Merakey

LumiLink Nursing Assistant Manager - Remote

Posted on:

November 5, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

Merakey is a leading developmental, behavioral health and education non-profit provider offering a breadth of integrated services to individuals and communities across the country. We leverage our size and expertise to develop innovative solutions and new models of care to meet the needs of individuals, their families, public and private healthcare funders and community partner organizations. We recognize that complex needs require a holistic approach. With our experience, expertise and compassion, we empower everyone within our communities to reach their fullest potential.

Position Type: Full-Time Shift: 2nd Shift - with week-ends Work Schedule: Wednesday - Sunday 3pm-11pm with every other week on call responsibilities Are you looking for an opportunity to advance your career while working with an extraordinary team? Our Merakey affiliate (LumiCare) is looking for a Remote Nursing Assistant Manager to join the team.

Schedule requirements - Wednesday - Sunday, 3pm-11pm with every other week on call responsibility (1st, 2nd, 3rd, weekends) Current/active U.S. Pennsylvania State RN licensure. Compact RN license or will obtain PA compact license within 1 month of hire (internal applicants) Minimum of 2 years’ clinical experience in an acute or ambulatory care setting within the U.S. Preferred IDD group home and supervisory experience

The Assistant Nursing Manager is responsible for providing scheduled on-call support to nursing staff, ensuring continuity of care and effective triage for health-related concerns. This role involves being available for staff questions, training, and scheduling needs during assigned on-call periods. The Assistant Nursing Manager will alternate weekend/after-hours on-call responsibilities with the Nursing Supervisor every week, including holidays, and may be required to flex shifts as needed to maintain adequate coverage and support nursing staff. Additional responsibilities include assisting in maintaining 24/7 RN coverage, responding to inquiries, and managing healthcare monitoring dashboards for the Health Monitoring Package and Nurse Connect Program. The role will serve in a leadership capacity with direct reports, overseeing performance, conducting interviews, and participating in hiring and termination decisions. This role will also be responsible for employee relations, providing coaching and support to ensure team accountability, growth, and alignment with organizational values.

Insight Global

Case Management Nurse

Posted on:

November 5, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Insight Global is an international professional services and staffing company specializing in delivering talent and technical solutions to Fortune 1000 companies across the IT, Non-IT, Healthcare, and Engineering industries. Fueled by staffing and talent experts, Evergreen, our professional services brand, brings technical advisors and culture consultants to help customers tackle their biggest challenges. With over 70 locations across North America, Europe, and Asia, and global staffing capabilities in 50+ countries, our teams of tech-enabled recruiters are dedicated to finding the right talent and technical solutions to help our customers thrive. At our core, we are dedicated to empowering people to do great things. That’s why we’re passionate about developing our people personally, professionally, and financially so they can be the light to the world around them. To find out more, visit www.insightglobal.com

Position: RN Care Managers Location: Remote (Must be in a Compact License State!) Duration: 6-month C2H Pay Rate: $35 - $40/hr Schedule: 40 hours per week, 9:00am – 6:00pm (1 hour lunch)

Active, unrestricted RN Compact license (Must reside in the state their license is valid in) 2+ years in case management, care management, or disease management for a health insurance company, a health navigator or a TPA 2+ years of remote care or telephonic case management Bachelor of Science in Nursing (BSN) Plusses: CCM (Certified Case Manager) certification

Insight Global is looking for a Remote Nurse Care Manager to support a virtual care and healthcare navigation company. This individual will act as a clinical partner helping high-risk and rising-risk members through proactive outreach, post-discharge planning, and care coordination. They will collaborate with a multidisciplinary team to develop and execute holistic care plans while ensuring that each member receives the guidance, education, and support they need throughout their healthcare journey. Day-to-day responsibilities include but are not limited to, coordinating communication with hospital care management teams, supporting medication reconciliation efforts, and navigating members to their employee resources. This is an awesome opportunity to join a tech-enabled care integrator and contribute to a growing Care & Case Management team!

Clarest Health

Remote Licensed Practical Nurse

Posted on:

November 5, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Akansas

CSS Health (a division of Clarest Health) is a software company that supports health insurance companies by providing software solutions and outsourced services. We license software to help manage medical programs, particularly the Medication Therapy Management (MTM) Program required by CMS for Medicare Part D. We also offer outsourced MTM services, utilizing our team of pharmacists, clinicians, and support staff to conduct Comprehensive Medication Reviews (CMRs) for our clients' members. These reviews are crucial for maintaining high star ratings in Medicare Part D programs.

