians. (Required) Current knowledge of regulatory and accreditation requirements related to data abstraction and reporting, quality assurance, performance improvement and required measurement systems. (Required) Working Conditions Lifting: Consistently operates computer and other office equipment. Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work. Environmental Conditions: Predominantly operates in an office environment. Some time spent on site in medical/hospital setting. Mental/Visual: Ability to communicate and exchange accurate information. The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading.

Manages, schedules and receives patient records for abstracting from multiple PeaceHealth hospitals; abstracts moderate to highly complex clinical data using established definitions and abstraction guidelines; maintains an abstracting volume to meet internal and external reporting deadlines. Enters abstracted data into the appropriate registry or third-party vendor software within the established deadlines for data submission. Conducts or coordinates audits of patient records or other information to support the quality assurance and performance improvement program in each PeaceHealth community and evaluate compliance with established standards and/or regulatory and accreditation requirements. Identifies potential areas of concern/interest; interprets actual trends and develops reports that display variances from established standards of care or regulatory standards; summarizes findings and draws conclusions; maintains ongoing variance reports and communicates findings to provider, clinical value improvement caregivers and/or leadership in a timely manner; works with providers to interpret data trends and/or variances. Maintains accuracy in abstraction by following published guidelines and abstraction specifications; maintain accuracy and integrity of audit information by following standards and guidelines; facilitates and participates in quality assurance audits of abstracted/audited data to ensure a high level of inter-rater reliability among the clinical data abstractor team and achievement of acceptable validation results from external audits. Creates case finding or internal audit reports in an acceptable format for additional review by providers, clinical value improvement caregivers and/or leadership. Participates in teleconferences, webinars, and/or onsite educational opportunities. Shares knowledge with clinical value improvement caregivers and teams. Creates and supports an environment that fosters and supports teamwork; works collaboratively with providers, clinical value improvement caregivers, health information management, and operational leaders. Participates in team or committee meetings to present and discuss data and identify trends as appropriate. Performs other duties as assigned.

Cedars-Sinai

Registered Nurse

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

Are you ready to bring your clinical skills to a world-class facility recognized as top ten in the United States for transplant services? Do you have a passion for the highest quality and patient satisfaction? Then please respond to this dynamic opportunity available with one of the best places to work in Southern California! We would be happy to hear from you. With expert surgical and medical proficiency in lung, heart, liver, kidney, and pancreas transplantation, the Cedars-Sinai Comprehensive Transplant Center is one of the most successful facilities of its kind. Here, patients find a compassionate environment and hope for a longer, healthier life.

This is a remote on-call position with a 24-hour shift schedule (7:00am - 7:00am). You will be required to take patient calls from home and also participate in meetings in-office. Required hours will be 6-7 shifts per month. As a Clinical Program Coordinator, Transplant on the Heart and Lung Transplant team, you will screen initial calls from the OPO, review and manage the EHR candidate wait list, review all offers with the appropriate physician teams to arrange and organize donor procurement and transplant candidate preop. You will serve as a reference for the members of the interdisciplinary team as needed for transplant specialty services. This role also includes participation in education and outreach activities related to organ allocation and transplantation to patients, healthcare providers and the community.

Education: BSN degree required License/Certification/Registration: Current, unrestricted California RN License required Specialty certification required - CCTC OR CCTN Current BLS from the American Heart Association required Experience: A minimum of 5 years of nursing experience required At least 3 years of Acute care, including minimum of 1 year Critical Care experience, Cardiac setting required Organ transplantation experience required (for Remote Team) Demonstration of excellent organizational skills as well as interpersonal skills Demonstrated knowledge of case management required Experience in data management required

Triage patient calls after-hours and over the weekend Participate in the development of guidelines, protocols, pathways, and other performance improvement activities as required for the On-Call CPC role Engage in research activities. Act as a patient advocate throughout the patient care process. Represent the Medical Center at regional and national meetings/conferences.

Optum

RN Case Manager - Remote

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

New York

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

Optum NY, (formerly Optum Tri-State NY) is seeking a RN Case Manager to join our team in Poughkeepsie, NY. Optum is a clinician-led care organization that is changing the way clinicians work and live. As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone. This position is mostly remote, with attendance to the Poughkeepsie, NY office as required for onsite meetings or training. This is high volume, customer service environment. You’ll need to be efficient, productive and thorough dealing with our members over the phone. Solid computer and software navigation skills are critical. You should also be solidly patient-focused and adaptable to changes. Optum NY/NJ was formed in 2022 by bringing together Riverside Medical Group, CareMount Medical and ProHealth Care. The regional alignment combines resources and services across the care continuum – from preventative medicine to diagnostics to treatment and beyond across New York, New Jersey, and Southern Connecticut. As a Patient Centered Medical Home, Optum NY/NJ can provide patient-focused medical care to the entire family. You will find our team working in local clinics, surgery centers and urgent care centers, within care models focused on managing risk, higher quality outcomes and driving change through collaboration and innovation. Together, we’re making health care work better for everyone.

Required Qualifications: Registered Nurse licensed to practice in New York State (NYS) with current NYS registration and in good standing 3+ years of diverse clinical experience; preferred in caring for the acutely ill members with multiple disease conditions Experience and proficiency working with electronic medical records Remote telephonic experience Knowledge of utilization management, quality improvement and discharge planning Knowledgeable in Microsoft Office applications including Outlook, Word and Excel Preferred Qualifications: Bachelor of Science in Nursing (B.S.N.) Certified Case Manager (CCM) Experience with Complex Case Management and NCQA requirements

Make outbound calls and receive inbound calls to assess members’ current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self-management Make referrals to outside sources Provide a complete continuum of quality care through close communication with members via telephonic interaction Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels

US Veterans Health Administration

Advanced Practice Nurse

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

NP/APP

State License:

District of Columbia

The Advanced Practice Nurse (APN) practices in the Veterans Integrated Systems Network within VISN 10 Caregiver Support Program. Providing state of the art continuum of services, education and resources to caregivers of Veterans with complex needs. Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: 8:00am -4:30pm, Monday - Friday Note: This position potentially requires flexibility in schedule and assignments; occasional travel and tour of duty changes may be required to meet logistical needs. Remote: This is a remote position but subject to any Return-To-Office (RTO) notices that either are, or have been implemented by VISN 10 under efforts to meet the January 2025 RTO Executive Order.

U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. English Language Proficiency. In accordance with 38 U.S.C. 7402(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Selective Service Registration is required for males born after 12/31/1959. You may be required to serve a probationary period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Qualifications Advanced Practice Nurse (Nurse Practitioner) Basic Requirements Education: A post-master's certificate or master's or doctoral degree as a Nurse Practitioner. (Applicants pending the completion of educational requirements may be referred and tentatively selected but may not be hired until the education requirements are met.) Must be a graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE). NOTE: Foreign Education. Graduates of foreign schools of professional nursing programs, the nurse practitioner degree equivalency must be validated through an Agency recognized degree equivalency evaluation agency, such as the International Consultants of Delaware (ICD). Candidates with equivalent nurse practitioner masters or doctorate level degrees who possess current, full, active, and unrestricted registration and certification will meet the requirement of graduation from an approved school of professional nursing to warrant appointment. License - All APN (NPs) must possess and maintain an active, current, full, and unrestricted APN license to practice as an NP in a State, Territory or Commonwealth of the United States, or in the District of Columbia. Basic Board Certification - All APN (NPs) must maintain full and current basic board certification in one of the following: Family Nurse Practitioner (FNP), Adult Nurse Practitioner (ANP), Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP), or Gerontology Nurse Practitioner (GNP) from one of the following: the American Nurses Credentialing Center (ANCC), American Academy of Nurse Practitioners Certification Board (AANPCB), or other nationally recognized certifying body in the area in which the Nurse Practitioner is academically prepared.(b) The required basic certification as a Nurse Practitioner must be identified in support of any position being established or filled as an APN (NP). An approved list of NP/APN certifications may be found on the Office of Nursing site at the Office of Nursing Services. NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and an APN (NP) assignment that are also performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. The following Scope, Education and Experience, and Dimension criteria must be met to qualify for Advanced Practice Nurse (Nurse Practitioner) II: Exception to Licensure for Graduate Nurse Technicians. Candidates who otherwise meet the basic requirements, but do not possess the required licensure and/or certification, may be appointed at the entry step of the Nurse II, as a Graduate Nurse Technician - Nurse Practitioner on a temporary appointment up to any period not-to-exceed one year and a day under the authority of 38 U.S.C. § 405(c)(2)(B). Scope: Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others Education and Experience Requirement: Meets basic education requirement for APN (NP). Nurse II is considered the entry grade level for APN (NPs); no experience is required. Dimension Requirement: APNs (NPs) at level II are expected to meet the following dimension requirements: Clinical Practice. Delivers evidence-based health care, demonstrating proficiency in the ability to manage a patient panel, population, or program. Outcome Focus. Utilizes research and evidence-based practice to evaluate the patient care delivery system within a patient panel or program, presents findings and contributes to changes that enhance the quality and timeliness of veteran/patient care. Leadership. Works effectively as a leader within a team/unit/group and seeks interdisciplinary collaboration as appropriate to enhance patient care. Professional Development. Acquires knowledge and skills to develop expertise in area of practice. Professionalism/Collegiality. Demonstrates effective communication skills and professional behavior, promoting cooperation and teamwork. Participates in interdisciplinary teams and processes that positively impact patient outcomes. The following Scope, Education and Experience, and Dimension criteria must be met to qualify for Advanced Practice Nurse (Nurse Practitioner) III: Scope: Executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of complex client care. Education and Experience Requirement: Meets basic education requirement for an APN (NP) AND one year of specialized APN (NP) experience equivalent to the Nurse II grade level. Dimension Requirement: APN (Nurse Practitioners) at grade III are expected to meet the following dimension requirements: Clinical Practice. Influences and models the delivery of evidence- based health care, demonstrating expertise in the ability to manage a patient panel, population, or program. Outcome Focus. Leads and implements changes that enhance the quality and timeliness of Veteran/patient care applying research and evidence in the delivery of healthcare for patient populations. Leadership. Initiates and leads interdisciplinary teams informed by structured approaches and processes to improve outcomes that positively impact care for a patient panel, population, or program. Professional Development. Acquires knowledge and skills, then disseminates acquired information within and/or outside the medical facility. Professionalism/Collegiality. Initiates and leads interdisciplinary teams developing systems that positively impact outcomes at the panel, population, or program level. Demonstrates effective communication skills and professional behavior, promoting cooperation and teamwork Physical Requirements: The Physical Requirements of this position are concerned with the mental and physical ability of the applicant to satisfactorily perform the duties of the proposed assignment and may include requisite laboratory and other screening as required by Federal regulatory agencies.

Major duties and responsibilities of the position VN-0610-II: The CEAT CNP is a licensed independent practitioner with advanced education and national certification who provides evidence-based care. The CEAT CNP has the responsibility for expert knowledge of eligibility criteria for the program of comprehensive Assistance for Family Caregivers. The CEAT CNP uses clinical judgement in the interpretation of trends and patterns; application of regulation, policy, guidelines ;and the recommendation of program enhancements. The CEAT CNP plays a crucial role in understanding of prescribed medication and treatment on current levels of functioning, advocacy, and education. The CEAT CNP training in assessment and monitoring, diagnosing, treating, health restoration, wellness promotion, illness prevention, and coping facilitation are crucial to the CEAT's case review, including the CNP's knowledge of disease managements. The CEAT CNP applies advanced nursing clinical knowledge to promote staff involvement in planning, decision-making. Major duties and responsibilities of the position VN-0610-III: The CEAT CNP Evaluates current practice and formulates outcomes for groups of patients. The CEAT CNP works with interprofessional team members at Regional. The CEAT CNP delivers objectively with strong, consistent inter-rater reliability with documentation and communication of outcomes in a direct and coordinated manner. The CEAT CNP Coordinates with other Regional CEATs and Veterans Affair Central Office. The CEAT CNP Conducts and documents comprehensive clinical review of patient records to identify the presence of Veteran needs for assistance with personal care services. The CEAT CNP Assists the VISN with Mission Act implementation. The CEAT CNP Adjudicates first-level appeal for one of the other three CEAT Regions. Executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of complex patient care.

Health Care Service Corporation

Primary Nurse Case Admin Specialty (Oncology Certification)

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development.

Registered Nurse (RN) with current, valid, unrestricted license in state of operations 4 years clinical practice experience of direct clinical care, to include 3 years of recent Specialty (ONCOLOGY) clinical experience Knowledge of specialty diagnosis drugs, adjunct therapies and treatment protocols including side effects and complications Current certification in one of the following: OCN/ONS/ONCC PC proficiency to include Word, Excel, and database experience Clear and concise verbal and written communication skills Knowledge of UM/CM/DM activities and standardized criteria set Familiarity of ancillary services including HHC, SNF, Hospice, etc Verbal and written communication skills; analytical skills; sound clinical judgment Incumbents with nursing licenses in positions/departments requiring multi-state licenses are required to obtain and maintain additional current, valid, and unrestricted applicable nursing licenses in other states as determined by management. Multi-state license fees will be provided by HCSC. Knowledge of drugs and treatment protocols including side effects and complications Knowledge of diets relating to assist members Knowledge of Problem Solving, Healthy Coping and establishing SMART goals. Current Certified Specialists must maintain their certification PREFERRED JOB REQUIREMENTS: RN Compact License required ONCOLOGY CERTIFICATION REQUIRED CCM certification PREFERRED Experience in managing complex or catastrophic health cases Inpatient and Outpatient experience preferred. 1-year experience in Care Management in a health insurance/managed care setting Knowledge of medical management policies and procedures 1-year education experience in Specialty area This position is Telecommute (Remote) role: Must reside within 250 miles of the office or anywhere within the posted state. #LI-Remote

This position’s primary focus is the management of members with specialty (ONCOLOGY) diagnoses. This position will be responsible for performing all functions of case management (CM) and is a primary source of contact for members, health care personnel and all other entities involved in managing specialty care. The primary nurse case administrator performs care coordination; identifies alternate treatment programs; consults with physicians, providers, members, and other resources to evaluate options and services required to meet an individual’s health needs; promotes quality and cost- effective outcomes; and serves as liaison to physicians and members. Provide education/local resource information and encourage member (self) education functioning in a clinical care advisory role, the primary nurse case administrator assesses members for case management, introduces members to our website tools, educates members regarding their specific condition, and facilitates the coordination of care for identified members.

Health Care Service Corporation

Behavioral Health Coordinator

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

None Required

State License:

Texas

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development.

1 year of college and 2 years’ experience with automated systems OR 3 years’ experience with automated systems. 1 year experience with managed care system(s). Experience coordinating member needs, providing assistance to members, and analyzing member needs. Knowledge of medical terminology. Database experience or PC applications experience. Customer service skills. Verbal and written communications skills including interpersonal skills to assist members and coordinate care with physician offices, developing written correspondence to members and to other department personnel, and to support departmental personnel and functions. #LI-FW1 #LI-Remote

This position is responsible for responsible for providing support to members and physicians on case management or outpatient services including responding to inquiries, conducting outbound calls, scheduling appointments, conducting research, performing data entry, resolving problems by working across departments, and supporting the behavioral health case management and outpatient clinicians.

UMass Memorial Health Care

Clinical Documentation Specialist (RN)-REMOTE

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Massachusetts

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day. Drawing upon clinical knowledge and experience, closely collaborates with physicians and other team members to ensure that patient records accurately document the status, complexity and intensity of patient conditions and care.

Required: Massachusetts licensure as a registered nurse required Preferred: Bachelor’s degree preferred Experience/Skills Required: Experience in direct patient care, case management, utilization review or equivalent required. Knowledge of clinical documentation practices and principles and ICD-10-CM diagnosis codes required. Excellent interpersonal skills and demonstrated ability to interact with physicians in a collaborative and professional manner. Ability to effectively use specialized computer based systems for gathering, reporting, and analyzing critical data. Preferred: 1-3 years of CDI experience preferred Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Works collaboratively with physicians, nurses, and other staff to ensure accurate and complete medical record documentation to appropriately reflect severity of illness and risk of mortality. Reviews inpatient medical records for identified payer populations or clinical specialties upon admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation. Communicates with attending physicians either verbally or electronically to validate observations and suggest additional and/or more specific documentation. Supports Physician leaders with focused documentation reviews and special projects as directed. Supports appropriate documentation for coding, reimbursement and quality purposes.

Cooper University Hospital

Clin Documentation Spec III, RN & Coding Certification Required - Remote

Posted on:

August 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New Jersey

AtCooper University Health Care, our commitment to providing extraordinary health care begins with our team. Our extraordinary professionals are continuously discovering clinical innovations and enhanced access to the most up-to-date facilities, equipment, technologies and research protocols. We have a commitment to our employees to provide competitive rates and compensation programs. Cooper offers full and part-time employees a comprehensive benefits program, including health, dental, vision, life, disability, and retirement. We also provide attractive working conditions and opportunities for career growth through professional development. Discover why Cooper University Health Care is the employer of choice in South Jersey.

This is a remote position. You must self provide high speed internet access and a phone line. Depending on shortages, you may be required to self-provide additional monitors (you will need to work on a minimum of 2 monitors). This job does not require any travel.

Experience Required: EPIC EHR Clintegrity CDE software 5 years minimum experience as Clinical Documentation Specialist in an acute setting, preferably Level 1 Trauma Center. CDI Subject matter expert for ALL PAYORS, all DRG groups (MS-DRG, APR-DRG, AP-DRG) PSI/HAC/HCC (Risk adjustment coding) knowledge/experience Education Requirements: Registered Nurse, any state. BSN or higher preferred License/Certification Requirements: CCDS or CDIP Registered Nurse, any state. BSN or higher preferred Coding certification: CCS or CRC Special Requirements: Essential mental abilities: excellent critical thinking skills, able to assess, evaluate and teach. Must be self governed, disciplined, and organized. Requires excellent work ethic, analytical thinking, problem solving, excellent computer skills, excellent verbal and written communication with knowledge of email etiquette . Must be proficient in Word, Excel, PowerPoint and typing (60 WPM)

Responsible for ensuring the overall quality and completeness of medical record Documentation for all payor groups, all DRG’s, including MS, AP, and APR. Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregiver and Health Information coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes Educates all members of the patient care team on an ongoing basis, as needed. Professional team player, able to communicate well with others on all levels. Regular electronic contacts with other personnel throughout and outside the hospital Contacts may be in by telephone or through e-mail correspondence. Flexible with a working knowledge of all areas of adult medicine. Ability to sit for very long periods of time, manual dexterity and mobility for extensive use of computer screen, keyboard, copy and facsimile machines, reader/printer and other office equipment. Adequate to perform essential functions of the job with the type of judgments and potential consequences outlined above.

Epathusa Inc

Medical Review Nurse

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Iowa

Seeking Registered Nurse for fully remote role to perform complex medical record and claim reviews (Standard or Program Integrity) to make coverage determinations based on applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization/practice guidelines, clinical review judgment and when appropriate, monitor for potential indicators of fraud, waste, and abuse. Provides professional assessment, planning, coordination, implementation, and reporting of complex data to support the Medical Review Accuracy Contract (MRAC).

Registered Nurse, with a current unobstructed license to practice nursing in the United States. Graduate of a Board approved Registered Nursing program. A Bachelor’s Degree in Nursing (BSN) or other related field is preferred. Certification in coding highly preferred. A minimum of five (5) years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice. A minimum of three (3) or more years’ experience in medical/utilization medical record review particularly with Medicare Part A, Skilled Nursing Facility, and/or Home Health. Minimum of 2 (two) years’ experience in the medical review processes of MACs, SMRC, CERT, QICs and/or BFCC-QIOs. Desired experience performing medical review for fraud, waste, and abuse (FWA) investigations. Knowledgeable of ICD-9-CM, ICD-10, CPT-4 and HCPCS coding. One year or more of utilizing InterQual and/or Milliman guidelines against inpatient services experience is preferred.

Perform complex medical record and claims review in accordance with all State and Federal mandated regulations/guidelines. Accurately enter medical review data into the medical review system. Apply clinical review judgment, based on clinical experience when applicable and review completeness of documentation to determine if documentation supports claim as billed. Reasonably determines appropriateness to consult a Subject Matter Expert (SME) for clarification. When performing Program Integrity (PI) reviews, assess investigative allegations and medical review findings, and/or other claims data to determine patterns and detect potential indicators of fraud, waste and abuse (FWA). Accurately identify additional findings in the review of evidence of potential FWA not detected by the Medical Review Contractor. Consistently meet or exceed productivity and accuracy standards of 98% minimum IRR established by the customer and/or the Company.