Our Licensed Practical Nurse will play a key role in performing telephonic patient outreach, interviewing patients about their medications, and ensuring adherence and patient safety. This position does not involve hands-on care. Dept: Medication Management and Care Coordination Reports To: Nursing Supervisor Location: Remote eligible in AR, CA, FL, GA, IL, ME, MI, MO, NY, NC, OH, OK, OR, PA, TX, WV and WY Salary: Start at $22/hr with ample opportunity to increase base comp throughout the first year Schedule: Monday through Thursday: 11 a.m. to 7:00 p.m. and Friday: 9:00 a.m. to 5:00 p.m

Graduation from an accredited nursing program (LPN) or (LVN) with an active license. (Must be in good standing) At least 1 year of experience in the healthcare industry and/ or call center experience preferred. Intermediate understanding of Microsoft Office Suite (Excel, Word, etc.) and database navigation. Understanding of HIPAA, Privacy, Safety, and Compliance guidelines. Understanding of Medicare and Medicaid programs preferred. Knowledge of MTM and Transition of Care procedures and processes preferred. Skills + Abilities: Strong multitasking abilities to manage patient interactions and documentation efficiently. In-depth knowledge of medications, including common uses, side effects, and interactions. Ability to work as a team member, demonstrate professionalism, and possess strong telephonic communication skills. Attention to detail and exercise professional work ethics. Maintain a student mentality to continuously learn and improve in the role. Ability to navigate database systems efficiently. Excellent record-keeping techniques. Specific vision abilities include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus. Proficient with computers and comfortable learning new programs. Must have high-speed internet.

The ability to adhere to Clarest’s Code of Conduct, follow Clarest Compliance policies and procedures, and report any suspected violations of any federal or state laws to either their direct supervisor, Human Resources or the Compliance Officer Conduct telephonic patient interviews in both Spanish and English about their medications, including prescriptions and over-the-counter items. Discuss adherence, adverse effects, current health status, and provide therapeutic recommendations. Accurately document clinical data in patient charts. Identify potential issues based on patient interviews and information gathered. Maintain current knowledge of medications and adhere to CSS Health policies and procedures, including HIPAA, privacy, and security. Operate office equipment such as voicemail messaging systems, email, and various software applications to support operational processes. Multitask effectively to manage multiple patient interactions and documentation tasks simultaneously. Maintain a student mentality, continuously seeking opportunities to learn and stay updated on the latest in medication management and care coordination. Perform other duties or tasks as assigned or required. Must have high-speed internet.

Clarest Health

Remote Licensed Practical Nurse - Bilingual (Spanish)

Posted on:

November 5, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Virginia

CSS Health (a division of Clarest Health) is a software company that supports health insurance companies by providing software solutions and outsourced services. We license software to help manage medical programs, particularly the Medication Therapy Management (MTM) Program required by CMS for Medicare Part D. We also offer outsourced MTM services, utilizing our team of pharmacists, clinicians, and support staff to conduct Comprehensive Medication Reviews (CMRs) for our clients' members. These reviews are crucial for maintaining high star ratings in Medicare Part D programs.

Our Bilingual LPN Clinical Interviewer will play a key role in performing telephonic patient outreach, interviewing patients about their medications, and ensuring adherence and patient safety. This position does not involve hands-on care. Dept: Medication Management and Care Coordination Reports To: Nursing Supervisor Location: Remote Salary: Start at $23/hr with ample opportunity to increase base comp throughout the first year Schedule: Monday through Thursday: 11 a.m. to 7:00 p.m. and Friday: 9:00 a.m. to 5:00 p.m

Graduation from an accredited nursing program (LPN) or (LVN) with an active license. (Must be in good standing) At least 1 year of experience in the healthcare industry and/ or call center experience preferred. Fluency in both Spanish and English. Intermediate understanding of Microsoft Office Suite (Excel, Word, etc.) and database navigation. Understanding of HIPAA, Privacy, Safety, and Compliance guidelines. Understanding of Medicare and Medicaid programs preferred. Knowledge of MTM and Transition of Care procedures and processes preferred. Skills + Abilities: Strong multitasking abilities to manage patient interactions and documentation efficiently. In-depth knowledge of medications, including common uses, side effects, and interactions. Ability to work as a team member, demonstrate professionalism, and possess strong telephonic communication skills. Attention to detail and exercise professional work ethics. Maintain a student mentality to continuously learn and improve in the role. Ability to navigate database systems efficiently. Excellent record-keeping techniques. Specific vision abilities include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus. Proficient with computers and comfortable learning new programs. Must have high-speed internet.

The ability to adhere to Clarest’s Code of Conduct, follow Clarest Compliance policies and procedures, and report any suspected violations of any federal or state laws to either their direct supervisor, Human Resources or the Compliance Officer Conduct telephonic patient interviews in both Spanish and English about their medications, including prescriptions and over-the-counter items. Discuss adherence, adverse effects, current health status, and provide therapeutic recommendations. Accurately document clinical data in patient charts. Identify potential issues based on patient interviews and information gathered. Maintain current knowledge of medications and adhere to CSS Health policies and procedures, including HIPAA, privacy, and security. Operate office equipment such as voicemail messaging systems, email, and various software applications to support operational processes. Multitask effectively to manage multiple patient interactions and documentation tasks simultaneously. Maintain a student mentality, continuously seeking opportunities to learn and stay updated on the latest in medication management and care coordination. Perform other duties or tasks as assigned or required. Must have high-speed internet. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of this employee for this role.

BridgePoint Healthcare

Appeals Nurse (28670)

Posted on:

November 5, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Virginia

BridgePoint Healthcare is dedicated to promoting healing and wellness in a safe and welcoming environment, with an individualized path to recovery for each patient. BridgePoint Healthcare provides patient-centered, individualized care for patients requiring longer hospitalizations in post-acute care settings. We are a diversified provider of post-acute care in settings ranging from long-term acute care hospitals to skilled nursing facilities. Our locations include two in Washington, DC (BridgePoint Hospital National Harborside and BridgePoint Hospital Capitol Hill), and one in New Orleans (BridgePoint Continuing Care Hospital - West Jefferson Campus).

At BridgePoint, whether you work with patients every day or support those who do, you are making a difference that matters. We know the path to recovery doesn't happen alone. As a team, we work cohesively to meet each patients unique needs. We are a team-driven environment and we care about our own! Our employees form the foundation of everything we do optimizing patient healing and wellness, and creating a warm and welcoming environment. It is because of the dedication of our employees that we can live out our mission, vision, and company values every day. It is at BridgePoint where care, community, and careers happen.

Education: Associates degree. Bachelor's degree preferred. Licenses/Certification: Current RN - Registered Nurse license. Experience: Minimum 2 years of acute care experience in a hospital or LTACH. Safety Sensitive-Designated Positions

Here at BridgePoint, the Appeals Nurse is responsible for managing payer denials and coordinating the appeal process to ensure accurate reimbursement for medically necessary LTACH services. The Appeals Nurse role involves detailed clinical review of medical records, preparation of evidence-based appeal letters, and collaboration with physicians and clinical teams to support medical necessity, continued care, and regulatory compliance. The Appeals Nurse plays a critical role in protecting hospital revenue, improving documentation quality, and reducing denial rates across LTACH facilities.

Summit Home Care & Hospice

Quality Assurance Registered Nurse (9435)

Posted on:

November 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Ohio

Summit Home Care is a skilled home care agency committed to providing comprehensive health care in the comfort and convenience of home. Our mission is to positively impact quality of life by redefining the delivery of care. We are driven to exceed the standard of care that our competitors accept. The vision of Summit Home Care is to revolutionize health care in the home by becoming the unmatched leader across the US.

Summit Home Care and Hospice is searching for an experienced and motivated Quality Assurance Registered Nurse to join our Home Health & Hospice teams. At Summit, we believe healthcare should be personal, compassionate, and delivered where it matters most—at home. QA Registered Nurse Hours: Monday – Friday; Standard Business Hours (40 Hours/Week) Work Setting: Remote Approved Remote Location: Ohio Pay Rate: $28.00 – $31.00 per Hour Job Summary: The Quality Assurance (QA) Nurse is a professional, Registered Nurse (RN) responsible for analyzing data integrity and consistency of OASIS documentation and assessment processes. This position will ensure appropriate ICD-10 coding and sequencing and will work with clinical staff to clarify documentation and data integrity issues.