CVS Health

Clinical Team Lead - Remote - Kentucky

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Leadership / 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.

The Team Lead plays a key role in supporting the daily operations of the team and serves as a vital resource for both staff and leadership. While this role does not include direct supervisory responsibilities, it requires a strong understanding of workflows, policies, and procedures to help ensure team success. The Team Lead is instrumental in onboarding new team members, monitoring quality, triaging assignments, and leading designated projects. Acting as the first point of contact for clinical issues, the Team Lead provides guidance and support to staff while maintaining open communication with leadership.

Required Qualifications: Behavioral Health License in State of Kentucky or Registered Nurse license in State of Kentucky or Compact RN 5+ years of clinical practice experience in physical or behavioral healthcare. 2+ year’s managed care experience is required 2+ years of experience with personal computer, keyboard navigation, and MS Office Suite applications. 2+ years of healthcare management experience required (preferably in a managed care setting) Ability to work core business hours, Monday-Friday, 8am-5pm, with flexibility to work occasional weekend hours is required. Ability to provide on-call UM coverage for nights and weekends on a rotational schedule Education: Master's Level of Education resulting in independent Behavioral Health licensure (LCSW, LPCC, LMFT, LPAT, LP) Registered Nurse (RN) with unrestricted state license with psychiatric specialty, certification, or experience.

Additionally, the Team Lead actively contributes to team meetings and fosters a collaborative work environment. Responsibilities include, but are not limited to: Promoting teamwork and collaboration across the department Serving as a knowledgeable resource and mentor to team members Modeling best practices in clinical standards, quality, and critical thinking Supporting adherence to plan sponsor performance goals Assisting in the development and implementation of policies and procedures Encouraging continuous improvement through critical thinking and feedback Providing performance insights and coaching to enhance team effectiveness Upholding company values, especially regarding confidentiality Communicating clearly and effectively with diverse audiences Managing tasks with strong organizational and prioritization skills Supporting a positive, team-oriented work culture Assisting supervisors as needed Maintaining responsibility for individual caseloads, as applicable Responding to inquiries and resolving issues promptly Performing sedentary work, including extended periods of sitting, computer use, and document review

Visiting Nurse Service of New York d/b/a VNS Health

RN Clinical Supervisor, Hospice Intake

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

New York

VNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us — we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.

Oversees, supervises, coordinates, facilitates and supports all aspects of the Hospice Liaison Intake process. Establishes and maintains relationships with customers and referral sources. Ensures the care directed to acute symptom management is provided within the standards of practice for all clinical disciplines. Demonstrates knowledge and commitment to excellence in clinical practice and customer service. Works under general direction.

License and current registration to practice as a Registered Professional Nurse in the state of New York required Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs Education: Bachelor's Degree in Nursing required Work Experience: Minimum of three years of progressive clinical experience in home care, Hospice or related field required Demonstrated knowledge of the regulatory and reimbursement requirements governing Hospice preferred Effective oral/written communication and interpersonal skills required Prior experience managing multiple teams/staff located in multiple locations required

Engage in compassionate goals-of-care conversations with patients and families who are uncertain about hospice, providing clear, empathetic explanations of available services and guiding them through the transition from curative to comfort-focused care. Serve as the primary clinical liaison for high need patients referred from priority accounts, including physician practices, ensuring a high-touch, responsive experience throughout the intake process. Available to patients to families over time as a resource and navigator in care, providing clinical oversight and support to ensure continuity of care and timely response to patient and referral needs. Supervises the day to day operations of the onsite and remote intake operations, including onsite visits, as needed. Ensures effective triaging of new referrals/admissions and reinforces implementation of new initiatives (i.e. electronic and real time communication with team). Assists administration to ensure full regulatory compliance with Hospice Conditions of Participation, standards of practice, compliance with VNS Hospice policies and procedures and contractual services. Collaborates with Quality Improvement/Education in the development and implementation of quality improvement and educational activities to ensure professional practice standards are consistently met for each member of the interdisciplinary team. Works effectively with administration to design, implement, evaluate and modify quality initiatives and educational plan as directed and appropriate. Communicates effectively with VNS Hospice Care management and hospice agencies under contractual relationship with VNSNY Hospice Care. Serves as an effective member of the clinical team demonstrating teamwork, effective supervision and collaboration at all times. Performs all duties inherent in a supervisory role in collaboration with the Hospice Team Manager. Ensures effective staff training, interviews candidates for employment, evaluates staff performance, and recommends hiring, promotions, and terminations, as appropriate. Participates in special projects and performs other duties as assigned.

Iowa Total Care

Supervisor, Care Management - LTSS

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Iowa

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. ***Remote role with field based travel. Preferred candidate may reside in either Muscatine County, Linn County or surrounding areas. ***

Education/Experience: Requires a Bachelor's degree and 4+ years of related experience. Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position. License/Certification: For Iowa Only: Bachelor's degree with 30 semester hours or equivalent quarter hours in a human services field (including, but not limited to, psychology, social work, mental health counseling, marriage and family therapy, nursing, education, occupational therapy, and recreational therapy) and at least four years of experience in the delivery of services to the population groups or current state's Registered Nurse (RN) license and at least six years of experience required

Position Purpose: Supervises the care coordination team that serves long-term care members to promote quality and efficacy of care management delivery. Supervises day-to-day escalations and care management issues related to members or providers. Monitors and reviews long-term care management required documentation to maintain and ensure compliance with federal and state regulations and contractual agreements Assigns caseloads and work assignments to long-term care management team based on state requirements, care management staff experience, and member needs Works with long-term care senior management on escalated and complex care cases, and provides guidance to junior team members to address member concerns Educates and provides resources for long-term care management team on key initiatives and member outreach to facilitate on-going communication between care management team, members, and providers Evaluates long-term care management team performance and provides feedback regarding performance, goals, and career milestones Provides coaching and guidance to long-term care management team to improve member and provider experience and facilitate delivery of high-quality care Assists with onboarding, hiring, and training long-term care management team members Leads and champions change within scope of responsibility Performs other duties as assigned Complies with all policies and standards

UnitedHealthcare

Utilization Review Nurse, LTSS and HCBS - Remote in Michigan

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Michigan

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 Utilization Management Nurse is responsible for conducting clinical reviews and authorizations for LTSS and HCBS services. This role ensures that members receive medically necessary, cost-effective, and person-centered care in the least restrictive environment. The nurse collaborates with interdisciplinary teams, care managers, and providers to support member goals and improve health outcomes. If you reside in Michigan, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Active and unrestricted RN license in the state of Michigan 3+ years of clinical experience 1+ years of experience in LTSS, HCBS, or managed care Solid knowledge of Medicaid programs, HCBS waiver services, and person-centered planning Proficiency in clinical documentation systems and utilization management platforms (e.g., ICUE, Community Care, OCM) Proven excellent communication, critical thinking, and organizational skills Must reside in Michigan Preferred Qualifications: Certified Case Manager (CCM) Utilization Management certification Experience with D-SNP or similar Medicaid managed care programs Familiarity with risk stratification tools and interdisciplinary care planning Demonstrated ability to work independently and manage multiple priorities in a fast-paced environment

Review and process prior authorization requests for LTSS and HCBS services including Personal Care Services (PCS), Home and Environmental Modifications and others Apply clinical judgment and decision support tools to determine medical necessity and appropriateness of services. Participate in secondary reviews for complex cases, including transitions between community and institutional settings. Collaborate with care managers, physicians, and other stakeholders to ensure continuity of care and alignment with the member’s service plan. Monitor utilization patterns and identify opportunities for improved care coordination and cost containment. Document all clinical decisions and communications in accordance with regulatory and organizational standards. Stay current with federal and state regulations, including 42 CFR Part 456 and CMS guidelines for HCBS and LTSS. Support quality improvement initiatives and participate in audits and compliance reviews. Participate in annual Inter-Rater Reliability testing and pass with a score of 90% or higher Appropriately identifies the need for secondary reviews or case consultations with the Medical Director Documents concise case reviews Apply relevant regulatory requirements to ensure compliance with clinical documentation. Identify potential quality of care concerns, including instances of over/or underutilization of services and escalate these issues as needed. Participate in state or plan-required audits and comply with all reporting requirements by area of responsibility

Trinity Health

Clinical Documentation Specialist Audit Coordinator (Remote)

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Michigan

Work Remote Position Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review. Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.

Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) or related education and experience. Must possess one of the below: Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP). Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, related field, or as an inpatient coder preferred. Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team. Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation. Ability to use other software as required to perform the essential functions on the job. Experience with databases, spreadsheet software and presentation software preferred. Data entry skills and typing skills at minimum 30 wpm. Must be comfortable operating independently and in a collaborative environment. Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Trinity Health. PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles. Must possess the ability to comply with Trinity Health policies and procedures. Must be able to spend majority of work time utilizing a computer, monitor and keyboard. Must be able to work with interruptions and perform detailed tasks. Ability to concentrate and read for long periods of time. Ability to work in an onsite and virtual environment. Must possess a valid driver’s license and be able to travel to the various Trinity Health sites (10%) as needed.

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions. Demonstrates understanding of appropriate clinical documentation to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes. Serves as a resource for appropriate clinical documentation. Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement. Identifies learning opportunities for healthcare providers. Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation. Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures. Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities. Codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR). Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care. Resolves all discrepancies in a courteous manner. Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors. Leverages the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness. Performs other duties as assigned by leadership. Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

BlueCross BlueShield of South Carolina

RN Managed Care Coordinator II CM-DM

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

South Carolina

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior) — making us the only health insurance company in South Carolina with that rating. We’re the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

We are currently hiring for a Managed Care Coordinator II to join BlueCross BlueShield of South Carolina. In this role as a Managed Care Coordinator II, care management interventions focus on improving care coordination and reducing the fragmentation of the services the recipients of care often experience, especially when multiple health care providers and different care settings are involved. Taken collectively, care management interventions are intended to enhance client safety, well-being, and quality of life. These interventions carefully consider health care costs through the professional care manager's recommendations of cost-effective and efficient alternatives for care. Thus, effective care management directly and positively impacts the health care delivery system, especially in realizing the goals of the "Triple Aim," which include improving the health outcomes of individuals and populations, enhancing the experience of health care, and reducing the cost of care. The professional care manager performs the primary functions of assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy. Integral to these functions is collaboration and ongoing communication with the client, client's family or family caregiver, and other health care professionals involved in the client's care. Location: This position is full-time (40-hours/week) Monday-Friday from 8:30am-5:00pm and will be fully remote.

Required Education: Associate's in a job related field. Degree Equivalency: Graduate of Accredited School of Nursing or 2 years job related work experience. Required Experience: 4 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical. Required Skills and Abilities: Working knowledge of word processing software. Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools: Microsoft Office. Required License/Certificate: An active, unrestricted RN license from the United States and in the state of hire OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) OR, active, unrestricted licensure as social worker from the United States and in the state of hire (in Div. 6B) OR, active, unrestricted licensure as counselor, or psychologist from the United States and in the state of hire (in Div. 75 only). For Div. 75 and Div. 6B, except for CC 426: URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager. What We Prefer You to Have: Preferred Education: Bachelor's degree- Nursing Preferred Work Experience: 7 years-healthcare program management. Prior case management experience. Prior experience working with insurance companies. Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. Preferred Licenses and Certificates: Case Manager certification, clinical certification in specialty area.

Provides active care management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions that consist of: intensive assessment/evaluation of condition, at-risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement. Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. May identify, initiate, and participate in on-site reviews. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.

UnitedHealthcare

Field Care Coordinator, RN - Remote in Multiple Locations, WA

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Washington

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.

If you want to achieve more in your mission of health care, you have to be really smart about the business of health care. As a Case Manager working with Medicaid members you’ll wear many hats, and work in a variety of environments. Sometimes, you’ll interact with members leaving the hospital – possibly with new medications or diagnoses. Or perhaps you’ll perform home visits, assisting members with safe, effective transitions from care environments to where they live. You may also act as an intermediary between providers and members – serving in numerous roles, such as educator, evaluator, service coordinator, community resource researcher and more. The result? Fewer hospitalizations, ER visits and costly service gaps; and a less stressed, more effective health care system for us all. Want more flexibility, want more autonomy? Work from your own home and coordinate a visiting schedule that is mutually beneficial to you and the members we serve. What makes your clinical career greater with UnitedHealth Group? You’ll work within an incredible team culture; a clinical and business collaboration that is learning and evolving every day. And, when you contribute, you’ll open doors for yourself that simply do not exist in any other organization, anywhere. If you are located in or within commutable driving distance to Snohomish, King or Pierce Counties in Washington, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Current, unrestricted RN or behavioral health license in State of Washington 2+ years clinical experience in a hospital, acute care, home health/hospice, direct care or case management 1+ years of experience directly working with individuals with special healthcare needs Computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications Access to high speed internet from home Reliable transportation, a valid driver’s license, and the ability to travel up to 50% within a designated territory Reside in or within commutable driving distance from Seattle, Everett, Tacoma, Washington Preferred Qualifications: Bachelor’s degree or greater Certification in Case Management (CCM) 2+ years of clinical experience in a behavioral health setting Case Management experience Home care/field-based case management experience Medicaid, Medicare, Managed Care experience Experience with vulnerable subpopulations include children and youth with special health care needs, adults with serious mental illness, members with substance use disorders and members with other complex or multiple chronic conditions

Provide a complete continuum of quality care through close communication with members via phone interaction or in-person interaction Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels Assist members with the transition from a care facility back to their home May require some field work- meeting members in homes, facilities if difficult to engage telephonically or at the request of management Meet NCQA Population Health Management Standards Meet state-specific contractual requirements related to the delivery of care management

University Hospitals

Clinical Documentation Specialist (CDI), Professional Fee (Remote)

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

The Professional Fee Clinical Documentation Specialist (CDS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity, risk profiles and appropriate E/M levels thereby supporting the provider’s efforts and their professional fee billing. The CDS primarily assist providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient acuity. The Professional Fee CDS will focus on the recapture and identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs), which directly impact the patient risk adjusted profile (RAF score) calculated by the associated risk plans. They will also assist with highlighting opportunities based on the provider’s medical decision making to appropriately reflect the level of service provided for patient care. The Professional Fee CDS will be responsible for completing pre-visit and post-claim reviews as well as providing clear communication and education to providers on their documentation, coding and billing practices, in adherence to compliance standards set by governing entities such as CMS, AHA, etc.• Pre-visit reviews are intended to identify documentation opportunities for the provider to recapture previously documented HCCs diagnoses, or new suspect conditions not previously captured that are identified by the CDS’s comprehensive chart reviews. These efforts assist in establishing accurate risk profiles and related health care costs• Post-claim reviews focus on E/M encounters and highlight opportunities based on a provider’s medical decision making and the patient’s acuity to support appropriate and accurate E/M level assignments as well as any HCCs identified• The Professional Fee CDS will also coordinate with colleagues from the CDI Program or other members of the organization regarding education and training geared towards improving clinical documentation based on findings from pre-visit and post-claim reviews

Education: High School Equivalent / GED (Required) Associate’s Degree (Preferred) Work Experience: 3+ years Coding and/or clinical documentation integrity (Required) Hierarchical Condition Categories (HCC) experience (Preferred) Knowledge, Skills, & Abilities: Extensive clinical knowledge and understanding of pathophysiology (Required proficiency) Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators supporting patient acuity and clarifications of the medical record (Required proficiency) Excellent written and verbal communication skills (Required proficiency) Strong project management skills (Required proficiency) Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization (Required proficiency) Ability to work independently in a time-oriented environment (Required proficiency) Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred) (Required proficiency) Proficient with personal computer applications (Excel, Word, and Power Point) (Required proficiency) Ability to build education material that is meaningful for providers and team members (Required proficiency) Strong problem solving and investigative skills (Required proficiency) Licenses and Certifications: Certified Coding Specialist (CCS) (Required) or Certified Professional Coder (CPC) or CRC, or other coding or CDI credential (Required) Registered Nurse (RN), Ohio and/or Multi State Compact License or Licensed Practical Nurse (LPN), Ohio and/or Multi State Compact License (Preferred)

Coordination with Professional Fee CDI Program leadership and colleagues. Fosters teamwork and utilizes strong team building measures Performs pre-visit chart reviews to assist in highlighting relevant documentation and diagnoses in compliance with governing policies and industry guidelines. Applies a “clinical detective” mindset to identify new HCC diagnosis capture opportunities based on appropriate clinical indicators for the patient. Also performs post-claim reviews focused on appropriate E/M level assignments and any opportunities related to level of service and HCCs. Uses performance and outcome data from third-party support or other sources to identify high priority providers Creates specialty-specific education on relevant topics as identified in data analytics and from clinical encounter reviews and post-claim education chart reviews Develops and maintains a systematic education schedule and approach for providers in the hospital and clinic/office setting including but not limited to complete documentation, appropriate diagnosis code selection, E/M level assignments and updates to coding guidelines. Delivers ongoing feedback and education to communicate importance of complete documentation and key concepts during regular clinic or provider meetings or on individual basis, as needed Upholds working knowledge and stays current on latest CMS and industry guidelines, with specific understanding of HCCs and implications for documentation Maintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelines Additional Responsibilities: Shares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive to its mission. Demonstrates knowledge of and follows departmental and hospital policies and physician office procedures Seeks out opportunities for individual growth and development, including attending various meetings, conferences, courses, seeking certifications, as required. Uses tact and sensitivity when communicating with patients, visitors, co-workers, and other personnel Serves on department and/or institutional committees as requested Performs other duties as assigned. Complies with all policies and standards. For specific duties and responsibilities, refer to documentation provided by the department during orientation. Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

Florida State University

Registered Nurse - Young Parents Project (Miami, FL)

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Florida

One of the nation's elite research universities, Florida State University preserves, expands, and disseminates knowledge in the sciences, technology, arts, humanities, and professions, while embracing a philosophy of learning strongly rooted in the traditions of the liberal arts and critical thinking. Founded in 1851, Florida State University is the oldest continuous site of higher education in Florida. FSU is a community steeped in tradition that fosters research and encourages creativity. At FSU, there’s the excitement of being part of a vibrant academic and professional community, surrounded by people whose ideas are shaping tomorrow’s news!

Qualifications: Bachelor's Degree and two years of experience. Registered Nurse (RN) License. A valid State of Florida Driver’s License or the ability to obtain prior to hire. Preferred Qualifications: Master's Degree. Previous experience working with court-involved youth. International Board-Certified Lactation Consultant (IBCLC).

Responsible to providing nursing care including an independent assessment of the health and well-being of the young mother and child. Ensures the establishment of a medical home and communicates with the family's medica provider as needed. Utilizes knowledge of infant development, attachment, early emotional development, parent-child relationships and the impact of trauma on the teen's willingness to access health care, the birth experience, and parenting. Educates about reproductive health, pre-post-natal care, nutrition, labor and delivery, child health and development, safety/injury prevention, and family planning. Provides observation and screening of baby's development. Responds to crisis situations in the home, to triage and coordinate with other mental health and/or medical providers as needed including emergency service to ensure the optimal health and safety of the young mother and baby. Works with providers in the community for appropriate treatment or referral for treatment, regarding perinatal and adolescent health, family planning, well-baby, sick child, and immunization visits. This position is required to transport project participants and their children in their personal vehicles to essential community services/appointments and supports/educates the teen during visits. Coordinates home visits as part of the professional team working with the Infant Mental Health Specialist, the Project Director and FSU Faculty. Participates in joint case reviews and team meetings to develop and coordinate goals for change for the teen and baby. Receives supervision/consultation regarding the Nurse's role in the Minding the Baby replication model. Ability to maintain accurate records. Documents within timeframes - work schedule, progress notes, screening and assessments, primary care and infant immunizations, and medical updates. Provides medical information in a timely manner for reports. Contributes to the development of manuals and training materials, particularly related to the medical needs of your families. Attends training to increase knowledge/skills as requests. Shares lessons learned from experience in working with teen parents and children with others in the field. Completes tasks as assigned by the Team Leader/Project Director. Co-Facilitate 20-Hour Breastfeeding Counselor Course and/or Partners for a Healthy Baby curriculum training virtually or in person.

Optum

Orthopedic Nurse Case Manager RN - Remote

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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.