Associate or bachelor’s degree in nursing from as accredited school of nursing. A valid/active RN license in the state of Ohio. At least one (1) year of OASIS review required. 1-2 years of clinical home health experience preferred. OASIS certification preferred. Working knowledge of OASIS and ICD-10 coding. Knowledge of federal regulations and state licensure requirements. Proficient in Wellsky EMR. Working knowledge of Microsoft 365. Excellent coordination and communication skills. Detail oriented and able to work with minimal supervision. Must successfully pass a background check in accordance with state and federal regulations.

Prospectively review all OASIS assessments to ensure appropriateness, completeness, and compliance with federal and state regulations and organization policy. Utilize OASIS variation or alert reports when reviewing OASIS data. Ensure appropriate ICD-10 coding and sequencing as it relates to the patient's medical condition. Consult with appropriate clinical staff to clarify any data integrity issues and will work with the clinician to make appropriate corrections according to policy. Review visit utilization for appropriateness of care guidelines and patient condition; reports potential financial losses and/or underutilization to the clinical manager/designee. Notify organizational leadership of problematic trends as a result of OASIS review. Work with managers to address trends that affect the agency's outcome and process measures noted during OASIS review. Participate in Quality Improvement and Corporate Compliance activities as assigned. Assist with other chart audit activities as assigned. Maintain professional and technical knowledge by attending educational workshops and reviewing professional publications. May be requested to perform job-related tasks other than those stated in this description.

MPF Federal, LLC

Remote Call Center Nurse (RN-BSN) December Start

Posted on:

November 5, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

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 Shifts Available (Share Your Schedule Preference!) Day Shifts Evening Shifts Night Shifts Training Approximately 6 Weeks Paid Training | Monday-Friday, 8:00 AM - 4:30 PM Start Date: December 1, 2025 - You will be required to also work BOTH Christmas and New Years

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.

Mercor

Critical Care RN Nurse

Posted on:

November 5, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

California

Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.

Position: Registered Nurse Type: Independent Contractor Compensation: $60–$110/hour Location: Remote Duration: 3–4 weeks Commitment: 30–40 hours/week

Must-Have: 4+ years professional experience in your domain. Excellent written communication with strong grammar and spelling skills. Start Date: Immediately Compensation & Legal: Hourly contractor, Paid weekly via Stripe Connect.

Create deliverables addressing common requests in your professional domain. Review peer-developed deliverables to enhance AI research. Diagnose and solve real issues in AI model training and evaluation. Work independently and asynchronously to meet deadlines. Collaborate with AI research teams to improve model outputs.

Central California Alliance for Health

Temporary Quality Improvement Nurse PQI

Posted on:

November 5, 2025

Job Type:

Contract

Role Type:

Primary Care

License:

RN

State License:

California

We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.

Location: Mariposa County, California; Merced County, California; Monterey County, California; San Benito County, California; Santa Cruz County, California ABOUT THIS TEMP POSITION: This is a temporary position and the length of assignment is estimated to the end of the year with an opportunity for extension. The length of the assignment is always dependent on business need and dates may change. While the assignment would be at the Alliance, if selected, you would be an employee of a temporary employment agency that we would connect you with. OTHER INFORMATION: We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams. While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected. In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process. This is a temporary position and does not provide the benefits that are listed below (it is standard language from our regular job posts and cannot be altered or removed).

Desirable Qualifications: Experience in process improvement, practice coaching, or health care quality improvement Experience performing PQI activities Working knowledge of managed care, the Medi-Cal program, and related policy Working knowledge of the methods of conducting and interpreting quantitative and qualitative analysis Some knowledge of NCQA HEDIS abstracting guidelines Some knowledge of CPT and ICD coding principles To read the full position description, and list of requirements click here. Knowledge of: The principles and practices of clinical nursing Medical practice operations and healthcare delivery systems Ability to: Participate in and support internal and external audits Identify issues, conduct research, gather and analyze information and data, reach logical and sound conclusions, and make recommendations for action Analyze information and data and prepare oral and written reports Education and Experience: Current, unrestricted license as a Registered Nurse issued by the State of California Bachelor’s degree in Nursing and a minimum of three years of experience as a Registered Nurse in acute care or primary care with an emphasis on preventative care (a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

Reporting to the Clinical Safety Supervisor, this position: Develops, manages, and measures a comprehensive healthcare strategy in alignment with Department of Health Care Services (DHCS) standards of care and in collaboration with internal stakeholders and network providers to promote best evidence-based practices and improve member health outcomes Evaluates patient safety and quality issues and communicates findings to internal stakeholders, network providers and community partners

Ivim Health

Nurse Practitioner

Posted on:

November 5, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

At Ivim Health, we are redefining health and wellness through personalized care and innovative solutions. Our mission is to empower patients to achieve their health goals by tailoring care to their unique needs and perspectives. We believe in fostering collaborative partnerships with our patients, ensuring that their voices are at the heart of every decision. By combining compassion, continuous innovation, and a commitment to affordability and accessibility, we aim to create a world where personalized health care is not just a privilege but a standard. Together, we strive to enrich lives by supporting physical, mental, and emotional well-being—one patient at a time.

Job Title: Nurse Practitioner Department: Medical Reports To: Care Team Lead Nurse Practitioner Compensation: The starting base salary for this position is $125,000 annually, with a planned increase to $135,000 annually following a successful 90-day review period. Final compensation will be based on experience, qualifications, and performance during the initial ramp-up period Your Impact Starts Here At Ivim Health, we’re building a new standard for care—one that’s personal, accessible, and rooted in science. As a Nurse Practitioner on our clinical team, you’ll play a key role in delivering care that supports long-term wellness through evidence-based, patient-centered treatment. You’ll be joining the #1 rated telehealth platform, and the only platform with published, peer-reviewed data to support our high quality care model. We’re looking for an experienced NP (minimum 3 years of clinical practice and previous telehealth experience) who is confident in delivering care through telehealth. This fully remote role offers the opportunity to work with a diverse patient base focused on weight optimization, hormone balance, longevity, and overall wellness—including FDA-approved and compounded therapies, lifestyle-based plans, and data-informed strategies. In addition, the position offers a unique opportunity in telehealth to participate as a full-time, salaried, W2 provider with a full benefits package while having the flexibility offered by working through a remote platform. You’ll be part of a supportive, multidisciplinary team, collaborating to provide consistent, high-quality care to patients looking to take control of their health!

Required: Active NP license in one or more U.S. states (multi-state licensure preferred) Minimum of 3 years’ post-licensure clinical experience Prior experience in telehealth or virtual care delivery Strong understanding of obesity treatment, metabolic health, or hormone management Proficiency with digital health platforms and EHR systems Preferred: Experience in functional, integrative, or preventive care Familiarity with GLP-1s and compounded medication protocols Familiarity with HRT and bioidentical hormone replacement therapy Familiarity with anti-aging and longevity strategies to promote healthy aging Skills That Matter: Strong clinical decision-making and diagnostic skills. Excellent communication and interpersonal skills for telehealth patient interactions. Ability to work collaboratively in a fast-paced, remote multidisciplinary team. Commitment to patient-centered care with an empathetic approach to obesity management. Strong research and data analysis skills to stay informed on best practices.

Patient Evaluation & Management Conduct thorough medical evaluations for patients seeking weight management, hormone replacement, sexual health, longevity, and anti-aging programs focused on holistic, preventative care Develop comprehensive treatment plans incorporating nutrition, behavior modification, and pharmacological interventions. Monitor and adjust treatment plans based on patient progress, lab results, and response to medications. Patient Education & Support Educate patients and their families on health conditions, treatment options, and long-term wellness strategies. Guide patients in using remote health monitoring devices and telehealth applications. Multidisciplinary Team Collaboration Work within a multidisciplinary team, including physicians, nurse practitioners, registered nurses, nutritionists, and patient experience specialists. Foster effective communication to ensure a seamless, patient-centered care experience. Administrative & Quality Improvement Maintain accurate, confidential patient records within electronic health systems. Engage in continuous quality improvement initiatives to enhance telehealth services. Technical Skills & Digital Health Proficient in using EHR and telemedicine platforms for virtual consultations. Adapt quickly to new healthcare technologies and digital platforms.