As a part of our continued growth, we are recruiting for a RN Case Manager for the Orthopedic Health Support team. In this role you will be responsible for the clinical management across the continuum of care for members with musculoskeletal (neck, shoulder, back, hip and knee) conditions. Schedule: Monday – Friday, Normal business hours in your time zone, also includes 2 nights per month until 8pm You’ll enjoy the flexibility to work remotely* from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Current, unrestricted RN license in your state of residence Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses 3+ years of recent orthopedic experience where working with orthopedic patients was your main responsibility working with neck, shoulder, back, hip and knee conditions educating patients/members on physical therapy, occupational therapy, pre and post operations Computer proficiency including the ability to type and talk at the same time and to navigate within Microsoft Windows Access to high-speed internet from home (Broadband cable, Fiber or DSL) Dedicated workspace from home Preferred Qualifications: Compact RN License 7+ years of Orthopedic experience working with neck, shoulder, back, hip and knee conditions as the main part of your job Experience with pain management both acute and chronic Physical therapy experience Occupational therapy experience Experience with weight management Conservative orthopedics experience Surgical orthopedics experience

Provide information to members to facilitate an improved care experience which includes illustrating cost savings, highest quality pairing of a center of excellence and surgeon, and ensuring a seamless administrative experience Telephonic Case Management which includes assessments in the pre-operative and post-operative phases of Orthopedic surgery to ensure positive outcomes Identifying gaps in treatment plans and coordinate ongoing care with providers Provide patient education to encourage self-management and healthy lifestyle change Works with minimal guidance; seeks guidance on only the most complex tasks Coaches, provides feedback, and guides others Acts as a resource for others with less experience

Superior HealthPlan

Senior LTSS Service Care Manager, RN

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Registered Nurse Case Manager needed in West Texas: Reside near Haskell, Munday, Throckmorton, Seymour, Stamford, or Wichita Falls, TX. Schedule: Monday - Friday: 8:00 am - 5:00 pm (CST)

Education/Experience: Requires Graduate from an Accredited School of Nursing or a Bachelor's degree and 4–6 years of related experience. Bachelor's degree in Nursing preferred License/Certification: RN - Registered Nurse - State Licensure and/or Compact State Licensure required For Superior: Resource Utilization Group (RUG) certification must be obtained within 90 days of hire required Preferred Experience: Clinical Registered Nurse with experience in Acute Care settings – Critical Care, Home Health, Hospice, Multi-Specialty ICU, (MSICU), Med/Surg, Internal Medicine, LTC, SNF, or Nursing Rehab RN Case Management and/or RN Care Coordination with medical services/DME for adult members Clinical knowledge and ability to determine overall health of members including treatment needs and appropriate level of care for complex medical conditions Must be able to navigate between multiple databases, screens, Microsoft Office applications (e.g. Outlook, Excel, One Note, MS Teams, ZOOM video conferencing) Strong clinical assessment and critical thinking skills required to communicate with clinical staff, members, and providers Direct Managed Care with Government or State sponsored health programs is a plus, but not required

Position Purpose: Performs care management duties to assess and coordinate all aspects of medical and supporting services across the continuum of care for complex/high acuity populations with primary medical/physical health needs to promote quality, cost effective care. Develops a personalized care plan / service plan for long-term care members, addresses issues, and educates members and their families/caregivers on services and benefit options available to receive appropriate high-quality care. Evaluates the service needs of the most complex or high risk/high acuity members and recommends a plan for the best outcome Develops and continuously assesses ongoing long-term care plans / service plans and collaborates with care management team to identify providers, specialists, and/or community resources needed to address member's needs Coordinates and manages as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services Monitors care plans / service plans and/or member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / needs Monitors member status for complications and clinical symptoms or other status changes, including assessment needs for potential entry into a higher level of care and/or waiver eligibility, as applicable Reviews member data to identify trends and improve operating performance and quality care in accordance with state and federal regulations Reviews referrals information and intake assessments to develop appropriate care plans / service plans Collaborates with healthcare providers as appropriate to facilitate member services and/or treatments and determine a revised care plan for member if needed Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and clinical guidelines Provides and/or facilitates education to long-term care members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits Acts as liaison and member advocate between the member/family, physician, and facilities/agencies Educates on and coordinates community resources. Provides coordination of service authorization to members and care managers for various services based on service assessment and plans (e.g., meals, employment, housing, foster care, transportation, activities for daily living) May perform home and/or other site visits (e.g., once a month or more), such as to assess member needs and collaborate with resources, as required Partners with leadership team to improve and enhance quality of care and service delivery for long-term care members in a cost-effective manner May precept clinical new hires by fostering and building core skills, coaching and facilitating their growth, and guiding through the onboarding process to upskill readiness May provide guidance and support to clinical new hires/preceptees in navigating within a Managed Care Organization (MCO) and provides coaching and shadowing opportunities to bridge gap between classroom training and field practice May engage and assist New Hire/Preceptee during onboarding journey including responsibility for completing competency check points ensuring readiness for Service Coordination success Engages in a collaborative and ongoing process with People Leaders and cross functional teams to measure and monitor readiness Performs other duties as assigned Complies with all policies and standards

St. Peter's Health Partners

RN Coding - Eddy Visiting Nurse and Rehab Association

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

New York

Eddy Visiting Nurse and Rehab Association has a rewarding opportunity for Nurse who is Coding and OASIS certified and understands Homecare regulations. Position must review and understand both. This role is hybrid/remote position with flexible Days and Hours! Enjoy the independence of working a hybrid/remote scheduled! Oversight and training are provided, with a full-team approach! Be a part of an agency that focuses on quality for our patients! If you are someone that has these skills or close to accomplishing, please consider applying!

Must understand homecare regulations in New York State Must have started or completed coding training and certification EPIC EMR knowledge a plus Valid NYS driver’s license and proof of current certifications Valid professional License. Organized, strong communication skills

Cedars-Sinai

Nurse Navigator - Digestive Disease - 8 Hour Days

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

At Cedars-Sinai, we are dedicated to encouraging an inclusive and encouraging workplace where your skills and ambitions will be nurtured. We provide fair compensation and benefits packages, professional growth opportunities, and the chance to create a profound impact on the lives of our patients. Join us in our mission to provide world-class healthcare and be part of a team that strives for excellence in every aspect of patient care.

At Cedars-Sinai, we offer an outstanding opportunity for a motivated and dedicated Digestive Disease Pancreatic Nurse Navigator to join our world-class team in Los Angeles, CA. This role is crucial in providing compassionate, comprehensive care to our pancreatic patients, ensuring they receive the highest standard of support throughout their treatment journey. You will have the chance to work alongside groundbreaking medical professionals in a collaborative environment that values your expertise and dedication.

A valid Registered Nurse (RN) license in the state of California. A minimum of 3 years of nursing experience, preferably in oncology or a related field. Proven expertise in patient navigation or case management is highly desired. Outstanding communication and interpersonal skills to effectively interact with patients, families, and multidisciplinary teams. Strong organizational abilities and the capacity to prioritize effectively in a fast-paced environment. A compassionate and empathetic approach to patient care. Ability to successfully implement patient-centered care plans and adapt to changing patient needs. Dedication to promoting inclusivity and collaborating within a diverse and dynamic team. Education: BSN required License/Certification: Current, unrestricted California RN license required BLS from the American Heart Association required Specialty certification required or willing to obtain within 12 months from start date (for external hires) Experience: A minimum of 5 years of experience as a Registered Nurse preferred Experience using Epic charting software required Experience with Pancreatic Biliary preferred

As a Nurse Navigator, you will be instrumental in guiding patients through the complexities of their diagnosis and treatment. Your primary responsibilities will include: Providing individualized patient education and support to help patients understand their diagnosis, treatment options, and care plans. Coordinating with multidisciplinary teams to ensure seamless, flawless care delivery. Monitoring patient progress and outcomes to strictly ensure the highest levels of patient safety and quality care. Acting as a liaison between patients, families, and healthcare providers to facilitate effective communication and collaboration. Developing and implementing patient care plans that are tailored to meet the outstanding needs of each patient. Assisting in the scheduling of appointments, procedures, and follow-ups to ensure timely access to care. Advocating for patients to ensure they receive necessary services and support. Participating in continuous professional development and staying current with advances in pancreatic care.

Cedars-Sinai

Structural Heart Nurse Navigator

Posted on:

August 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

Cedars-Sinai, ranked among the top hospitals in the nation, is seeking an experienced cardiovascular registered nurse to serve as a Structural Heart Nurse Navigator within the Interventional Cardiology department! This role is designed for a highly organized and meticulous nurse who excels in patient care coordination, workflow optimization, and electronic patient tracking.

The Structural Heart Nurse Navigator will play a critical role in managing patient progression from referral through consultation, diagnostic testing, intervention, and post-procedure follow-up. This position requires strong collaboration with physicians, nurse practitioners (NPs), schedulers, and researchers to ensure timely and efficient patient care.

Registered Nurse (RN) with cardiovascular experience required: Minimum of three years of experience in cardiovascular nursing, case management, or care coordination. Experience with Epic workflows, patient tracking systems, and national registry documentation. Strong ability to coordinate multidisciplinary teams and manage complex patient workflows. Highly organized with strong attention to detail and problem-solving skills. License/Certification: Current, unrestricted California RN license required BLS from Red Cross or American Heart required Specialty certification required or willing to obtain within 12 months from start date Experience: A minimum of 5 years of experience as a Registered Nurse preferred Experience using Epic charting software required

Patient Coordination and Navigation: Serve as the primary liaison for patients undergoing structural heart interventions, ensuring all necessary steps are completed. Work closely with nurse practitioners, physicians, researchers and scheduling staff to facilitate smooth patient transitions from referral to treatment. Identify and address barriers to care, improving patient access and adherence to scheduled appointments. Structural Heart Patient Tracking and Electronic Management: Oversee and maintain the Structural Heart Patient Tracking (SHPT) system to ensure accurate and timely updates on patient status. Monitor patient progression through electronic tracking tools, ensuring all diagnostic and procedural requirements are met. Proactively manage pending interventions, flagging cases that require follow-up or additional scheduling coordination. Compliance and Registry Management: Support compliance with the TVT Registry and ensure completion of reporting measures such as the Kansas City Cardiomyopathy Questionnaire (KCCQ), 5-Meter Walk Test (5MWT), echocardiogram (ECHO), and electrocardiogram (EKG). Identify gaps in documentation and work with scheduling and clinical teams to ensure compliance with national reporting standards. Assist in developing workflow optimizations and supporting Epic integration efforts to enhance automation and efficiency. Multidisciplinary Collaboration: Serve as a central resource for the Structural Heart Program team, ensuring clear communication and coordination of patient care. Work closely with researchers to ensure clinical trial participation is accurately tracked. Provide input on workflow improvements to enhance patient throughput and reduce loss to follow-up.

Northeast Georgia Health System

Registered Nurse RN - Clinical Documentation Improvement Specialist - CDIP ACDIS AHIMA - Mon - Fri 8:00am - 5:00pm - Remote

Posted on:

August 3, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Georgia

Northeast Georgia Health System (NGHS) is a non-profit on a mission of improving the health of our community in all we do. Our team cares for more than 1 million people across the region through five hospitals and a variety of outpatient locations. Northeast Georgia Medical Center (NGMC) has campuses in Gainesville, Braselton, Winder, Dahlonega and Demorest – with a total of more than 850 beds and more than 1,200 medical staff members representing more than 60 specialties. Learn more at www.nghs.com.

Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with Physicians, Nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer (Medicare, Blue Cross, other payors as determined by CDI departmental goals). Ensures the accuracy and completeness of clinical information used for measuring and reporting Physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis.

Minimum Job Qualifications: Licensure or other certifications: Current RN Licensure in the State of Georgia. Educational Requirements: Associates Degree Minimum Experience: Five (5) years in the practice of professional nursing. Preferred Job Qualifications: Preferred Licensure or other certifications: CCDS or CDIP Preferred Educational Requirements: Bachelor's Degree in Nursing. Additional education in Finance, Healthcare regulations and diagnoses-procedure coding. Preferred Experience: Experience in Healthcare Utilization and Revenue Management.

Demonstrates aptitude in critical care or medical-surgical nursing Must demonstrate excellent observation skills, analytical thinking, problem-solving abilities, and excellent written and verbal communication by organizing work priorities and following standard of work Working knowledge of DRG coding optimization strategies and clinical documentation requirements are helpful Demonstrates interpersonal skills including professionalism practicing positive approaches to the position The position requires computer skills and the ability to be self-directed Familiar with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, coding software (preferably 3M 360 Encompass) Leadership skills are required Maintains requirements contained in Remote Agreement or forfeit the opportunity Essential Tasks and Responsibilities: Improves the overall quality and completeness of clinical documentation by performing admission / continued stay reviews using the Compliant Documentation Program Management (CDMP) guidelines. Facilitates modifications to clinical documentation to ensure that appropriate severity of the patient is documented and to ensure appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer (Medicare, Blue Cross and others as determined by CDI program goals) Conducts on-going follow-up reviews to ensure points of clarification have been recorded in the patient's medical record using department standard work to set workflow priority and scheduling.. Works with Physicians concurrently, during the patient's stay, to educate and receive specific documentation pertinent to all requirements in question. Refers questionable quality, patient safety indicators, and utilization concerns to CDI Director, nursing and case management as indicated Writes queries to provide professional clinical inquiry about missing documentation (clinical indicators, diagnoses, or more descriptive) for conversion to codable terms following compliant, non leading format. Monitors the documentation against "core measure" quality indicators and addresses non-compliance documentation with Physicians and other appropriate staff. Interacts on a regular basis with Physician, nursing and case managers to ensure continuity of documentation. Works collaboratively with the coding staff to assign the "working" DRG to contribute for IDT Rounds. Processes all discharges by updating the DRG worksheet to reflect changes in patient status, procedures and/or treatments and concurs with the attending Physician to finalize diagnoses. Maintains a leadership role to ensure specific and compliant documentation is achieved recognizing its use in quality measures and reporting medical center and Physician outcomes. Educates various customer audiences on clinical documentation opportunities, coding, reimbursement and performance methodologies. Ensures documentation is meeting "medical necessity" for specific level of care and that services provided to the patient has a reasonably beneficial effect; refers cases to Utilization Review as indicated. Demonstrates a working knowledge of the DRG system and coding guidelines to facilitate recovery of appropriate payments for services rendered. Utilizes results of DRG analysis to have on-going dialogue with Physicians, nurses, coders, and case managers, to improve overall knowledge and performance. Participates in efforts to contain cost and/or generate revenue. Submits written ideas for reducing cost or adding revenue. Organizes and performs work effectively and efficiently by achieving daily reviews as assigned. Maintains and adjusts schedules to meet team performance and is willing to change workload or assignments as indicated. Meets assigned deadlines and departmental productivity standards. Assists with special projects as needed and all other duties as assigned. Maintains requirements in Remote Agreement in order to retain work from home opportunity. Work collaboratively with CDI team members to complete daily work of the team.

CVS Health

Case Manager Registered Nurse

Posted on:

August 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Arizona

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 Case Manager RN position is 100% remote, no travel is expected with this position. Normal Working Hours: Monday through Friday, 8 hour shift between 7am to 5pm Arizona time The Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management activities with members from our Federal Plans. The Case Manager is responsible to evaluate the medical needs of the member in order to facilitate and promote the member’s overall wellness. The Case Manager develops a proactive course of action to address issues presented to enhance the member's short and long term outcomes.

Required Qualifications: Must have active, current and unrestricted RN licensure in state of residence and have the ability to be licensed in all non-compact states. Must be willing and able to work Monday through Friday, 8 hour shift between 7am to 5pm Arizona time 3+ years of clinical practice experience required 1+ years of experience utilizing MS Office suites Preferred Qualifications: Case management experience preferred Case Manager Certification Education: Associate's degree required BSN preferred

Apply data driven methods of identification of members to fashion individualized case management programs and/or referrals to alternative healthcare programs. Conduct comprehensive clinical assessments. Evaluate needs and develop flexible approaches based on member needs, benefit plans or external programs/services. Advocate for patients to the full extent of existing health care coverage. Promote quality, cost effective outcomes, and make suggestions to improve program/operational efficiency. Identify and escalate quality of care issues through established channels. Provide an expected very high level of customer service. Utilize assessment techniques to determine member’s level of health literacy, technology capabilities, and/or readiness to change. Utilize influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health.

Sentara Healthcare

Supervisor, Integrated Care Utilization Management - Remote

Posted on:

August 3, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

Sentara and many other companies across the US are being targeted by cyber criminals who are impersonating representatives of the company, claiming to have job offers. Sentara will never ask you for banking or personal identification information via email or text. We will never ask an applicant to pay money for training, supplies, or other so-called expenses. If you suspect you have received a fraudulent job offer, e-mail taadmin@sentara.com. Award-winning: Sentara is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering more than 500 sites of care including 12 hospitals, PACE (Elder Care), home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan. The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years. U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years. Sentara offers professional development and a continued employment philosophy!

Sentara Health is currently seeking a full-time remote Supervisor, Integrated Care Utilization Management. Position Status: Full-time, Day Shift Remote opportunities available in the following states: Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington (state), West Virginia, Wisconsin, Wyoming Standard Working Hours: Monday – Friday, 8:00AM – 5:00PM EST.

Education: Bachelor's degree in Nursing Required Certification/Licensure: Registered Nurse Licensure in the state of Virginia (or compact/multi-licensure) Required Experience: Case Management – 3 years Required Previous supervisory expiree Required Must have utilization management experience and a background in long term serviced and support (LTSS)

Assumes responsibility, accountability and leadership for the daily operations including coordination of work, quality, and service. First line supervisor in the Department of Medical Care Management for assigned site/function. Facilitates the work of assigned team members. Provides a leadership role in ongoing case manager competency assessment, needs identification and educational offerings. Provides educational services to the Medical Care Management staff. Participates in the work activities of assigned teams and provides case management services as needed. For Integrated Care Management departments, specialty certification required within one year of eligibility (ACM, CCM, CCCTM or RN-BC). For other service lines, certification based on specialty area required within one year of eligibility. BLS (if in a clinical setting).

Optum

RN, Preservice Review Nurse - Remote

Posted on:

August 3, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

We’re making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that’s driving the health care industry forward. As a Telephonic Specialty Medication Preservice Review Nurse you will be performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of outpatient services following evaluation of medical guidelines and benefit determination. Ready for a new path? Apply today! You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Current, unrestricted RN license in your state of residence Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses 3+ years of recent RN experience Computer proficiency, to include proficient data entry skills and the ability to navigate a Windows environment Distraction free, Dedicated workspace with access to high-speed internet from home (Broadband cable, Fiber, or DSL) Preferred Qualifications: BSN Compact RN license Experience working with ICUE Experience working with prior authorizations for medications ICD Coding experience or solid knowledge of codes Specialty medication experience Background in preservice review/utilization review/utilization management/Prior Authorizations Background in managed care IL Resident

Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial) Validate that cases/requests for services require additional research Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources) Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited) Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity) Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports) Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax) Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., PNL list, EPAL list, state grid, LCDs, NCDs) Identify and validate usage of non-standard codes, as necessary (e.g., generic codes) Apply understanding of medical terminology and disease processes to interpret medical/clinical records Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research) Review care coordinator assessments and clinical notes, as appropriate Identify relevant information needed to make medical or clinical determinations Identify and utilize medically-accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical

Asante Health System

Clinical Appeals Specialist (Patient Accounting)- Remote

Posted on:

August 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Oregon

Clinical Appeals Specialist (Patient Accounting)- Remote Additional Position Details: FTE: 1.000000 | Full Time | Primarily Mon - Fri / 8AM - 5PM Please Note: This is a remote position. Candidates will be required to have reliable broadband internet and personal cell phone service. Remote work may include online training and working day-to-day operations during Pacific Standard business hours. Starting Wage: $36.79-$50.59 per hour, depending on experience

Minimum 3 years of Clinical RN experience, including 1 year of Denial Management OR Case Management OR related experience AND 1 year of current experience with reimbursement methodologies, required RN: Registered Nurse licensed by the Oregon State Board of Nursing OR RN (Registered Nurse) with an active license in a state approved for remote work in this position, required Bachelor's degree in Nursing or allied health field or equivalent, preferred Experience preparing appeals for clinical denials, preferred CCDS: Certified Clinical Documentation Integrity Specialist by ACDIS, preferred CCM: Certified Case Manager, preferred

The Clinical Appeals Specialist is responsible for managing clinical denials by conducting a comprehensive review of clinical documentation and formulating a timely and defensible written response based on clinical documentation, evidence-based medical necessity criteria, physician documentation, and medical policies of the payor. Communicates identified denial trends and patterns to the Manager of Patient Accounting, the Director of Revenue Cycle, and all applicable patient accounting leaders. Works to review, evaluate, and improve the enterprise clinical denial and appeal process. At the direction of the Manager of Patient Accounting, this individual will orchestrate education and other performance improvement initiatives to impact clinical quality, improve efficiency, and mitigate lost revenue related to medical necessity denials.