Titan Financial LLC

Nurses/ NPs Healthcare- Remote Work

Posted on:

November 5, 2025

Job Type:

Part-Time

Role Type:

License:

NP/APP

State License:

New Jersey

We are seeking motivated healthcare professionals who want to work remotely in a flexible, part-time role. This position focuses on educating families and professionals about financial wellness while offering an opportunity to build extra income outside of your current career. What We Offer: Comprehensive training provided – no prior finance experience required Flexible schedule – work part-time or alongside your healthcare role Remote work – anywhere with internet access Mentorship and support from experienced leaders Growth opportunities for those who want to expand in sales & marketing

Current or former healthcare professional (RN, NP, PA, allied health, etc.) Passion for helping others improve their financial health Strong communication and relationship-building skills Self-motivated with a positive, coachable attitude Looking for additional income and flexibility

Educate individuals and families on financial literacy concepts Share financial solutions tailored to clients’ needs Network and connect with professionals Participate in ongoing training and development Support the team in sales and marketing initiatives

Banner Health

Associate Manager RN Denials Management

Posted on:

November 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Arizona

Headquartered in Arizona, Banner Health is one of the largest nonprofit health care systems in the country. The system owns and operates 33 acute-care hospitals, Banner Health Network, Banner – University Medicine, academic and employed physician groups, long-term care centers, outpatient surgery centers and an array of other services; including Banner Urgent Care, family clinics, home care and hospice services, pharmacies and a nursing registry. Banner Health is in six states: Arizona, California, Colorado, Nebraska, Nevada and Wyoming.

$37.14 - $61.90 / hour, based on location, education, & experience. In accordance with State Pay Transparency Rules. Innovation and highly trained staff. Banner Health recently earned Great Place To Work® Certification™. This recognition reflects our investment in workplace excellence and the happiness, satisfaction, wellbeing and fulfilment of our team members. Find out how we’re constantly improving to make Banner Health the best place to work and receive care. As an Associate Manager of RN Denials Management, you will be an integral part of leadership within the team. During your typical duties, you will have the opportunity to educate and develop team members, roll out process changes and projects, as well as troubleshooting questions from your team and outside stakeholders, and conducting review of findings. In this role you will have 10-12 direct reports who will be working centralized denials management for our 31 Banner facilities. A typical day would include overseeing RN denials mgt specialists and Audit team, posting bill reviews, and managing workflow and queue designation. The team is very independent and work remotely. Location: Remote, Banner supplies equipment Schedule: Exempt, Mon-Fri 8am-4:30pm AZ Time (No Weekends or Call) Position Summary: This position provides leadership, direction and support in response to denials from federal, state and commercial reimbursement programs. Provides leadership in clinical, financial, and personnel management within the department to result in overall reduction in payer clinical denials. Collaborates with Care Coordination, physician, Utilization Review, and other internal/external departments to overturn and/or reduction of payer denials. Reviews internal department practices and standards with staff to ensure maximum reimbursement while ensuring the provision of high quality, safe, and cost effective patient care. Demonstrates account denial and appeal review expertise and oversees the leadership of clinical, financial, and personnel management of the assigned department. This position supervises employees and participates in selection, orientation, counseling, evaluation and staff scheduling. Maintains clinical, leadership and post-acute care services knowledge and competency to evaluate denial and/or appeal outcomes related to delivery of clinical services.

Ideal Candidate: Must have at least 5 years experience as an RN, with current licensure in state of practice; Must have a bachelors degree or equivalent experience; At least 2 years of leadership, including Direct Reports; Ideal candidate will be experienced in Denials Management, Case review, and understanding of insurance. This can be a remote position if you live in the following state(s) only: AL, AK, AR, AZ, CA, CO, FL, GA, IA, ID, IN, KS, KY, LA, MD, MI, MN, MO, MS, NC, ND, NE, NH, NY, NM, NV, OH, OK, OR PA, SC, TN, TX, UT, VA, WA, WI, WV, WY Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care. Requires a level of education as normally demonstrated by a Bachelor’s degree. Requires Registered Nurse (R.N.) licensure in the state of practice. Requires experience in federal, state and commercial reimbursements and in reviewing clinical information typically acquired in three years auditing DRG coding and reimbursements. Requires five or more years of clinical nursing and/or related experience. Experience in hospital operations, reimbursement methods, medical staff relations, and the charging/billing is required. A working knowledge of utilization management and patient services is required. A working knowledge of medical and third party payer requirements and reimbursement methodologies is required. Highly developed human relation and communication skills are required. Must demonstrate critical thinking, problem-solving, effective communication, and time management skills. Must demonstrate ability to work independently as well as effectively with team members. Must have developed leadership skills, interpersonal skills and the ability to work collaboratively in a matrix model as normally demonstrated through increased scope with project work, stretch assignments, progressive scope and complexity. Preferred Qualifications" BSN preferred. Additional Related Education And/or Experience Preferred. Anticipated Closing Window (actual close date may be sooner): 2026-02-27