Asante Health System

Utilization Review RN ARRMC (Case Management) - Remote

Posted on:

August 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Oregon

The Utilization Review RN monitors utilization practices from preadmission to discharge to assure cost-effective utilization of resources, quality patient care, and compliance with regulatory requirements. This role is responsible for reviewing the medical record to ensure documentation demonstrates medical necessity according to regulatory guidelines. The Utilization Review RN will actively manage and communicate with key members of the care team to secure accurate documentation and admission status. Utilization Review RN ARRMC (Case Management) - Remote Additional Position Details: FTE: 1.000000 | Full Time | Primarily Mon - Fri / 8AM - 5PM Please Note: This is a remote position. Candidates will be required to have reliable broadband internet and personal cell phone service. Remote work may include online training and working day-to-day operations during Pacific Standard business hours. Starting Wage: $49.34-$67.84 per hour, depending on experience

2 years of progressive nursing experience in an acute care setting, preferably within discharge, utilization, and/or case management, or equivalent combination of education and/or experience, required RN: Registered Nurse licensed by Oregon State Board of Nursing OR Registered Nurse (RN) with an active license in a state approved for remote work in this position, required Preferred Qualifications: Bachelor's degree in nursing CCM: Certified Case Manager ACM: Accredited Case Manager

Receiving and disseminating information related to system, departmental, and patient processes Participating in data collection activities to support departmental programs and services Monitoring and reporting on patient outcomes and actively working with other members of the interdisciplinary team to facilitate improved delivery of cost-effective services Conducting utilization review, evaluating clinical information, and communicating findings to payors within the framework of contractual and government regulations Reviewing all admissions for appropriate inpatient vs. outpatient/observation status

Sunflower Health Plan

Care Manager (RN)

Posted on:

August 3, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. THIS POSITION IS REMOTE/WORK FROM HOME WITH POTENTIAL 10% TRAVEL IF RESIDING IN THE STATE OF KANSAS. THIS ROLE SUPPORTS MEDICAID AND SOME DUALLY ELIGIBLE KANSAS MEMBERS BEING DISCHARGED FROM THE HOSPITAL. IF RESIDING OUTSIDE OF THE STATE OF KANSAS, MUST HAVE ACTIVE UNRESTRICTED COMPACT RN LICENSURE. THE WORK SCHEDULE IS MONDAY - FRIDAY 8AM - 5PM CENTRAL TIME ZONE; NO WORK ON HOLIDAYS, NO ON-CALL SCHEDULE, NO WEEKENDS.

Education/Experience: Requires a Degree from an Accredited School of Nursing or a Bachelor's degree in Nursing and 2 – 4 years of related experience. License/Certification: RN - Registered Nurse - State Licensure and/or Compact State Licensure required

Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families. Evaluates the needs of the member, barriers to accessing the appropriate care, social determinants of health needs, focusing on what the member identifies as priority and recommends and/or facilitates the plan for the best outcome Develops ongoing care plans / service plans and collaborates with providers to identify providers, specialists, and/or community resources to address member's unmet needs Identifies problems/barriers to care and provide appropriate care management interventions Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services Provides ongoing follow up and monitoring of member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs Provides resource support to members and care managers for local resources for various services (e.g., employment, housing, participant direction, independent living, justice, foster care) based on service assessment and plans, as appropriate Facilitate care management and collaborate with appropriate providers or specialists to ensure member has timely access to needed care or services May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators Provides and/or facilitates education to members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner Other duties or responsibilities as assigned by people leader to meet business needs Performs other duties as assigned. Complies with all policies and standards.

Color Health

Oncology RN, Cancer Screening & Prevention Services

Posted on:

August 3, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Color Health is revolutionizing cancer care with the nation’s first Virtual Cancer Clinic, delivering high-quality, physician-led multidisciplinary care across all 50 states. Our innovative, guideline-based approach spans cancer screening, risk assessment, prevention, diagnosis, treatment support, and survivorship. In addition to personalized direct medical care, our services include cancer genetics risk assessment, nutrition, mental health support, and at-home cancer screening diagnostics. Using technology-driven, patient-centric solutions, Color is transforming how employers, unions, health plans, and governments address cancer. Color’s goal is to close critical gaps in cancer care, improve cancer outcomes, and guide patients with empathy through their healthcare journeys. In June 2023, Color and the American Cancer Society (ACS) introduced a cancer screening and prevention program for employers and labor organizations, combining the ACS’s expertise in cancer screening, prevention, and risk reduction with Color’s leadership in population-scale healthcare delivery. Since announcing our partnership with the American Cancer Society, our program has expanded to support diagnosis management, cancer treatment and care, and survivorship. Through our Virtual Cancer Clinic, Color is helping employees and members diagnose cancer at an earlier, more treatable stage; caring for patients going through their diagnostic journeys with empathy and efficiency; helping cancer survivors navigate return-to-work challenges and complex clinical needs; and closing critical gaps in cancer screening for high-burden cancers. Cancer patients and survivors spend more time fighting their way through a fragmented healthcare system than they do fighting their disease. If you are passionate about changing that, apply to join Color and do the most meaningful work of your career.

We are seeking a dedicated and experienced Oncology RN to join our Virtual Cancer Clinic care team to support cancer screening and prevention for our patients. This role is essential in providing comprehensive cancer risk management, screening, and prevention remotely for patients. It also increases adherence to cancer screening guidelines and ensures prompt management of patients with abnormal results for quick follow-up and treatment. As one of the Virtual Cancer Clinic’s initial hires, you will play a key role in shaping the design and successful impact of our oncology care management and navigation program. The ideal candidate will be passionate about oncology, cancer screening, and prevention, skilled in using Telehealth technology, and dedicated to improving outcomes in early cancer detection and prevention. You have a deep understanding of the challenges patients face and the disruptive impact cancer has on their lives, and you are eager to help them address these issues.

Bachelor of Science in Nursing (BSN) required. Active and unrestricted Registered Nurse (RN) license with eligibility to obtain additional state licenses as needed. Minimum of 7 years of nursing experience, including at least 5 years in oncology healthcare settings. Oncology-related certification (e.g., OCN, AOCN, AOCNS, CCM) required or to be obtained within 12 months of hire. 3+ years of adult outpatient clinical experience. Proficient in motivational interviewing and patient-centered, guideline-based care. Relentless drive to remove barriers and defragment the current healthcare system for your patients. Strong verbal and written communication skills, with a focus on empathy and active listening. Commitment to evidence-based, technology-enabled cancer care and improving healthcare system accessibility. High standards for quality of care and patient outcomes. Preferred: Multi-state Nurse Licensure Compact (NLC) license. Experience collaborating with cross-functional technical and operations teams. English/Spanish bilingual preferred.

Serve as a vital clinical resource for patients we are supporting on cancer prevention, screening, and early detection. Actively engage with patients via phone, async messaging, and video communication to address their clinical needs or issues, such as triage and management of high-risk symptoms and abnormal results, care escalations, coordination with patients’ healthcare providers, provider referrals, and planning for in-person care appointments. Conduct comprehensive cancer risk assessments and develop cancer screening and prevention plans for review by Color Medical physicians. Triage and manage patients reporting symptoms suggestive of cancer and patients with abnormal screening results to make sure they quickly get follow-up workups completed to rule out or confirm a cancer diagnosis, in coordination with their healthcare providers. Provide compassionate, empathetic care, establishing close, trust-based relationships with patients, and going above and beyond to help and support patients and motivate them to take actions that reduce their risk of cancer and/or catch cancer early for optimal outcomes. Triage symptoms and medical history disclosed during patient contact. Collaborate with Care Advocates to address non-clinical support and coordination needs. Develop clinical protocols and best practices to coordinate care and provide clinical support for cancer prevention, screening, and high-risk management, in close collaboration with other Color Care Team members (e.g., oncologists, primary care physicians, genetic counselors, and care advocates). Participate in care team sessions to monitor member progress, provide updates, and collaborate on targeted support plans. Maintain thorough and detailed documentation of encounters with patients. Educate patients about cancer risk factors, including screenings and lifestyle modifications based on national guidelines, specialty guidelines, and Color’s clinical protocols. Serve as an RN-level escalation point to non-licensed members of the clinical team.

Central Oregon Pediatric Associates

Patient Operations Specialist (Remote)

Posted on:

August 3, 2025

Job Type:

Full-Time

Role Type:

License:

None Required

State License:

Oregon

Central Oregon Pediatric Associates (COPA) has provided excellent, comprehensive and compassionate medical care to children in Central Oregon for over 45 years. Our mission is to provide all children with outstanding medical care and exceed their expectations in a friendly and welcoming environment. COPA is a thriving, independent partnership whose healthcare quality measures exceed all medical care facilities in the region. In addition to pediatric primary care services and procedures, COPA’s Pediatric Center of Excellence also provides behavioral health specialists, lactation services, care coordinators, and newborn patient advocates. We’re committed to serving families where English is not the first language and have interpreters at every location and all shifts. COPA hosts in its clinics over a dozen visiting pediatric specialists from children’s hospitals in Portland, Oregon. COPA has four convenient locations in Bend and Redmond, and is open seven days a week with extended hours, and offers 24/7 telephone pediatric nurse advice.

Central Oregon Pediatric Associates (COPA) of Bend, OR is the largest pediatric practice in the region, is hiring a full time Remote Patient Operations Specialist. This position is available to applicants remote in Oregon. Schedule: Monday - Friday, 8:00am-5:00pm At COPA, the Patient Operation Specialist is a member of the Patient Operations Department and plays an integral role serving patients at our friendly and welcoming medical clinic for children of all ages. The purpose of the Patient Operations Specialist is to ensure patients have access to medical care through appointment scheduling, patient check-in and check-out as well as the MyHealth Portal. To ensure success in these areas of responsibility, patient operations team members must understand policies, rules, workflows, legal obligations (HIPAA, OSHA, PHI, etc.), and possess competent skills in varying software applications with outstanding attention to detail. The department is ultimately responsible for providing a family friendly environment which is welcoming to all people.

Experience: Three years of customer service experience required, clerical experience in clinical setting preferred. Intermediate and advanced phone, verbal and computer skills. Ability to work well under pressure with minimal supervision. Flexibility and willingness to handle a variety of tasks. Ability to handle the changing needs of the department and organization Must be flexible and willing to work any COPA site during the evenings, weekdays and weekends as needed by organization for coverage purposes. Epic EMR experience preferred. Proficient with Microsoft Office Suite. Bilingual in Spanish and English a plus. Physical Requirements: Use of clear and audible speaking voice and the ability to hear normal speech level in person, over the telephone or through use of other required technology. Sitting or standing for long periods of time. Frequent repetitive motion includes computer keyboard use, reaching with hands and arms, and walking. Occasional lifting and or moving up to 30 pounds and on rare occasion up to 50 pounds. Specific vision abilities required include viewing computer monitor for long periods of time, close vision, distance vision, color vision, peripheral vision, and depth perception. Must be able to wear appropriate personal protective equipment (PPE) as required. Working Conditions: Work inside in a general medical office or personal office (HIPAA Compliant) Setting with ergonomically configured equipment. Travel between COPA clinics, business office and community partners as required.

The role of the Patient Operations Specialist will include but is not limited to the following duties: Maintains an in-depth knowledge of principles, practices, standards, and techniques and demonstrates knowledge in accordance with COPA policies and procedures within pertinent laws and regulations in the following areas: Greeting and Welcoming Customers with exceptional customer service in person and by phone Registration information verification in person and by phone Checks in patient properly and thoroughly without errors. Listens to patient thoroughly while making them feel welcomed and without disrupting them while speaking Fills in all required fields within EMR to ensure quality care Clear communication with staff across all departments to ensure proper daily flow Scanning and labeling documents into the proper locations Handing out correct forms and release of information to patients and parents for proper flow for providers and clinical staff Answering and transferring calls correctly Creating encounters to clinical departments, providers, and other departments efficiently Scheduling future and same day appointments correctly (repeating date, time & location correctly) Insurance verification and knowledge of insurances Maintaining Patient Portal/ My Health appointments and assisting to help create accounts for families Delivering labs and faxes the appropriate areas Restocking forms as needed Collection of money and copays by phone and collect in person, posting payments correctly and balancing tills Quality assurance of fee slips for processing Audits accounts for accuracy. Proper follow through with follow up appointments/check out Relays appropriate appointment detail and financial information to patients prior to appointments Exercises problem-solving and conflict resolution within provider schedules Knowledge of HIPAA & rules for medical records regulations May be asked to participate in the training program for all new hires May be required to travel between COPA clinics and business office. Performs other related work as directed by immediate supervisor

Central Oregon Pediatric Associates

RN - Phone Advice/Triage

Posted on:

August 2, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Oregon

Central Oregon Pediatric Associates (COPA) of Bend, Oregon, the largest pediatric practice in the region, is hiring a remote - local to Oregon, part-time (0.6 or 0.8 FTE) Pediatric Phone Advice/ Triage RN. At COPA, the Pediatric Phone Advice/ Triage RN plays an integral role serving patients at our friendly and welcoming medical clinic for children of all ages. The Pediatric Phone Advice/ Triage RN is a collaborative member of the Patient Centered Primary Care Home and performs the primary functions of a Registered Nurse in assessing patient’s medical conditions over the phone and dispensing the appropriate medical advice. The age ranges that will be evaluated are the infant, toddler, preschool, school age or adolescent patient. The RN is responsible for meeting the standards of advice/triage care established by the organization.

Education and Certification: Graduate of an accredited Nursing program, BSN preferred. Current Oregon RN Licensure and license must be in good standing. Recognized certifications in addition to OR RN (required) include: CPN, CPEN, OHA HCI Qualified or Certified Interpreter Experience: Nursing experience required; pediatric experience and telephone triage preferred. Experience with working with electronic medical records systems and MS Office. Epic experience preferred. Bilingual in Spanish and English a plus. Physical Requirements: Use of clear and audible speaking voice and the ability to hear normal speech level in person, over the telephone or through use of other required technology. Sitting or standing for long periods of time. Frequent repetitive motion includes computer keyboard use, reaching with hands and arms, and walking. Occasional lifting and or moving up to 30 pounds and on rare occasion up to 50 pounds. Specific vision abilities required include viewing computer monitor for long periods of time, close vision, distance vision, color vision, peripheral vision, and depth perception. Must be able to wear appropriate personal protective equipment (PPE) as required. Working Conditions: Position may qualify to be located local-remote to include on-site meetings and shifts in COPA clinics, business office or community partners. Refer to Remote Work Policy for details. Position may qualify to be located remote outside of Central Oregon in approved geographic regions. Refer to Remote Work Policy for details. Work inside in a general medical office setting with ergonomically configured equipment. The employee is subject to hazards including a variety of physical conditions such as proximity to mechanical parts and chemicals including odors. The employee has been identified as having the likelihood of occupational exposure to blood and other potentially infectious materials, therefore are included in the OSHA Exposure Control Plan with specification for preventing contact with the above materials.

The role of the Pediatric Phone Advice/ Triage RN will include but is not limited to the following duties: Maintains an in-depth knowledge of principles, practices, standards, and techniques and demonstrates knowledge in accordance with COPA policies and procedures within pertinent laws and regulations in the following areas: Excellent interpersonal communication skills and the ability to interact with a diverse population using superior nursing process skills. Excellent clinical judgment, knowledge and experience directs the conversation with the patient/family to guide the RN in a decision to give care advice, access appointment or seek emergency assistance. Telephone triage nurse provides patient education when appropriate via verbal skills and written skills within Epic EMR and Clear Triage. Responds with the appropriate standards of care for specific cases and documents advice given and patient’s/family’s response. Provides individualized patient assessments, prioritizing the data collection based on the infant, toddler, preschool, school age or adolescent patients’ immediate condition or needs within timeframe specified by practice’s policies, procedures, or protocols. Demonstrates ability to plan, organize and prioritize their workday effectively. Ability to accurately forecast pediatric immunizations. Calculates safe medication doses following the Seven Rights. Maintains own clinical skills staying current in skills, equipment, and trends in nursing. Assists in the orientation of new personnel and student practicums. Assists with coordinating daily staffing assignments for all offices and providing support to other RNs. Performs essential duties and functions of the Phone Advice Nurse position including triage and care coordination activities. Within electronic health records, can “pend” medications and order labs tests as directed by providers.

Conduit Health Partners

Conduit Registered Nurse (RN) Triage Specialist

Posted on:

August 2, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence. Job Description Primary Function/General Purpose of Position The RN Triage Specialist provides telephonic triage to assist callers to determine the most appropriate level of care needed for the current situation expressed or assessed, following workflows and utilizing protocols/resources to provide supportive service to patients and customers. The RN Triage Specialist will maintain a performance standard that prioritizes safety, quality and experience and coincides with the organization's mission and identified key strategic or performance initiates. Full Time Day Shift - 6a-330p - Every other weekend and holiday

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation and appropriate within the scope of practice for the registered nurse. Licensing/Certification RN license required in applicable state(s). Multistate/Compact RN Licensure preferred Education: ADN or Diploma Nursing required BSN preferred Work Experience 1 year of acute care nursing experience required. Triage experience preferred. Training: EPIC Electronic Health Record (preferred) Working Conditions - Periods of high stress and fluctuating workloads may occur. General office environment. May have periods of constant interruptions. Required to car travel to off-site locations, occasionally in adverse weather conditions. Prolonged periods of working alone. Other: Remote/ At Home work Environment Opportunity may be provided. This is dependent upon business needs and capability. Will require a signed agreement. Minimum internet speed of primary and secondary work locations is: download speed of 100Mpbs; upload speed of 20Mbps. Reference policy: Conduit Health Partners Work from Home.

Provides telephonic triage or requested support and / or virtual monitoring. Offers subsequent recommendations, education or care advice using decision making tools, clinical judgement, and defined workflows. Participates in care coordination, by partnering with customers to reduce readmissions, enhance chronic disease management, manage health risk and injury reporting. Schedules provider appointments and facilitates provider communication. Ensures accurate, timely documentation in the EMR (Electronic Medical Record) according to best practice, guidelines, or workflows. Participates in virtual monitoring and subsequent reporting and escalation to support services identified by customer. Provides additional support to Conduit Health Partners business functions as identified to ensure all patient needs are being met and continuity of Conduit Health Partners business operations is maintained. Participates in process improvement, professional development, peer development and peer review

IntellaTriage

Remote Nurse Triage RN PT 5a-10a/10p-5a rotation

Posted on:

August 2, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

IntellaTriage continues to GROW! 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 **Minimum of 2 years as a Nurse **Minimum of 1 year of experience in a fast-paced environment (i.e. ED, Critical Care, Surgical Services, Med/Surg, etc.) **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have no concerns typing **Must be available to work 2 out of every 3 weekends & 1 weekday per week. 3 shifts weekly Mon-Fri, rotating 5a-10a and 10p-5a CST 2 of every 3 weekend rotation (Sat & Sun) rotating 5a-10a and 10p-5a CST

MUST have or be willing to obtain a Compact Nursing License (States with pending legislation or future implementation dates are not considered current compacts until the implementation date.) 3+ years as a RN Experience in a fast-paced environment: i.e. ED, Surgical Services, or Critical Care. Must be comfortable with technology and accessing multiple applications remotely to perform documentation during calls. Ability and comfort typing. 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 the 3-week orientation and training (Schedule listed in this posting). Must be available to work Saturday & Sunday on your team's required weekends; 2 of every 3 weekends. Holidays as they are required (rotation). Able to handle stress and multitask when calls are coming in (minimum of 5+ calls per hour on weekdays, and much higher on weekends). Able to communicate with patients and families with empathy while also maintaining adherence to client protocols. Must maintain CEU’s as designated by the states you are answering calls in. Must attend any in-services, additional training on an as needed basis. Able to pass background check and nurse licensing check.

Our Nurse Advice Line Nurses: Have proven experience in a fast-paced, critical-thinking environment; ED, Critical Care, Surgical Services, etc. Work a minimum of 2-3 shift per week (Mon-Fri). Preferred scheduling for their weekday requirements. Work 2 weekends or every 3 weeks, both Saturday and Sunday on those weekends with rotating times. (For example: weekend 1: work, weekend 2: work, weekend 3: off) Train for 3 weeks. First week is Monday-Thursday 9a-6p CST. Remaining two weeks training will be dependent upon preceptor availability but will likely be an evening shift. Must have a compact license and live in that compact state. (no states with pending legislation or future implementation dates are considered current compacts) What is important to know? We are growing and excited to be able to support our clients’ nursing staffs in the field who need time to focus on work-life balance, as well, while being able to trust that we are there to support them and their patients during nights and weekends! Patient care is #1. We do not have call quotas. We employ the best nurses to provide the best care. When our patients or their families reach our triage line, they immediately speak directly with a nurse. We do not have PRN positions. We are super busy. If you like fast-paced roles, keep reading… Any nurse may pick up additional shifts, if shifts are available for the clients’ they are trained to support. We will provide you with a laptop and headset. Nurses are required to provide their own high-speed internet (only fiberoptic or coaxial cable internet is compatible with our remote call center technology). Our laptop is required to be directly connected to your modem. Working through Wi-Fi is not compatible with our systems. The calls will drop. It is essential to have a home office or quiet space free from noise or distractions in your home (Privacy/HIPAA compliant space is required). Training is provided remotely and is paid; no travel is required in this role. MUST be able to follow instructions (verbal and written) and be comfortable with technology (tech savvy). Must remain in good standing and ensure their home state license remains active. IntellaTriage will cover the cost of non-compact state licensure based on the client(s) that are assigned for support. All nurses must have a compact license and reside/work in that state. Shift prep is a minimum clock-in of 30 minutes prior to taking calls; this is paid time to prepare. Once calls roll to the next team/shift, our nurses remain clocked in and complete any remaining charting before leaving for the day. This may take 30 minutes or this may take 2 hours. It depends on the pace of the calls received during that shift and the pace of your ability to quickly navigate technology and type.

CEDARS-SINAI

Registered Nurse - Lung Transplant Coordinator III - Remote ON CALL

Posted on:

August 2, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

California

Are you ready to bring your clinical skills to a world-class facility recognized as top ten in the United States for transplant services? Do you have a passion for the highest quality and patient satisfaction? Then please respond to this dynamic opportunity available with one of the best places to work in Southern California! We would be happy to hear from you. With expert surgical and medical proficiency in lung, heart, liver, kidney, and pancreas transplantation, the Cedars-Sinai Comprehensive Transplant Center is one of the most successful facilities of its kind. Here, patients find a compassionate environment and hope for a longer, healthier life. This is a remote on-call position with a 24-hour shift schedule (7:00am - 7:00am). You will be required to take patient calls from home and also participate in meetings in-office. Required hours will be 6-7 shifts per month.

Education: BSN degree required License/Certification/Registration: Current, unrestricted California RN License required Specialty certification required - CCTC OR CCTN Current BLS from the American Heart Association required Experience: A minimum of 5 years of direct experience required At least 3 years of Acute care, including minimum of 1 year Critical Care experience, Cardiac setting required Organ transplantation experience required (for Remote Team) Demonstration of excellent organizational skills as well as interpersonal skills Demonstrated knowledge of case management required Experience in data management required

As a Clinical Program Coordinator, Transplant on the Heart and Lung Transplant team, you will screen initial calls from the OPO, review and manage the EHR candidate wait list, review all offers with the appropriate physician teams to arrange and organize donor procurement and transplant candidate preop. You will serve as a reference for the members of the interdisciplinary team as needed for transplant specialty services. This role also includes participation in education and outreach activities related to organ allocation and transplantation to patients, healthcare providers and the community. Triage patient calls after-hours and over the weekend Participate in the development of guidelines, protocols, pathways, and other performance improvement activities as required for the On-Call CPC role Engage in research activities. Act as a patient advocate throughout the patient care process. Represent the Medical Center at regional and national meetings/conferences.

Fidelis Care

Utilization Review Nurse I

Posted on:

August 2, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

New York

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: The Utilization Review Nurse I provides first level clinical review for all outpatient and ancillary services requiring authorization. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers Utilization Management directed telephone calls; managing them in a professional and competent manner. Processes all prior authorizations to completion utilizing appropriate review criteria. Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity. Acts as liaison between the TRICARE beneficiary and the Network Provider.

Graduate of Nursing program; BSN desired or Graduate in Clinical Psychology or Clinical Social Work. Three years clinical experience in a health care environment; managed care experience desired. NYS RN license & NYS Driver's License Required For Fidelis Care only: NYS RN, OT or PT license required

Provides first level RN review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using appropriate criteria, referring those requests that fail review to the medical director for second level review and determination. Completes data entry and correspondence as necessary for each review. Conducts rate negotiation with non-network providers, utilizing appropriate CMAC, DRG, HCPC reimbursement methodologies. Documents rate negotiation accurately for proper claims adjudication. Acts as liaison between the TRICARE beneficiary and the provider, facility and the MTF to utilize appropriate and cost effective medical resources within the direct care and purchased care system. Identifies and refers potential cases to Disease Management, Case Management, Demand Management and Transitional Care. Refers all potential quality issues and grievances to Clinical Quality Management and suspected fraud and abuse to Program Integrity. Performs other duties as assigned Complies with all policies and standards

UT Southwestern

CDI Quality Review RN

Posted on:

August 2, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report(Opens in a new window), we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you’ll discover a culture of teamwork, professionalism, and a rewarding career!

The CDI Quality Review Nurse (QRN) will work under the direction of the Clinical Documentation Integrity (“CDI”) Manager and conduct second-level reviews of targeted cases to identify and capture opportunities to improve the integrity of the medical record. The focus of the Quality Review Nurse will be on identifying and capturing methodology-specific risk variables (Vizient, HCC’s, Elixhauser) on a post-discharge, pre-coding/billing basis, as well as identifying potential process improvements to capture the opportunities concurrently. The Quality Review Nurse will also validate that the record reflects the most appropriate principal diagnosis and diagnosis related group (DRG). The Quality Review Nurse will support the objective for accurate reflection of patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations.

Education: Bachelor’s Degree in Nursing Experience: 5 years patient care nursing experience in an acute care setting and 3 years Clinical Document Integrity experience Licenses and Certifications: (RN) REGISTERED NURSE Upon Hire and (CCDS) Cert Clinical Documentation Upon Hire or (CDIP) CERT DOCUMNTATN IMPROVMNT PRAC Upon Hire Preferred Education: Master’s degree in Nursing Experience: 7 years patient care nursing experience in an acute care setting 5 years Clinical Document Integrity experience Experience working in a remote environment

Conduct post-discharge, pre-coding/billing reviews on targeted records identified for second-level review for opportunity to accurately capture methodology-specific risk variables (Vizient, HCCs, Elixhauser); present on admission (POA) status, patient admission source, avoidable patient safety indicators (PSI‿s), and DRG assignment in compliance with industry rules and regulations If a documentation opportunity is identified, place physician query and follow up for response If coding opportunity is identified, coordinate with Coding Team to review and address opportunity, as applicable Utilize methodology-specific risk calculators and guidance documents to understand if additional diagnoses and/or risk variables will impact the reported quality impact of a specific patient encounter Maintain a summary of opportunities identified through second-level review for feedback and education with the CDS Team, Providers, and Coding Team Identify and communicate any process improvement opportunities for front-end correction and education Periodically review the criteria established for cases triggering a second-level review and recommend updates or modifications to the criteria to maximize impact on quality scores Maintains an expert level of knowledge of CDI and Coding related guidelines and practices Other duties as assigned

UNC Health Care

Supervisor Clinical Call Center - Nurse Connect

Posted on:

August 2, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

North Carolina

Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: The Clinical Call Center Supervisor oversees the daily (24/7/365) clinical operations for all of the Clinical Contact Center services. The Clinical Contact Center provides remote clinical assessment and decision making for primary and specialty care patient populations across the UNC Health System. This role is charged with implementing and maintaining clinically safe, high quality and reliable services across UNC Health. This position oversees a team of approximately 20-25 triage nurses requiring advanced training in a high-risk patient virtual care setting including UNC Virtual Practice Services, and is responsible for: recruitment and hiring, training and education, clinical nursing service quality, technology support, information security and nursing documentation for all Clinical Contact Center telehealth services. This position coordinates with medical leaders across the health care system to provide comprehensive and timely access to care, including our rapidly growing clinical and telehealth services at UNC Health. This position also works closely with scheduling and patient navigation teams across the system to ensure a seamless patient experience, triaging patients and making sure they get the right care they need quickly. This position collaborates with administrative, technical and clinical staff across the UNC Health Care system. Legal Employer: NCHEALTH Entity: Shared Services Organization Unit: Nurse Connect Work Type: Full Time Standard Hours Per Week: 40.00 Salary Range: $35.52 - $51.05 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Remote Work Schedule: Variable Location of Job: US:NC:Chapel Hill Exempt From Overtime: Exempt: No

Education Requirements: Bachelor’s degree in nursing Licensure/Certification Requirements: Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: Five (5) years of professional nursing in tertiary care and one (1) year of supervisor or team lead experience in specialty area. 2 or more years of telephonic nurse triage experience is preferred.

Clinical Support and planning – Responsible for supervising a shift staff of 24/7/365 shared service clinical contact center offerings ensuring adequate health care access, high quality clinical care and patient satisfaction to a diverse patient and provider population. Actively monitor personnel performance and patient satisfaction. Education/Research-Participates in and stays current with clinical education and training activities from high impact nursing and telehealth research. Participates in short and long range planning. Actively participates in the overall vision, mission, direction, goals and objectives of the UNC Health Care system. Participates in continuous improvement projects that align with strategic priorities and improve the patient experience with access to care. RN level Triage Telehealth- Share clinical expertise in Clinical Call Center triage nursing across the health care system. Collaborate extensively with key health care stakeholders, providers and managers across the health care continuum Qualitative Analysis-Work with manager on qualitative analysis with attention to detail and Technology Integrity. Engages with technology advocates to enhance patient access through virtual visits, texting platforms and telephony. Reviews and analyzes performance ongoing, identifies gaps, and develops recommendations for improvement. Leading change- Discovers and validates opportunities to provide highly effective telehealth services to diverse populations and settings disproportionately affected by access to health care.

BJC HealthCare

Part Time Clinical Triage Nurse - Access Center

Posted on:

August 1, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Missouri

BJC Medical Group is the multi-specialty physician-led organization of BJC HealthCare and includes over 600 doctors and advanced practice providers who are affiliated with top-ranked hospitals in the Midwest region. Since 1994, BJC Medical Group has provided access to extraordinary care in over 145 locations and over 25 specialties in the greater St. Louis, mid-Missouri and southern Illinois areas. Our providers are nationally recognized for excellent patient satisfaction, quality health care, and improving the health and well-being of the communities we serve.

Do you have recent RN experience in the Emergency Department or Medical Surgical Floor? BJC Medical Group is looking for a Part Time Clinical Triage Nurses! Must live within 1 hour of St. Louis, Missouri [ MO or IL] Typing Test Required (minimum speed 35 wpm, 90% accuracy) 32 hours per week- Part Time Benifit Eligible Rotating schedule; 10-1830 Every other Weekend (1 day) plus holiday rotation required Ideal candidate: Med Surg, Emergency Room, and/or triage experience in Family Medicine Role Purpose The RN – Telehealth (Access Center) provides direct telephonic care to adult and pediatric patients in collaboration with primary care providers. This position uses assessment skills, critical thinking, and clinical judgment to direct patients to the correct level of care. This position also uses multiple computer applications and works in a fast-paced remote environment.

Education: Nursing Diploma/Associate's Experience: 2-5 years Supervisor Experience: No Experience Licenses & Certifications: RN Preferred Requirements: Education Bachelor's Degree: Nursing Licenses & Certifications: Basic Life Support (BLS)

Uses the nursing process, clinical judgment, and decision support materials to assess patients telephonically; directs patients to the appropriate level of care, including scheduling appointments for patients across various resources; ensures accurate and complete communication with primary care providers. Provides patient education and support, including verbal and written instructions; uses the appropriate tools and techniques to assess the patient’s and/or family’s ability to receive education; takes initiative to problem solve and demonstrates critical thinking skills. Utilizes various technologies to coordinate patient care, to include multiple software applications, computerized clinical guidelines, specialized telephony equipment, etc. Applies standard work procedures to tasks, such as routine medication refill requests, ordering testing, scheduling appointments, etc. with a high level of attention to detail. Collaborates and interacts professionally with other members of the healthcare team, including physicians, advanced practice practitioners (APP), office staff, etc.; works with a multi-disciplinary team to provide appropriate, safe care; displays excellent written and verbal communication skills; provides the highest level of customer service to callers. BJC has determined this is a safety-sensitive position. The ability to work in a constant state of alertness and in a safe manner is an essential function of this job.

Elevance Health

Telephonic NICU Nurse Case Manager II

Posted on:

August 1, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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.

Telephonic NICU Nurse Case Manager II Location: Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. “Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.” Hours: Monday - Friday 8:00am to 4:30pmEST. May be able to start at a later time if desired but cannot start earlier than 8am EST. ***This position will service members in different states; therefore, Multi-State Licensure will be required. The Telephonic NICU Nurse Case Manager II is responsible for the NICU Case Management. Assess, develop, implement, coordinate, monitor, and evaluate care plans designed to optimize member health care across the care continuum. Performs duties telephonically.

Minimum Requirements: NICU experience required. Requires BA/BS in a health related field and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. Preferred Capabilities, Skills and Experiences: Certification as a Case Manager. Managed Care experience. Ability to talk and type at the same time. Demonstrate critical thinking skills when interacting with members. Experience with (Microsoft Office) and/or ability to learn new computer programs/systems/software quickly. Ability to manage, review and respond to emails/instant messages in a timely fashion. Knowledge of health insurance/benefits, medical management process, care management, and utilization review management strongly preferred.

Ensures member access to services appropriate to their health needs. Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Coordinates internal and external resources to meet identified needs. Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. Negotiates rates of reimbursement, as applicable. Assists in problem solving with providers, claims or service issues. Assists with development of utilization/care management policies and procedures.

Elevance Health

Triage Nurse I - Bilingual Spanish - CareBridge - Virtual

Posted on:

August 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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.

Seeking bilingual Spanish-speaking candidates who have an active, unrestricted RN Compact license or Multi-state RN licenses in either of the following states: AZ, FL, IA, IN, KS, MA, NM, OH, TN, TX or VA. Location: Virtual - This role enables associates to work virtually full-time, with the exception of required in-person training sessions (when indicated), providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Work Shift: 11am - 9pm or 1pm - 11pm (Central Standard Time) The RN will work eight (8)10-hour work shifts, in a two-week period which includes Saturday and Sunday every other weekend. CareBridge Health is a proud member of the Elevance Health family of companies, within our Carelon business. CareBridge Health exists to enable individuals in home and community-based settings to maximize their health, independence, and quality of life through home-care and community based services The Triage Nurse I - CareBridge - Bilingual Spanish is responsible for determining the appropriate Care Management program for members referred through internal and external sources and various data sources and reports. Utilizing department guidelines, completes triage process and applies established criteria to assign members to appropriate care management component. Deals with least complex cases having limited or no previous Triage care experience.

Position requirements: Requires AS in nursing and minimum of 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in the applicable state(s) required. Preferred qualifications, skills, and experiences: Current, active, RN Compact license highly preferred. Emergency Room and/or Urgent Care experience highly preferred. Telehealth experience. Bilingual Spanish is strongly preferred. Experience with EMR systems. BS in nursing preferred. Participation and/or certification in a managed care or utilization management organization preferred. Ability to understand clinical information and prepare a concise summary following department standards strongly preferred. Basic knowledge of the medical management and care management process and role preferred.

Utilizes the nursing process to meet an individual’s health needs, utilizing plan benefits and community resources. Educates members about contracted physicians, facilities and healthcare providers. Learn to develop favorable working partnerships and collaborative relationships with members, physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. Works in collaboration with medical management and care management associates to identify issues, problems, and resource needs and assign to appropriate care management program. Facilitates selecting appropriate candidates for referral to CM and/or DM. Partners with social work as appropriate. Identifies and refers cases or issues to QI, SIU, Subrogation, Underwriting, or other departments as appropriate. Documents appropriate clinical information, decisions, and determinations in a timely, accurate, and concise manner. Develops a working knowledge of member benefits, contracts, medical policy, professional standards of practice, and current health care practices.

Elevance Health

Triage Nurse I - CareBridge - Virtual

Posted on:

August 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading. Improving health means more than just treating what ails us – it means addressing the physical, behavioral and social drivers that impact whole health. Grounded in our mission and fueled by our bold and ambitious purpose to improve the health of humanity, we are committed to making whole health a reality for our consumers, their families, and our communities.

Seeking candidates who have an active, unrestricted RN Compact license or Multi-state RN licenses in either of the following states: AZ, FL, IA, IN, KS, MA, NM, OH, TN, TX or VA. Carebridge Health is a proud member of the Elevance Health family of companies, within our Carelon business. Carebridge Health exists to enable individuals in home and community-based settings to maximize their health, independence, and quality of life through home-care and community based services Location: Virtual This role enables associates to work virtually full-time, with the exception of required in-person training sessions (when indicated), providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Work Shift: 11am - 9pm or 1pm - 11pm (Central Standard Time) The RN will work eight (8)10-hour work shifts, in a two-week period which includes Saturday and Sunday every other weekend. The Triage Nurse I - Carebridge is responsible for determining the appropriate Care Management program for members referred through internal and external sources and various data sources and reports. Utilizing department guidelines, completes triage process and applies established criteria to assign members to appropriate care management component. Deals with least complex cases having limited or no previous Triage care experience.

Position requirements: Requires AS in nursing and minimum of 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in the applicable state(s) required. Preferred qualifications, skills, and experiences: Current, active, RN Compact license highly preferred. Emergency Room and/or Urgent Care experience highly preferred. Telehealth experience. Experience with EMR systems. BS in nursing preferred. Participation and/or certification in a managed care or utilization management organization preferred. Ability to understand clinical information and prepare a concise summary following department standards strongly preferred. Basic knowledge of the medical management and care management process and role preferred.

Utilizes the nursing process to meet an individual’s health needs, utilizing plan benefits and community resources. Educates members about contracted physicians, facilities and healthcare providers. Learn to develop favorable working partnerships and collaborative relationships with members, physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. Works in collaboration with medical management and care management associates to identify issues, problems, and resource needs and assign to appropriate care management program. Facilitates selecting appropriate candidates for referral to CM and/or DM. Partners with social work as appropriate. Identifies and refers cases or issues to QI, SIU, Subrogation, Underwriting, or other departments as appropriate. Documents appropriate clinical information, decisions, and determinations in a timely, accurate, and concise manner. Develops a working knowledge of member benefits, contracts, medical policy, professional standards of practice, and current health care practices.

Indiana University Health

Registered Nurse Outpatient-Triage-PRN-Call Center

Posted on:

August 1, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Indiana University Health is Indiana’s largest and most comprehensive healthcare system and is home to the IU Health Medical Center which is ranked #1 in Indiana by U.S. News & world Report. A unique partnership with the Indiana University School of Medicine—one of the nation’s largest medical schools—gives patients access to groundbreaking research and innovative treatments, and it offers team members access to the latest science and the very best training—advancing healthcare for all. At IU Health, your personal and professional growth is a top priority. You will have access to many diverse opportunities to learn and develop in meaningful ways that matter most to you, such as advanced clinical training, leadership development, promotion opportunities and cross-training development.

We are seeking an individual with a minimum of 5 years of RN experience for this role. As an employee of Indiana’s most comprehensive health system, we are excited to support team members who are inspired by challenging and meaningful work for the good of every patient. People who are compassionate and serve with a purpose. People who aspire to excellence every day. Your personal and professional growth is our top priority. IU Health is invested in the lives of Hoosiers, leading the transformation of healthcare to make Indiana one of the nation’s healthiest states. We are seeking a Triage nurse to provide exceptional care to our patients in the Indianapolis, IN Central Region! This is an excellent opportunity for an independent nurse who likes a stimulating environment with a positive opportunity to educate patients.

Requires Basic Life Support certification through the AHA. Other advanced life support certifications may be required per unit/department specialty according to patient care policies. Requires an Associates of Nursing (ASN); Bachelor of Nursing (BSN) preferred. Requires that the RN has graduated from a nationally accredited nursing program. Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license. Two years' experience in an ambulatory setting preferred. Knowledge of procedures for performing the functions appropriate to the specific clinical area and familiarity with designated pieces of equipment and supplies. Requires ability to coordinate a number of functions for a group of patients in an effective timely manner. Requires awareness and understanding of legal implications of patient care activities and performance as a Registered Nurse. Requires ability to assess patients without face-to-face interaction.

Under the guidance of the Director of Nursing Practice, nurses ensure that quality care is provided in an efficient and safe manner. Responsible for telephone nursing including post-op care and urgent needs of ill patients, acting as liaison with the physicians and other partner team members. Nurses follow the Nursing Process for patient assessment and dispositioning. Being an IU Health nurse means building a professional nursing career crafted by you, with competitive benefits, a culture that adopts your outstanding strengths, and supports your goals. If you are seeking an organization where you can engage professionally, develop clinical expertise, further learning, cultivate new relationships, and fuel your spirit of inquiry, join us.

Fallon Health

RN Triage Nurse

Posted on:

August 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Massachusetts

Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality. Fallon Health’s Summit ElderCare® is a Program of All-Inclusive Care for the Elderly–PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE— in the region.

Responsible for the effective management and delivery of direct nursing care to PACE participants in any setting utilizing nursing process and adhering to standards of nursing practice. Competencies: Demonstrates commitment to the Fallon Community Health Plan Mission, Values and Vision. Specific competencies essential to this position: Customer Focus      Commitment Through Action      Contributes to Team Performance Focus Upon Quality    

Education: Graduate of an accredited school of nursing     License/Certifications License:Current license as an RN in the state of Massachusetts   Certification: CPR and Alzheimer’s certification, or willingness to be certified within 60 days of hire, is essential Experience: At least two years of recent experience in the direct care of adults or chronically disabled persons with at least one year caring for a frail or elderly population. Ambulatory care or home care experience helpful.    

Reviews and implements Provider’s orders. Conducts nursing assessments according to policy guidelines including physical, psychosocial, behavioral, and MDS-HC as indicated. Involves participants and significant other(s) based on needs and abilities. Delivers care to participants in any setting, including skilled services, based on individualized needs and according to age-appropriate nursing standards. Provides for cultural and diverse needs of participants when providing care. Monitors and evaluates therapeutic interventions. Participates in the development and ongoing review of each participant’s care plan.      Delegates participants’ care responsibilities to other members of the health care team, when appropriate. Identifies emergency situations and initiates appropriate nursing orders/interventions. Meets the needs of participants in a timely manner. Participates in the interdisciplinary team (IDT) process and collaborates with IDT members to meet the needs of participants. Consistently documents all aspects of participant care, including significant changes in health status, monthly nurses’ notes and health care teaching in the medical record. Participates in training and orientation of new nursing staff as assigned. Assists in the delivery of other nursing services as assigned. Participates in the nursing “on-call” rotation as assigned. Performs all duties in accordance with FCHP and Summit ElderCare policies and procedures. Participates in Weekend RN On Call rotation

Monogram Health

MH FIRST Registered Nurse - Bilingual

Posted on:

August 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors.

The Bilingual Triage RN with our Monogram Health FIRST program is pivotal in providing critical support to field teams facing urgent and complex patient concerns. The Registered Nurse has expertise that will ensure patients receive the care, resources, and support they need, especially during high-stress situations and environmental crises.

Maintain a current and valid compact RN license, allowing you to practice across multiple state lines. Minimum of 3 years of clinical nursing experience, with a preference for emergency care, critical care, or triage backgrounds. Bilingual (Spanish/English) required. Availability to adjust shift flexibly in response to peak coverage or staffing needs. Demonstrate the ability to communicate calmly and confidently during high-stress situations. Build strong relationships with team members and patients through effective rapport-building. Exhibit meticulous attention to detail and outstanding organizational skills. Show unwavering dedication to patient safety and delivering high-quality care. ER/ED/ICU/Floor Experience preferred. Licenses & Certifications Preferred: Registered Nurse

Utilize licensing and crisis management skills to assess and address urgent needs. Utilize proficiency in documentation and technology to streamline member care. Offer valuable support and guidance to patients and their families in critical situations. Primary point of contact for patients, Monogram field staff, and care center personnel needing immediate support. Provide seamless transitions by providing comprehensive handoffs to incoming staff. Conduct chart auditing during non-peak call volumes. Emergency/disaster outreach as events occur. Availability to adjust shift flexibly in response to peak coverage or staffing needs.

Monogram Health

Pulmonary Nurse Practitioner

Posted on:

August 1, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Georgia

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024’s No. 3 fastest growing private company in the United States, please visit here.

The Monogram Pulmonary Nurse Practitioner will be responsible for the delivery of personalized compassionate medical care to patients primarily with COPD and other pulmonary conditions. The Nurse Practitioner will be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. The successful candidate will work as a team with our physician specialists, field-based nurses, community health workers, and physicians and assist in delivering premium care to every patient. Primary duties include patient health assessment, creating strategies to improve or manage a patient health for cardiac conditions, and introduce habits for health promotion. He/she may also conduct physical exams, order tests, prescribe medications, and serve as a coordinator with the patient's primary healthcare provider and their specialists.

Active and unrestricted Registered Nurse and Nurse Practitioner license in one of the following states: GA, SC, NC, LA, TN, AL Up to 10% travel required Board certified by ANCC or AANP. Current and unrestricted DEA certificate. Ability to work without direct supervision and practice autonomously. Must be proficient with medical instruments and equipment required by the work. Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology. Ability to communicate effectively, in verbal and written form, with retail and medical partners at various levels, patients, family members, physicians and representatives of the community. Sound understanding of all federal and state regulations including HIPAA and OSHA. Minimum of 2 years of experience as an NP working in an inpatient or outpatient pulmonology setting, required (please no new graduates). Strong background in patient assessment, diagnosis, treatment, and management of pulmonology diseases. Excellent communication skills, works well in a team environment, and is adaptable.

Work with COPD patients to ensure medication compliance, monitoring dietary and lifestyle changes, regular follow ups and care coordination. Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first. Work collaboratively with the Pulmonologist and staff to provide high quality, patient centered care. Work closely with pulmonology team, other specialist teams, and clinical care teams. Conducts assessments on patients both in the patients' home and in the virtual environment. Counsels and educates patients and families about benefits and programs available to help them live healthier lives. Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan. Completes all documentation and paperwork in a timely manner. Maintains quality of care standards as defined by the practice. This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state. Prescribe medications, order tests, and collaborate with patient’s Monogram pulmonologist and physician. Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily. Assists patients with enrolling to access educational videos. Participates in the integrated care team meetings. Knowledge of disease diagnosis and prevention. Make assessment of patient's health status. Develop treatment plan. Implement a plan consistent with appropriate plan of care. Follow-up and evaluate patient's status. Other duties as assigned.

Monogram Health

Nurse Practitioner

Posted on:

August 1, 2025

Job Type:

Full-Time

Role Type:

License:

NP/APP

State License:

Florida

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home. Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors.

Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Our Nurse Practitioners and Physician Assistants help patients improve their quality of life in the home and slow the progression of kidney disease, enabling positive health outcomes. Your Impact Using your skills in this position will allow you to deliver personalized compassionate medical care to individuals mainly with CKD and/or ESRD/ESKD. You will also be responsible for caring for patients, maintaining accurate and current patient records and scheduling, and administering follow-up appointments to patients as required. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don’t positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do.

Bilingual (English/Spanish) highly preferred Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license  Board certified for appropriate licensure (NP: ANCC/AANP; PA: NCCPA)  Current and unrestricted DEA certificate  Ability to work without direct supervision and practice autonomously  Access to transportation, a valid driver's license, and car insurance  Must be proficient with medical instruments and equipment required by the work  Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology  Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community  Sound understanding of all federal and state regulations including HIPAA and OSHA    2 or more years of direct patient care required  Managed Care/IPA/Health Plan experience  Experience conducting annual wellness visits or similar comprehensive visits virtually or in the home  Licenses & Certifications Preferred: Nurse Practitioner

Conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment  Counsels and educates patients and families about benefits and programs available to help them live healthier lives  Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan  Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services  Completes all documentation and paperwork in a timely manner  Maintains quality of care standards as defined by the practice  This position will not be office-based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state  Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first   Prescribe medications, order tests, and collaborate with patient’s Monogram physician  Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily  Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing  Assists patients with enrolling to access educational videos  Participates in the integrated care team meetings  Knowledge of disease diagnosis and prevention  Make assessment of patient's health status  Develop treatment plan  Implement a plan consistent with appropriate plan of care  Follow-up and evaluate patient's status  Other duties as assigned  

Teladoc Health

Registered Nurse, RX Fulfillment

Posted on:

July 31, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New York

Teladoc Health is a global, whole person care company made up of a diverse community of people dedicated to transforming the healthcare experience. As an employee, you’re empowered to show up every day as your most authentic self and be a part of something bigger – thriving both personally and professionally. Together, let’s empower people everywhere to live their healthiest lives.

The Nurse - RX Fulfillment (N-RXF) plays an integral part in ensuring superior care of patients treated through Teladoc. The N-RXF will apply professional knowledge in processing prescriptions ordered by Teladoc providers (either via phone or electronically), support Teladoc providers as dictated by established policies and guidelines and provide member support by phone or electronic messages. This position will cover weekend and evening shifts.

Qualifications Required for Position: Active RN; with BSN or MSN, NP in good standing. 1-3 years of clinical experience. Customer service experience in a health care setting. Ability to work a flexible schedule including evenings, weekends, and holidays as assigned weekly based on business need. Qualifications Preferred for Position BSN Preferred: Recent experience in the outpatient/urgent care setting preferred Virtual work experience preferred. Ability to work independently and as part of a high performing team. Strong knowledge base of prescription medications Demonstrated proficiency in mathematics, particularly with medication dosage calculations Exceptional customer service skills. Excellent written and verbal communication skills Bilingual-Spanish Speaking a plus Strong time management and organizational skills, with ability to effectively manage multiple, competing priorities. Possess high degree of computer literacy and ability to manage multiple systems including Microsoft software.

Deliver exceptional service to members, providers, care team members and external facilities representing Teladoc Health in a professional and courteous manner through a variety of communication channels including written, telephone, and video. Apply professional knowledge to ensure prescriptions are processed accurately and in a timely manner using established protocols, guidelines, and provider communication Communicate empathetically with members, using conflict resolution and service recovery skills as needed Conducts health coaching related to Tobacco Cessation Maintain detailed and accurate case documentation in the electronic health record Manage daily assignment to meet department-specific performance metrics by applying clinical knowledge to support members with post-Teladoc visit needs. Works collaboratively and with appropriate clinical urgency to meet expected turnaround times Maintain knowledge of Teladoc policies and prescribing guidelines Analyze complex clinical situations and appropriately provide solutions based on established protocols and policies. Review laboratory results and use established processes to escalate as needed Maintain member confidentiality and adhere to all applicable regulations, including HIPAA

Molina Healthcare

IRIS Self Direct Personal Care (RN) (Dane County, WI)

Posted on:

July 31, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Wisconsin

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.

Are you seeking a unique nursing position that gives you a great work/life balance and lets you support people to live the lives that they choose? Then you’ll want to keep reading about this rewarding work opportunity! We are currently looking for a Registered Nurse licensed in Wisconsin to become our next IRIS Self-Directed Personal Care (SDPC) RN. This is a remote position, where you will partner with people in your community who are enrolled in the Wisconsin IRIS program – a Medicaid long-term care option for older adults and people with disabilities. People in the IRIS program who need personal care services have the choice to enroll in the IRIS Self-Directed Personal Care (IRIS SPDC) option. You can learn more about IRIS SDPC on the Wisconsin Department of Health Services website here, and learn about the IRIS program here. While this role is home-based, you will have regularly scheduled visits with people in their homes and communities. As an IRIS SDPC RN, you’ll provide oversight and guidance to the people enrolled in the IRIS SDPC option. You’ll also build relationships with the people you partner with and ensure that they’re getting the most out of the IRIS Self-Directed Personal Care option through assessment, oversight, training and education. IRIS SDPC RNs are responsible for administering the Wisconsin Personal Care Screening Tool; creating person-centered plans of care; providing personal care oversight to a group of people in IRIS, providing education and training for IRIS participants and care providers, and conducting the required documentation and follow-up. As an IRIS SDPC RN, you’ll play an important role in helping people of various backgrounds and abilities live their lives the way they choose.

REQUIRED EDUCATION: Associates Degree in Nursing REQUIRED EXPERIENCE: Minimum 2 years of experience in nursing with at least one year of home health serving individuals with developmental disabilities, physical disabilities, or the elderly. Demonstrated computer and software skills required, proficiency with Microsoft Office Suite and database operation/maintenance skills and data entry experience. Excellent written and verbal communication skills required and the ability to adapt communication styles to fit situation. Strong teaching and mentoring skills. Strong analytical and problem-solving skills. Good organizational and time management skills with ability to manage tasks independently. Flexibility in the work environment and willingness and ability to adapt to changing organizational needs. REQUIRED LICENSE, CERTIFICATION, ASSOCIATION: Current unrestricted license in the state of Wisconsin as a Registered Nurse. Valid Driver’s License PREFERRED EDUCATION: Bachelor’s Degree in Nursing PREFERRED EXPERIENCE: Experience providing care through the Wisconsin Medicaid Personal Care Program or one year of home care experience

Provides personal care assessments and oversight to the My Cares Groups by administering the Wisconsin Personal Care Screening Tool and addendums as required Documents assessment as required by individual tool and Department of Health Services policies and by completing oversight visits and calls as required Oversees a My Cares Groups of participants, develops individual plans of care, ensures physician orders for care are obtained and reviews and revises plan of care as needed Submits for Prior Authorization for personal care services Complies with all Department of Health Services policies and SDPC Guidelines, procedures, and practices along with documentation and program regulations Provides personal care training to participants or care providers as requested and provides educational materials as needed Completes collateral contacts with IRIS Consultants and Long-Term Care Functional Screeners and physicians to ensure care needs are met Completes other duties as assigned Overtime work may be required May be required to drive 50% of the time during a given day of member home visits Exposure to members homes which may include navigating stairs, exposure to different environments, and pets

North Shore Health

Regional MDS Coordinator - Full-Time

Posted on:

July 31, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Wisconsin

North Shore Health and its facilities proudly serve communities in Wisconsin, Minnesota, and North Dakota by offering long-term skilled nursing care, short-term rehabilitation, and assisted living facilities. With organizational values such as trust, engagement, competence, respect, and passion, North Shore is dedicated to being The Right Choice for families and employees by establishing a culture that reinforces the values necessary to be the premier health services provider and employer in each of the communities they serve.

Must be a Registered Nurse (RN) with valid license - will oversee multiple local skilled nursing facilities Trust, engagement, competence, respect and passion – these are the values under which North Shore Healthcare operates every day. Our dedicated team of professionals strive to deliver quality care to our residents and their families. We are one of the leading employers and providers of post-acute care in the Midwest and we are seeking exceptional individuals to join our team. If you value being a leader, working in a progressive environment and having opportunities to grow in your career, North Shore Healthcare is the Right Choice for you.

Required Education and Experience: Current license to practice in the State as an RN RAI Certification via CMAC or AANAC/willing to complete 3+ years of PDPM experience and working knowledge of state payor systems 3+ years of skilled nursing experience with RAI/CMI focus Working knowledge of the MDS assessment cycle and assessment information Computer proficiency with Microsoft products Preferred Education And Experience: Experience in a fast-paced environment Experience managing multiple Centers Local travel approximately 75%

Nurse will assume the Medicare technical oversight and managed care responsibilities onsite and or in a remote capacity in a cluster of centers. They will be accountable for coordinating and overseeing the full collaborative, interdisciplinary assessment and care planning process. This process includes managing the completion of the comprehensive resident assessments; care coordination and planning; staff teaching; and adherence to the RAI guidelines. Conducting meetings, tracking payors, reviewing skilled criteria and handling the technical areas of Medicare and Managed Care are core job components. This is a manager position overseeing multiple local Centers.

Humana

RN Case Manager

Posted on:

July 31, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Wisconsin

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers, and our company. Through our Humana insurance services, and our 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.

Say goodbye to nights and weekends and hello to a work/life balance and more time with your family. Humana is seeking a RN Case Manager to serve members in the Wisconsin Family Care (FC) program. As an RN Case Manager, you will be responsible for partnering with your fellow colleagues to provide top quality coordination of care to our members. They are looking to you in providing assistance when it comes to living their daily lives. The role is responsible for facilitating the coordination, communication, negotiation, and collaboration of streamlined healthcare delivery processes on behalf of the member.

Required Qualifications: Associate degree in nursing. Must be a Registered Nurse, licensed in the state of Wisconsin. Preferred Qualifications: Bachelor degree in nursing. One (1)+ years of experience with Family Care target group: frail elders and adults with intellectual, developmental, or physical disabilities. Care Management experience. Additional Information Workstyle: This is a field position where employees perform their core duties at non-company locations, such as providing services at business partner facilities or prospects' and members' homes. Work Location: Viroqua/Prairie du Chein and surrounding area. Travel: up to 40% throughout Vernon and Crawford Counties and surrounding area Typical Work Days/Hours: Monday through Friday, 8:00 am – 4:30 pm CST. WAH Internet Statement: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees 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. Employees 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 employees 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. Driving: This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100/300/100 limits. TB: This role is considered patient facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

Partner with a Care Coach (also referred to as a Community Resource Coordinator) and collaborate on an ongoing basis regarding the member and their plan. Perform face-to-face health-related assessments for members upon enrollment and at least every six (6) months thereafter in the member’s setting. Coordinate, perform, and track quarterly face-to-face visits and monthly phone contacts. Participate in the development and ongoing review and coordination of the member’s plan of care. Take the lead on all health issues for the member. Contact and coordinate with acute and primary care providers. Identify and coordinate clinical and functional supports needed for the member’s health and safety. Educate on and promote prevention and wellness and mitigate risk when assessed. Document activity and complete paperwork as required. Traveling will be required and eligible for mileage reimbursement.

Clearlink Partners

Utilization Management RN (DC Licensed)

Posted on:

July 31, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

District of Columbia

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity. Clearlink Partners is a Health Plan Alliance Preferred Business Sponsor and ACAP Preferred Vendor.

Competencies: Ability to translate member needs and care gaps into a comprehensive member centered plan of care Ability to collaborate with others, exercising sensitivity and discretion as needed Strong understanding of managed care environment with population management as a key strategy Strong understanding of the community resource network for supporting at risk member needs Ability to collect, stage and analyze data to identify gaps and prioritize interventions Ability to work under pressure while managing competing demands and deadlines Well organized with meticulous attention to detail Strong sense of ownership, urgency, and drive The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families Excellent analytical-thinking/problem-solving skills The ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads The ability to offer positive customer service to every internal and external customer Experience: Current unencumbered RN with active District of Columbia license Minimum of 5+ years of acute clinical experience Minimum 2 years’ experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.) HMO and risk contracting experience preferred In-depth knowledge of current standard of medical practices and insurance benefit structures. Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills. Proficiency in Microsoft Office Physical Requirements: Must be able to sit in a chair for extended periods of time Must be able to speak so that you are able to accurately express ideas by means of the spoken word Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types Must be able to fluently communicate both verbally and in writing using the English language Time Zone: Eastern or Central

Specific: Determine appropriateness of services through the application and evaluation of medical guidelines, benefit determinations and compliance with state mandated regulated based on approved criteria (MCG, InterQual, etc.) Perform 15-30 reviews per day Performs initial and concurrent review of inpatient admissions Performs reviews for outpatient surgeries, and ancillary services Concludes medical necessity and appropriateness of services using clinical review criteria Collaborate with Medical Director(s) for appropriate referrals, complex cases and adverse determinations to ensure timely access to medically necessary/ appropriate services Accurately documents all review determinations, contacting providers and members according to established requirements and timeframes General: Perform daily work with a focus on the core principles of managed care: patient education, wellness and prevention programs, early screening and intervention and continuity of care Work proactively to expedite the care process Identify priorities and necessary processes to triage and deliver work Empower members to manage and improve their health, wellness, safety, adaptation, and self-care Assess and interpret member needs and identify appropriate, cost-effective solutions Identify and remediate gaps or delays in care/ services Advocate for treatment plans that are appropriate and cost-effective Work with low-income/ vulnerable populations to ensure access to care and address unmet needs Gather and evaluate clinical information to assess and expedite referrals within the healthcare system including consideration of alternate levels of care and services Facilitate timely and appropriate care and effective discharge planning Work collaboratively across the health care spectrum to improve quality of care Leverage experience/ expertise to observe performance and suggest improvement initiatives Ensure understanding of industry standard competencies and performance metrics to optimize decisions and clinical outcomes Ensure individual and team performance meets or exceeds the performance competencies and metrics Contribute actively and effectively to team discussions Share knowledge and expertise, willingly and collaboratively Provide outstanding customer service, internally and externally Follow and maintain compliance with regulatory agency requirements

Presbyterian Healthcare Services

Utilization Management Nurse Specialist

Posted on:

July 31, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

New Mexico

Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Now hiring a Utilization Management Nurse Specialist Albuquerque Metro Residents Only. The UM Nurse Specialist conducts clinical reviews to ensure that services provided to members meet clinical criteria and are delivered in appropriate settings. Using clinical expertise, coordinates, documents, and communicates all aspects of utilization and benefit management, handling both prospective (pre-service and concurrent) and retrospective care reviews. They assist providers and members in coordinating care with in-plan providers and preferred out-of-plan providers. Responsibilities include validating and interpreting medical documentation using evidence-based criteria, consulting with PHP medical directors on cases that do not meet clinical criteria, and identifying members with complex conditions who may benefit from case management or disease management services, referring them as appropriate to a Care Management program. The role also includes conducting retrospective medical claims audits, covering coding and DRG reviews, medical necessity assessments, and pricing and referring cases for Quality Management or Special Investigative Review when quality-of-care issues or potential abuse/fraud are identified. Additionally, the nurse may perform on-call duties, occasionally audit entities delegated for utilization management, and play a pivotal role in streamlining the prior authorization process to reduce delays in care, ultimately supporting optimal patient outcomes.

Ideal Candidate: Bachelors. NM Nursing license. 3-5 years nursing experience and 1-3 years experience in utilization management, prior authorization, or case management Qualifications An active New Mexico Nursing license is required. Candidate must have 3-5 years nursing experience and 1-3 years experience in utilization management, prior authorization, or case management. Strong knowledge of healthcare terminology, clinical guidelines, and insurance authorization processes; proficiency with EHR and case management software; and excellent communication, critical thinking, and organizational skills. For LPNs: An active New Mexico Nursing license is required. LPNs candidate with 3-5 years nursing experience and 1-3 years experience in utilization management, prior authorization, or case management; strong knowledge of healthcare terminology, clinical guidelines, and insurance authorization processes; proficiency with EHR and case management software; and excellent communication, critical thinking, and organizational skills will be considered.

The Prior Authorization Nurse is responsible for reviewing, verifying, and processing requests for the approval of pre-service and concurrent services, supplies, and procedures, including inpatient hospitalizations, diagnostic testing, outpatient procedures, home health services, durable medical equipment, and rehabilitative therapies. This role involves conducting retrospective reviews and performing on-site or desktop audits at provider locations throughout New Mexico, ensuring all documentation is accurate and complete. The nurse integrates coding principles and maintains objectivity in medical audit and care review activities. They monitor trends in utilization both under and over-utilization and identify potential quality-of-care issues, reporting them to management as needed. Effective communication with providers, PHP medical directors, and applicable departments is essential, and the nurse is evaluated on communication effectiveness through audits, satisfaction surveys, and 360 evaluations. They are required to meet departmental and regulatory turnaround times for prior authorizations, concurrent reviews, and retrospective reviews while adhering to Service Level Agreements (SLAs) and maintaining high productivity and quality standards. In performing review and evaluation, the nurse assesses prior authorization requests for services, thoroughly reviewing clinical documentation such as medical histories, diagnostic results, and treatment plans to determine medical necessity and make informed authorization decisions. They document review outcomes accurately in electronic health records and case management systems and communicate authorization decisions to providers, patients, and insurance teams promptly. Complex cases are escalated to higher-level reviewers or physicians as necessary. The nurse collaborates closely with healthcare providers to clarify requests, gather additional documentation, and resolve discrepancies, serving as a valuable resource on authorization procedures and criteria. They ensure strict adherence to regulatory guidelines, internal policies, and payer requirements, staying updated on relevant healthcare regulations, insurance policies, and medical criteria changes. In quality improvement efforts, the nurse participates in quality assurance initiatives, identifies trends, suggests areas for improvement, and helps pinpoint training needs. This comprehensive role supports the efficient and effective management of prior authorization processes, contributing to streamlined care delivery and positive patient outcomes. Follow all departmental policies and procedures. Performs other functions as required

VillageCare

Utilization Review Nurse

Posted on:

July 31, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

New York

VillageCare is a pioneering and innovative continuing care organization that provides managed care and community care options. We strive to understand the current state of need of those we serve and pursue appropriate responses. VillageCare recognizes and supports self-directed, interactive care. This enables being served to control aspects of their own care and helps them maintain their independence. VillageCare delivers care and services for more than 35,000 unique individuals annually through its health plan and community programs. Guided by the people we serve, we provide leadership to improve the health and quality of life of the diverse communities we serve and the quality of care and well-being of the people we serve.

RN- Utilization Review Nurse Inpatient *Full Time - 100% Remote Opportunity* COME WORK FOR THE LEADING, LOCAL MANAGED CARE COMPANY - VILLAGE CARE! VillageCare is looking for a self-motivated and passionate RN as Utilization Review Nurse for a Full-Time position. This is an exciting and dynamic position from the comfort of your own home as you will be responsible for the assessment of member needs and identification of solutions that promote high quality and cost effective health care services.

We would like to speak to those who have a current unrestricted NYS RN license to practice professional nursing, URAC preferred. Seeking those who bring a BSN (advanced degree preferred), along with 2+ years of utilization review experience at a Managed Care Organization or Health Plan required. Working knowledge of Medicaid and/or Medicare regulations as well as coverage guidelines and benefit limitations. The ability to apply Interqual/ Milliman Care Guidelines and other applicable, evidenced-based clinical guidelines will be vital to this role. Inpatient experience required. MLTC and Hospital/SNF experience required. Must reside within the New York Tri-State Area - NY, NJ, or CT.

Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria - prospective, concurrent and retrospective review. Frequently collaborates and communicates with physician peer reviewers and medical directors in determining coverage of requested services. Provide intervention and coordination to decrease delays and denials. Maintains timely, complete and accurate documentation in compliance with VCMAX policies and procedures. Support Quality and Performance Improvement Initiatives. Timely follow-up on results of denial and internal appeal reviews.

Strategic Staffing Solutions

Registered Nurse Case Manager

Posted on:

July 31, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Michigan

Strategic Staffing Solutions (S3) is a woman-owned, global IT consulting and business services corporation that delivers staff augmentation, managed services, total workforce management programs, and direct hire recruiting with industry expertise in financial services, energy and utilities, healthcare, and insurance. S3’s Consultants are placed with Customers throughout the U.S., Europe, and the Americas. Founded in Detroit, MI in 1990, S3 has reported consistent growth and profit every year and carries zero debt. Since 2000, it has donated more than $44 million to charities and community organizations around the world.

STRATEGIC STAFFING SOLUTIONS (S3) HAS AN OPENING! Strategic Staffing Solutions is currently looking for an RN Case Manager for a contract opportunity with one of our largest clients located in Detroit, MI! Title: RN Case Manager Location: Detroit, MI (Remote however must be local to Michigan) Duration: 12+ Months W2 Pay Rate: 40/HR Schedule: Monday - Friday 8-5 Role Summary The Case 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 online messaging platform. The Case 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 Associates degree in nursing required. Bachelor’s degree in nursing strongly preferred. 3 years of clinical nursing experience in a clinical, acute/post-acute care, and community setting required. 1 year of case management experience in a managed care setting 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 Beware of scams. S3 never asks for money during its onboarding process

Lead the coordination of a regionally aligned, multidisciplinary team to provide holistic care to meet member needs telephonic and/or digitally. 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. 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).

Somatus

Registered Nurse Care Manager

Posted on:

July 30, 2025

Job Type:

Full-Time

Role Type:

Care 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. Showing Up for You We offer more than 25 Health, Growth, and Wealth Work Perks to help teammates learn, grow, and be the best version of themselves, including: Subsidized, personal healthcare coverage (medical, dental vision) Accrual of 3 weeks’ Vacation (PTO) Professional Development, CEU, and Tuition Reimbursement Curated Wellness Benefits supporting teammates physical and mental well-being Community engagement opportunities And more!

The RN Care Manager is a critical member of the care team consisting of nurses, dietitians, pharmacists, social workers, community health workers, and physicians. This position will be working closely with complex renal patients in their home, dialysis center, by phone and electronically as needed. The primary focus will be to improve patient outcomes by helping patients get permanent access, promoting home dialysis modalities & kidney transplantation, educating patients on self-management, addressing risks associated with comorbid conditions, and coordinating their care.

Required: 1+ years of nursing experience in case management or care management, preferably coordinating care across multiple settings. 2+ years healthcare related experience. Current, unrestricted compact Registered Nurse license Requires all teammates to maintain current, valid BLS certification ONLY from a licensed AHA or American Red Cross training facility or provider. Core values consistent with a patient-centered approach to care Proactively acts as a patient advocate and responds with resolve. Knowledge and experience to empower patients in self-management and shared decision making Enjoys working collaboratively with team members. Effective written and verbal communication skills demonstrating respect and cultural awareness during interactions with clients. Strong analytical and critical thinking skills. Strong community engagement and facilitation skills Preferred: Bachelor’s degree in nursing Demonstrates empathy, enthusiasm, a great sense of humor, and a strong work ethic. Experience working with vulnerable patient population (ESRD, geriatrics, minorities, low income, uninsured, etc.) Ability to establish rapport with patient and family by inquiring and listening. Familiar with electronic medical records Community Outreach experience preferred. Competence using MS Office products and telecom devices.

Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical, and social needs of the patient, identify gaps in care and barriers to good health; The RN Care Manager is expected to conduct approximately 12 assessments per week and manage a panel of about 150 assessed patients. Based on this assessment, and in conjunction with the patient, patient’s nephrologist & PCP, and other members of the care team, create and implement a care plan that will address identified needs, remove barriers to care, and improve the health of the patient; Coordinate care by serving as the advocate and resource for the patient, their family, and their provider(s); Facilitate care across the continuum of care, spanning settings such as the home, hospital, skilled nursing facility, and acute care facility; Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions; Assess the patient’s knowledge of their renal condition and provide education and self-management support; Provide ongoing reassessment and follow-up to improve patient outcomes. Provide clinical oversight to non-licensed support team of community health workers and health coaches and licensed support team of social workers and renal dietitians, and delegate tasks as appropriate. Measures of Success: Provider Relationships Dialysis Interventions monitoring and coordination Medical Management

Aptive Resources

Telehealth Registered Nurse - Case Manager

Posted on:

July 30, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Virginia

Aptive is a modern federal consulting firm focused on human experience, digital services, and business transformation. We harness creativity, technology, and culture to connect people and systems to impact the world. We’re advisors, strategists, and engineers focused on people, above all else. We believe in generating success collaboratively, leaving client organizations stronger after every engagement and building trust for the next big challenge. Our work inspires people, fuels change and makes an impact. Join our team to be part of positive change in your community and our nation.

Aptive Resources is seeking a dedicated and compassionate Registered Nurse Case Manager to support the Teleconology Division at the Veterans Health Services. This role involves providing high-quality, patient-centered care to our veterans. The ideal candidate will possess strong clinical assessment skills and a commitment to teamwork and excellence in patient care.

Minimum Qualifications: Graduation from an accredited school of professional nursing approved by the appropriate State agency. Current and unrestricted licensure as a Registered Nurse (RN). BLS certification is required; ACLS certification is preferred. Minimum of 2 years of clinical experience in an acute care setting is preferred. Strong clinical assessment and critical thinking skills. Excellent communication, interpersonal, and teamwork abilities. Commitment to providing compassionate, patient-centered care. Desired Qualifications: Experience working with veterans or within a VA medical facility. Familiarity with electronic health records and care coordination platforms. Ability to work independently and manage multiple priorities in a fast-paced environment.

Coordinate and manage comprehensive patient care plans for veterans, ensuring all medical and psychosocial needs are met. Collaborate with interdisciplinary teams at the Teleoncology Division to provide holistic care and optimize patient outcomes. Conduct clinical assessments and develop individualized care plans tailored to veterans' unique needs. Monitor patient progress and adjust care plans as necessary to ensure the highest quality of care. Educate patients and their families about health conditions, treatment options, and available resources. Facilitate communication between patients, families, and healthcare providers to ensure a seamless care experience. Maintain accurate and up-to-date patient records in compliance with VA policies and procedures.

Advantage Health Centers

Licensed Practical Nurse - Call Center (Work from home-In Michigan)

Posted on:

July 30, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

LPN/LVN

State License:

Michigan

Advantage Health is a Federally Qualified Health Center with a proven track record of providing comprehensive, quality, cost-effective, preventive and primary health care, including medical, dental, behavioral health, and social services, to persons who are uninsured, medically underserved, and homeless or have a history of homelessness. This health center receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

The LPN functions under the supervision of the clinical director and provides phone triage to determine the priority of care for established and new clinic patients. The LPN also manages messages of clinical matters such as external physician or specialist requests, medication refills, and referral inquiries to make sure information is given to the appropriate clinical parties. Individual must be able to manage demanding workload with accuracy. Position requires excellent customer service skills with patients, and their families, other staff, physicians, vendors, and the public.

Knowledge, skills, and abilities: Must possess excellent verbal and written communication skills as well as excellent interpersonal skills with patients, staff, and other health care professionals. Ability to assess, plan, implement and evaluate nursing care according to individual needs Basic understanding of health clinic processes and operations is required. Understanding of FQHC processes and operations preferred Knowledge of applicable Federal, State and local laws and regulations, the Integrity/ Compliance Program, Code of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior; Working knowledge of various clinical systems Minimum qualifications Education: Completion of certificate from accredited LPN course with passing of the NCLEX-PN exam. Licensure/Certifications Licensure with the Michigan Board of Nursing Basic Life Support (BLS) certificate (or within 3 months of hire) Work Experience: 2-3 years clinical experience Experience with an Federally Qualified Health Center (FQHC) or outpatient medical facility preferred Physical Requirements: Moderate exposure to adverse working conditions in performing certain activities Must be able to hear and speak clearly in order to communicate information to patients, staff, and other community members or visitors Vision adequate to read documents, a computer screen, clinic related documents and forms Manual dexterity; the ability to lift up to 20 pounds independently; ability to sit, stand, walk, and bend frequently

Answer calls and respond to emails Handle customer inquiries both over the phone and by email Research required information using available resources Enter new patient information into electronic medical record (EMR) system Update existing patient information Identify and escalate priority issues Route calls to the appropriate resource Follow up customer calls where necessary Document all call information according to standard operating procedures Complete call logs Produce call reports

CorroHealth

Trainer, Clinical Solutions

Posted on:

July 30, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Texas

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.

As a Clinical Trainer for CorroHealth, you’ll have the opportunity to provide education to new and existing clinical team members. You will be an interdisciplinary resource amongst the Versalus clinical teams, acting in a variety of roles – such as subject matter expert, coach, and mentor. CorroHealth offers a career path that allows you to continue using your clinical knowledge and allows for the work/life balance you desire while expanding your knowledge base in Utilization Review. Location: Remote within US only Required Schedule: Monday - Friday, 8:00 AM - 5:00 PM EST The Impact You Will Have: CorroHealth is led by like-minded clinicians who share the same innate calling to help. Over the last 20 years, many hospitals have struggled financially due to complex regulations and policy changes set forth by Medicare and private payer organizations. CorroHealth clinicians lead challenging and rewarding careers by providing our hospital clients with guidance to improve compliance and ensure appropriate payment for the care delivered. Your direct impact will not only help the hospitals we serve, but also the communities that rely on their services and clinicians providing hands-on patient care.

Registered Nurse (RN) with 2–3 years of recent hands-on experience in acute care settings-Emergency Department (ED), Trauma, ICU, or similar high-acuity hospital environments. Teaching, precepting, or onboarding background strongly preferred. You should feel confident guiding new clinicians and tailoring training to different learning styles. Highly proficient with technology and digital tools. The role demands seamless multitasking across multiple platforms and systems, often simultaneously. Excellent communication and collaboration skills. You’ll work closely with physicians, trainers, and operational teams, so an adaptable and professional demeanor is key. Detail-oriented with strong documentation skills. Experience reviewing EMRs and entering clinical data accurately is essential. Comfortable working remotely and navigating virtual training spaces with independence and accountability.

The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member. Serve as a key training resource for CorroHealth clinicians, offering high-quality education and feedback aligned with CorroClinical operational procedures. Navigate multiple digital systems simultaneously - you'll need to be extremely computer-savvy, comfortable toggling between platforms like EMRs, internal systems, and communication tools with precision and efficiency. Lead onboarding and training for new physicians, supporting them throughout intensive training periods ranging from 2 to 4+ weeks. You'll play a pivotal role in ensuring they understand documentation standards, platform navigation, and clinical workflows. Be cross trained across various training departments, expanding your expertise and building flexibility within the team. Your input will help shape onboarding strategies and operational training content. Access and analyze electronic medical records (EMRs) from clients remotely to identify critical clinical information, ensuring accurate documentation within CorroHealth’s information system. Collaborate with physicians, team leads, and operational leadership on training procedures, feedback mechanisms, and quality improvements. Deliver constructive feedback and maintain detailed documentation to support clinician development and operational excellence.

CVS Health

Case Manager, Registered Nurse (New Jersey)

Posted on:

July 30, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

New Jersey

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.

Standard Working hours Monday through Friday 8:00 AM -5:00 PM Eastern Standard Time (EST)\ Must reisde in New Jersey Help us elevate our patient 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 a life-changing impact on our members who are enrolled in Medicare 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 dually eligible members to change lives in markets across the country. Our Integrated Care Management (ICM) Care Managers are frontline advocates for members who cannot advocate for themselves. They are 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. The ICM care manager 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.

Required Qualifications: Must have active and unrestricted Compact Registered Nurse (RN) licensure in the state of New Jersey 3 years clinical practical experience preference: (diabetes, CHF, CKD, post-acute care, hospice, palliative care, cardiac) with Medicare members. 2 years Case Management, Discharge Planning, and/or Home Health Care Coordination experience Preferred Qualifications: Certified Case Manager 2 years Care Management, Discharge Planning and/or Home Health Care Coordination experience Bilingual preferred Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually Excellent analytical and problem-solving skills Effective communications, organizational, and interpersonal skills. Ability to work independently Effective computer skills including navigating multiple systems and keyboarding Demonstrates proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications Change management experience, being able to adapt to change. Education: Bachelor’s of Science Degree in Nursing

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. Collaborates with supervisor and other key stakeholders in the member’s healthcare 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. The protection and security of our colleagues is paramount. CVS Health encourages it’s nurses to meet with members in a public place if they feel that is more appropriate. If needed, security escort is also available

Optum

RN Case Manager

Posted on:

July 30, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

New York

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

Optum NY, (formerly Optum Tri-State NY) is seeking a RN Case Manager to join our team in Poughkeepsie, NY. Optum is a clinician-led care organization that is changing the way clinicians work and live. As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone. This position is mostly remote, with attendance to the Poughkeepsie, NY office as required for onsite meetings or training. This is high volume, customer service environment. You’ll need to be efficient, productive and thorough dealing with our members over the phone. Solid computer and software navigation skills are critical. You should also be solidly patient-focused and adaptable to changes.

Required Qualifications: Registered Nurse licensed to practice in New York State (NYS) with current NYS registration and in good standing 3+ years of diverse clinical experience; preferred in caring for the acutely ill members with multiple disease conditions Experience and proficiency working with electronic medical records Remote telephonic experience Knowledge of utilization management, quality improvement and discharge planning Knowledgeable in Microsoft Office applications including Outlook, Word and Excel Preferred Qualifications: Bachelor of Science in Nursing (B.S.N.) Certified Case Manager (CCM) Experience with Complex Case Management and NCQA requirements

Make outbound calls and receive inbound calls to assess members’ current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self-management Make referrals to outside sources Provide a complete continuum of quality care through close communication with members via telephonic interaction Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels

IntellaTriage

Remote Hospice Triage RN-PT 4:30a-11a+Sat & Sun 7:30-4p (CA RN license required)

Posted on:

July 30, 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 **MUST have an active California RN license **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 schedule: Work a minimum 2 shifts weekly 4:30a-11a 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

Sprinter Health

Family Nurse Practitioner - Indiana (Virtual - Contract through December 2025)

Posted on:

July 30, 2025

Job Type:

Full-Time

Role Type:

License:

NP/APP

State License:

Indiana

Sprinter Health is an on-demand mobile health service that sends medical professionals to patients’ homes to perform blood draws, diagnostic and low acuity services, and wellness visits. We are building the clinical and technological infrastructure to realize a future of healthcare untethered. We have a rapidly growing team of visionary leaders who are passionate about increasing access to care, lowering healthcare costs, and improving outcomes for patients.

Are you ready to join the pioneering healthcare team at Sprinter Health? We're looking for dynamic Nurse Practitioners who are ready to revolutionize healthcare delivery by conducting virtual wellness visits directly to patients in the comfort of their homes. As a Nurse Practitioner with Sprinter Health, you'll leverage your medical expertise to offer a wide range of healthcare services that could include but not limited to virtual adult and/or pediatric wellness visits, health assessments, and more! Successful candidates will have prior experience performing wellness visits, along with key traits such as dependability, professionalism, and problem-solving abilities. A commitment to delivering exceptional customer service is essential, as is the ability to work autonomously while maintaining high-quality standards. Above all, we're seeking individuals who are friendly, compassionate, empathetic, and deeply invested in providing personalized care to every patient they serve. If you're ready to make a difference in patients' lives and shape the future of healthcare, we invite you to join us at Sprinter Health.

Board Certified as a Family Nurse Practitioner Active Family Nurse Practitioner License Consistently exhibits the highest levels of professionalism, integrity, accountability, confidentiality, care and compassion to provide high quality health services Willingness to work in a revolutionary environment that sometimes necessitates last minute problem solving and out of the box thinking Technologically savvy and comfortable using tools such as laptops or mobile devices for charting and HIPAA secure messaging apps for care coordination Strong written and verbal communication skills Ability to work independently or in a team environment Pass national background check and valid clinical license search

Commencing the day… begin your day by reviewing your case load and preparing your technology, ensuring you have all of the right tools available to service your patients Navigating with ease… using easy and modern technology, you will navigate through your schedule for the day and partner with our clinical in-home team members (Sprinters) that will visit each patient’s home Creating meaningful bonds… you will have the opportunity to make a warm and welcoming connection with a diverse range of patients as you prepare to collect relevant information and perform various services Patient-centric, wellness exam… engage in proactive care by conducting thorough health risk assessments, medication reviews, cognitive screenings and empowering patients’ with educational information regarding their health and well-being Collaborative Patient Care … work directly with Sprinters to evaluate vital signs, arrange blood draws, and carry out necessary tasks to address the specific needs of the patient Comprehensive Care Coordination and Management… provide comprehensive care coordination and management, including preventive care interventions, medication management, referrals to specialists, community resources, and documentation of findings

Cambia Health Solutions

Care Management Nurse (Future Opportunities)

Posted on:

July 30, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Washington

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Work from home within Oregon, Washington, Idaho or Utah *Please be advised that this role is part of our candidate pool, which allows us to identify and attract exceptional talent for future opportunities. Although we may not have immediate openings, we invite you to submit your resume for consideration. By doing so, you will be included in our database and considered for all suitable positions as they become available, ensuring that you are among the first to be notified of new opportunities that match your skills and experience.* Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system. Who We Are Looking For: Every day, Cambia’s dedicated team of Care Management RN's are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our Care Management RN's provide clinical care management (such as case management, disease management, and/or care coordination) to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes. Oversees a collaborative process with the member and those involved in the member’s care to assess, plan, implement, coordinate, monitor and evaluate care as needed - all in service of creating a person-focused health care experience. Are you a Registered Nurse looking to transition out of bedside care and into a role that still utilizes your clinical expertise, but offers a fresh challenge? Is your goal to promote quality, cost-effective outcomes and improve overall health and wellbeing? Then this role may be the perfect fit.

Associate or Bachelor’s Degree in Nursing or related field 3 years of case management, utilization management, disease management, auditing or retrospective review experience Equivalent combination of education and experience Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) of direct clinical care. May need to have licensure in all four states served by Cambia: Idaho, Oregon, Utah, Washington. Must have at least one of the following: Bachelor’s degree (or higher) in a health or human services-related field (psychiatric RN or Masters’ degree in Behavioral Health preferred for behavioral health); or Registered nurse (RN) license (must have a current unrestricted RN license for medical care management) Skills and Attributes: Knowledge of health insurance industry trends, technology and contractual arrangements. General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems. Strong oral, written and interpersonal communication and customer service skills. Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively. Strong organization and time management skills with the ability to manage workload independently. Ability to think critically and make decision within individual role and responsibility.

Conducts case management activities, including assessment, planning, implementation, coordination, monitoring, and evaluation to identify and meet member needs. Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care, utilizing evidence-based criteria and practicing within the scope of their license. Collaborates with physician advisors, internal and external customers, and other departments to resolve claims, quality of care, member or provider issues, and identifies problems or needed changes, recommending resolutions and participating in quality improvement efforts. Serves as a resource to internal and external customers, responding to inquiries in a professional manner while protecting confidentiality of sensitive documents and issues. Provides consistent and accurate documentation, ensuring compliance with performance standards, corporate goals, and established timelines. Coordinates resources, organizes, and prioritizes assignments to meet goals and timelines. Monitors and evaluates the effectiveness of case management plans, gathering sufficient information to determine the plan's effectiveness and making adjustments as needed.

Guidehealth

RN Case Manager - Remote

Posted on:

July 30, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Illinois

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.  Join us as we put healthcare on a better path!!

As a registered nurse with an Illinois nursing license, you will work remotely to enhance the quality of member management, maximize both satisfaction and cost effectiveness, and assist in navigating the health care system as a collaborative health partner in their health care team. As an RN Case Manager, the RN will work closely with client and members alike to promote wellness, problem-solve, and assist members in realization of their personal health-care related goals. This role includes telephonic member and provider outreach, data collection and analyzation, reporting, clinical review, medical and behavioral health assessments, and documentation in compliance with Federal/State regulation, NCAQ standard, and company policies and procedures. This position is part of the Value Based Care Services team.

Current IL Registered Nurse License (State of Illinois requires Nursing Professional Staff to complete 20 hours of CE per 2-year license renewal cycle). Minimum of five years of experience in a variety of health care settings. Highly experienced in Case Management and Chronic Condition Management. Knowledge of utilization review, quality improvement, managed care, and/or community health. Previous remote and/or telephonic work experience. Basic knowledge of case management principles, healthcare management, and reimbursement components, with experience in motivational interviewing. Excellent clinical judgment, as well as highly skilled in verbal and written communication. Strong organizational. problem solving, and time management skills necessary. Ability to ensure timely completion of projects and assignments. Ability to prioritize and react based on rapidly changing business needs. Must have ability to work independently and remotely with multi-tasking skills for fast paced workflows. Must possess software knowledge including word processing and spreadsheets, computer skills including MS Word, Excel, Access, PDF, Outlook, etc. Experience navigating multiple EMR’s. A high speed/secured home internet connection, a private HIPAA compliant home office with a door that locks for security and privacy purposes, and back-up connection service options for internet outages. WHAT WE'D LOVE FOR YOU TO HAVE: Certification in Case Management preferred but not required

Pulling, sorting, and analyzing data to determine member eligibility for the Population Health management Program. Coordinating and providing care that is timely, effective, equitable, safe, and member-centric while following HMO processes. Managing case assignments which includes outreach, documentation, monitoring for case progression, and case closure. Meeting reporting and documentation standards while engaging in collaborative meetings with department staff and clients. Assisting members in reaching wellness and health-autonomy by addressing barriers, social determinants, member motivators, and psychosocial issues. Helping members make informed decisions by educating them on navigation through the HMO and healthcare spectrum while promoting quality and cost-effective interventions and outcomes. Supporting operational aspects of the division to meet the organization’s customer requirements and satisfaction. Maintaining confidentiality related to all computer programs, medical records, and data. Participation in QM/UM Committee Meetings including material preparation, minutes, data collection, and analysis, reporting, and follow-up tasks which may require in-person attendance. Rotation in off-hour/weekend calls if applicable. Responsible for continued professional growth and education that reflects knowledge and understanding of current nursing care practice as outlined in the Illinois Practice Act. Other responsibilities as assigned and per any changes in annual program requirements.

Molina Healthcare

RN Case Manager - Maternity/OB

Posted on:

July 30, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Michigan

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.

For this position we are seeking a (RN) Registered Nurse who must live and have a current active unrestricted RN license in the state of MI Case Manager RN will work in remote setting supporting our Medicaid Maternity/OB population. Looking for candidates with previous case management experience. We are looking for nurses who have vast experience with high-risk OB and/or maternity servcies. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. Local travel into our office (Detroit, MI) may be required (Team Meetings, Audits, and Trainings) Home office with internet connectivity of high speed required. Schedule: Monday thru Friday 8:30AM to 5:00PM EST (No weekends or Holidays) 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. Bachelor's Degree in Nursing preferred. Required Experience: 1-3 years in case management, disease management, managed care or medical or behavioral health settings. 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. Preferred Education: Bachelor's Degree in Nursing Preferred Experience: 3-5 years in case management, disease management, managed care or medical or behavioral health settings. Preferred License, Certification, Association: Active, unrestricted Certified Case Manager (CCM)

Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment. Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. Conducts face-to-face or home visits as required. Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Maintains ongoing member case load for regular outreach and management. Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members. Facilitates interdisciplinary care team meetings and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns. RNs provide consultation, recommendations and education as appropriate to non-RN case managers. RNs are assigned cases with members who have complex medical conditions and medication regimens RNs conduct medication reconciliation when needed.

Molina Healthcare

Telephonic Care Manager RN - High Risk OB

Posted on:

July 29, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Utah

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.

We are seeking a (RN) Registered Nurse who must live and have a current active unrestricted RN license in the state of UT. This position will support our Medicaid Population that is live within the state of UT. This position will have a case load and manage members enrolled in this program. We are looking for Registered Nurses who have experience working with manage care population and/or case management role. Excellent computer skills and diligence are especially important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. This is a Remote position, home office with internet connectivity of high speed required. (must be able to go into the office for team meetings and/or training events) Schedule: Monday thru Friday 8:00AM to 4:30 PM MST 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. Bachelor's Degree in Nursing preferred. Required Experience: 1-3 years in case management, disease management, managed care or medical or behavioral health settings. 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. Preferred Education: Bachelor's Degree in Nursing Preferred Experience: 3-5 years in case management, disease management, managed care or medical or behavioral health settings. Preferred License, Certification, Association Active, unrestricted Certified Case Manager (CCM)

Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment. Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. Conducts face-to-face or home visits as required. Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Maintains ongoing member case load for regular outreach and management. Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members. Facilitates interdisciplinary care team meetings and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns. 25- 40% local travel required. RNs provide consultation, recommendations and education as appropriate to non-RN case managers. RNs are assigned cases with members who have complex medical conditions and medication regimens RNs conduct medication reconciliation when needed.

CVS Health

Senior Manager, Clinical Health Services - Aetna Better Health VA - RN or BH

Posted on:

July 29, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

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.

The Senior Manager, Clinical Health Services plays a vital leadership role at Aetna Better Health of Virginia, overseeing the Maternal Health Team. This position is responsible for managing clinical team operations, fostering the development of high-performing teams, and ensuring the effective delivery of care management and coordination across the continuum of care—including assessment, planning, implementation, coordination, monitoring, and evaluation. The Senior Manager reports directly to the Senior Principal Clinical Leader. In this role, the Senior Manager helps establish and implement processes that support the efficient and effective delivery of healthcare services. They assist in coordinating patient care, optimizing care manager workflows, driving quality improvement initiatives, and maintaining compliance with regulatory standards. The Senior Manager collaborates closely with interdisciplinary teams to enhance member outcomes and contribute to overall operational excellence in clinical settings. This is a fully remote position with up to 35% in state travel. Eligible candidates must reside in Virginia.

Required Qualifications: Reside in Virginia Active and unrestricted Virginia RN or Clinical BH Licensure (LPC, LCSW, LMFT) Willing and able to travel up to 35% anywhere in the state of Virginia 2+ years of experience working directly with individuals who meet the Cardinal Care Priority Population criteria 2+ years of leadership experience Experience working in health care delivery systems Demonstrated ability to communicate with Members who have complex medical or Social Needs and who may have communication barriers Preferred Qualifications: 2+ years' experience managing multiple direct reports 3+ years' managed care experience with Aetna Education: If BH clinician, minimum of a master’s degree in behavioral health field and clinical license is required If RN, BSN degree preferred

Oversees managers of multiple teams, ensuring alignment with strategic goals. Mentors managers and assists in succession planning. Oversees operational efficiency across teams, identifies process improvements, and ensures compliance with state and federal guidelines. Acts as a subject matter expert for clinical knowledge to key internal and external constituents in the coordination and administration of benefits management initiatives and objectives. Develops and enforces policies to maintain regulatory compliance. Leads audit preparation and corrective action plans. Implements quality improvement initiatives to enhance the member experience and drive key performance metrics. Collaborates with executive leadership, state agencies, and external partners to align care management strategies with organizational goals. Analyzes performance trends, identifies gaps, and develops strategies for improvement. Develops training programs to enhance clinical and operational competencies across teams. Leads organization-wide initiatives to improve service delivery, regulatory adherence, and cost-effectiveness.

Urrly

Registered Nurse - Cardiology

Posted on:

July 29, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

At Urrly, we are transforming healthcare recruitment by specializing in both clinical talent and the professionals who power the business side of healthcare. Our true partnership approach combines expert recruiters with cutting-edge AI, automating administrative tasks and connecting candidates and companies at scale. This allows us to cut the average time to fill to 21.5 days—about half the industry average—while reducing hiring costs significantly. We excel in recruiting for clinical and telehealth roles, as well as sourcing finance professionals, technology experts, and executives who are critical to supporting healthcare operations. Our focus on value-based care models—including preventive, post-acute, telehealth, home health, and hospice—ensures that we match talent with organizations where they can have the greatest impact. Our proprietary role rubric allows us to assess both passive and active candidates with precision, delivering match scores that ensure the right talent fits the right opportunity. This tailored approach spans from nurse practitioners and allied health professionals to finance, IT, and leadership roles. By partnering with fast-growing healthcare organizations, we’ve reduced hiring costs by up to 85%, helping build the clinical and operational teams that shape the future of healthcare.

Step Into the Future of Cardiac Care – Fully Remote RN Role (PA License Required) Train on site for 2 days in Bethlehem, then work from anywhere. This is a remote RN role built for nurses who know cardiac care and want more control over their time. You’ll support cardiovascular patients virtually—no team to manage, just you and your clinical skillset doing what you do best.

Active RN license in Pennsylvania – No compact or multistate license required. Outpatient cardiology experience – 2+ years is a must. Strong communication – You’re clear, proactive, and know how to keep care moving. Tech comfort – Familiar with EMRs and telehealth workflows. Why This Role Works Remote-first – Train on-site, then do the work from home. No management – Zero supervisory responsibility. 100% clinical. Solid pay – $85K–$88K base salary. Mission-driven – Help shape how cardiovascular care is delivered—virtually.

Remote clinical support – Provide virtual education, care coordination, and follow-ups for cardiology patients. 2-day on-site training – You'll start with two days of on-site onboarding in Bethlehem, PA. EMR + telehealth tools – Work with systems that reduce admin work and make patient tracking smoother. Direct patient care – No direct reports or management. Just hands-on clinical nursing, virtually delivered. Care team collaboration – Coordinate care with physicians, APPs, and support staff to keep patients on track.

Urrly

Cardiology Nurse Practitioner

Posted on:

July 29, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Pennsylvania

At Urrly, we are transforming healthcare recruitment by specializing in both clinical talent and the professionals who power the business side of healthcare. Our true partnership approach combines expert recruiters with cutting-edge AI, automating administrative tasks and connecting candidates and companies at scale. This allows us to cut the average time to fill to 21.5 days—about half the industry average—while reducing hiring costs significantly. We excel in recruiting for clinical and telehealth roles, as well as sourcing finance professionals, technology experts, and executives who are critical to supporting healthcare operations. Our focus on value-based care models—including preventive, post-acute, telehealth, home health, and hospice—ensures that we match talent with organizations where they can have the greatest impact. Our proprietary role rubric allows us to assess both passive and active candidates with precision, delivering match scores that ensure the right talent fits the right opportunity. This tailored approach spans from nurse practitioners and allied health professionals to finance, IT, and leadership roles. By partnering with fast-growing healthcare organizations, we’ve reduced hiring costs by up to 85%, helping build the clinical and operational teams that shape the future of healthcare.

Remote cardiology, but with real connection. Train in person. Then work from anywhere. You’ll kick off with 4–6 weeks of in-person training in Bethlehem, PA. It’s how you get to know your cardiologists, build trust, and learn exactly how they practice. That connection? It’s what lets you work remotely at the top of your license—and do it with full confidence from the team. Training travel is fully covered. Whether you fly or drive, we provide a set budget and you decide how to use it. Fly a partner in for the weekend? Go for it. Just stay in budget.

Certified Nurse Practitioner license Active license in PA or NJ (both preferred) 3+ years in cardiology (outpatient preferred) Enrolled with Medicare/Medicaid + valid DEA Strong communication and comfort with tech

Treat and manage lower-acuity cardiac patients via telehealth Partner with cardiologists you trained with in person Monitor, adjust meds, and educate patients on lifestyle changes Keep care moving smoothly with EMRs and remote monitoring tools

Skin Clique

Advanced Practice Provider - Virtual Role for Former Skin Clique Providers

Posted on:

July 29, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

NP/APP

State License:

South Carolina

Founded by a Medical Doctor and Nurse Practitioner, Skin Clique was created to offer modern, science-backed care that empowers both providers and patients. We are committed to high-quality care, provider autonomy, and professional growth in the areas of aesthetics, skin health, and wellness. If you're ready to practice medicine your way—with flexibility, support, and a commitment to medically backed care that helps patients feel confident and well - Skin Clique is your next step. Sponsorship is not available for this position. U.S. work authoriziation is required.

Ready to Elevate Your Career in Telehealth with Flexibility, Wellness, and Skin Health at the Forefront? Skin Clique—the first nationwide concierge aesthetics and wellness practice, founded by a physician and nurse practitioner, and rooted in science—is expanding our provider network to include experienced, motivated Nurse Practitioners (NPs) and Physician Associates (PA-Cs) with a passion for skin health and comprehensive wellness. As a Telehealth NP/PA, you will conduct virtual consultations focused on skincare, prescribe medical-grade weight loss treatments, hair loss, sexual health, women’s health and prescription skin health; while offering expert guidance to improve patient wellness— from a remote, flexible setting. This role is ideal for a provider who is ready to build their own patient panel using personal and professional networks, while receiving full administrative, clinical, and regulatory support from Skin Clique. Why Join Skin Clique Build Your Patient Panel: Grow and manage your own patient panel by leveraging your connections and community, with the support and reputation of a nationally recognized brand. Remote Flexibility: Practice from anywhere. Conduct virtual synchronous and asynchronous visits and follow-ups without the need for in-person visits or a physical location. Training and Education: Receive comprehensive onboarding and continuous learning opportunities to stay current with recommended skin health, weight loss treatments, and wellness treatments. Operational Support: Access our EMR system, prescription tools, and back-end resources to streamline your workflow and reduce administrative burden. No Overhead: Eliminate the need for clinic or spa ownership. We handle logistics so you can focus on patient care including supervising physician as needed. Work-Life Balance: Set your own schedule and build a practice that works around your life—not the other way around.

Active and unrestricted NP or PA license in good standing Prescriptive authority and an active DEA license Ability to commit 10-20 hours per week building a robust patient panel Clinical experience in dermatology, primary care, weight management, or aesthetics is preferred Proven ability to independently build and manage a patient panel Proficiency with technology platforms and virtual consultations Strong interpersonal and communication skills Reliable internet connection and a quiet space for virtual care

Conduct asynchronous and synchronous visits for comprehensive skin health, weight loss, and wellness medicine Prescribe and manage medications Customize health treatment plans based on each patient’s needs and goals Build and retain a panel of patients through strong relationships and consistent follow-up Document asynchronous and synchronous visits and outcomes in Skin Clique’s digital EMR systems Stay informed on emerging clinical trends, product offerings, and compliance protocols

Skin Clique

Florida: Nurse Practitioner

Posted on:

July 29, 2025

Job Type:

Contract

Role Type:

License:

NP/APP

State License:

Florida

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.

Join Our Team as a PRN-1099 NP/PA for Concierge Aesthetics! No prior aesthetic experience required. Why Join the Clique Community? Best-in-Class Clinical Training: Receive industry-leading training focused on the latest techniques in aesthetic medicine, ensuring you stay ahead in clinical expertise and patient care. Hands-On Learning and Curriculum: Benefit from immersive, hands-on training combined with a comprehensive curriculum, blending virtual courses and live in-person sessions for real-world skill development. Competitive Compensation: Enjoy competitive reimbursement for both procedures and skincare sales, allowing you to earn while delivering exceptional care to your patients. Comprehensive Business Support: Focus on patient care while we handle the logistics. From insurance to electronic medical records and supplies, our operational support ensures you can thrive in your practice Practice-Building Guidance: Grow your patient base with expert strategies designed to help you build and scale a successful aesthetic practice, with ongoing support at every stage. Access to a Collaborative Community: Join a nationwide network of over 900 board-certified providers, where you can exchange knowledge, receive mentorship, and collaborate with peers dedicated to advancing skin health. Clinical Skincare Partnerships: Our national practice is already aligned with top-tier skincare brands, giving you access to high-quality products that complement your treatments and enhance patient outcomes. Ongoing Professional Growth: Stay at the forefront of aesthetic medicine with continuous education, mentorship, and advanced training opportunities, ensuring your skills and practice continue to evolve. A Chance to Transform Lives: Make a meaningful impact by improving the skin health of your patients, helping them feel confident and empowered through personalized, expert care. 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

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