Oversees the operations of the team to ensure smooth and efficient payer denial and/or appeal review. Assures appropriate team assignments. Completes daily rounding on team members to ensure quality reviews of payer denials and/or appeals. Accurately and thoroughly completes documentation required for claims payment of services approved through concurrent review Supervises the team to ensure internal/external client and employee satisfaction while promoting quality denial and/or appeal reviews and retention. Serves as a real-time resource and assists with clinical expertise for team members and physicians for problem-solving on various denials and/or appeals related patient services, processes, and specific denial issues. Identifies educational needs regarding payor issues, functions as preceptor, and provides appropriate education. Develops leadership skills among staff including communication, decision-making problem-solving/critical thinking and employee engagement. Leads the development of staff and supports career advancement opportunities. Functions as a role model and encourages staff to participate in their own development. Responsible for selection, orientation, on-boarding, and retention. Demonstrates leadership through coaching, performance evaluations, corrective actions, and development opportunities to create a culture of learning. Assists in the daily operational resource management including staff, approve/edit time cards, supplies, and equipment, and ensures optimal productivity for the department. Tracks, monitors and documents denial causes and resolutions with appropriate management staff. Builds and continually updates a knowledge of payer requirements for covered treatment protocols by diagnosis, approval requirements for procedures, and coverage norms.

Banner Health

Trauma Registrar Remote

Posted on:

November 4, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Arizona

Headquartered in Arizona, Banner Health is one of the largest nonprofit health care systems in the country. The system owns and operates 33 acute-care hospitals, Banner Health Network, Banner – University Medicine, academic and employed physician groups, long-term care centers, outpatient surgery centers and an array of other services; including Banner Urgent Care, family clinics, home care and hospice services, pharmacies and a nursing registry. Banner Health is in six states: Arizona, California, Colorado, Nebraska, Nevada and Wyoming.

You must have working knowledge in anatomy and medical terminology and ICD 10 coding and knowledgeable with computer use. 2 or more years of coding, abstracting and data management work experience is required. Requires the ability to abstract registry data from the patient’s medical/health record. Exceptional data entry and data management skill sets are required. Experience with Trauma One is preferred. Must be able to work effectively with common office computer software, the Trauma Registry software, the electronic medical records system and databases, spreadsheet and graphical programs. RHIT, RHIA and Coder CPC certification preferred and LPN or RN is preferred. The ideal applicant will hold an RHIT Certification, ICD 10 Training and have up to two years of Trauma Registrar experience. Innovation and highly trained staff. Banner Health recently earned Great Place To Work® Certification™. This recognition reflects our investment in workplace excellence and the happiness, satisfaction, wellbeing and fulfilment of our team members. We are proud to foster an environment where our team members feel supported, fulfilled, and motivated to deliver the best care possible. Join us an be part of an innovative, supportive team dedicated to making Banner Health the best place to work and receive care. This remote role is Monday through Friday. Eligible only for applicants who reside in the following states: Arizona (AZ), California (CA), Colorado (CO), Nebraska (NE), Nevada (NV), and Wyoming (WY)." Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care. POSITION SUMMARY: This position participates in activities associated with the trauma registry, including data gathering, data abstraction, timely and accurate data entry/coding, data validation and reporting that meets trauma center requirements. Acts as a member of the multi-disciplinary trauma team to support patient quality and performance improvement initiatives.

Requires a level of education equivalent to that of a Registered Health Information Technologist (RHIT) or certified coder, including advanced education in medical terminology, anatomy and physiology. Must have or will have required course work, including the ATS trauma registrar course, AIS training course, within one year of hire. Must have a level of experience and ability in coding, abstracting and data management as normally acquired over two or more years of clinical and/or experience in a coding or clinical data management position. Requires the ability to interpret and comprehend information contained within the patient’s medical record and to find all required data elements for the Trauma Registry. Requires the ability to abstract registry data from the patient’s medical/health record using the above standard setters regarding abstracting and coding procedures. Must have excellent organizational, written and verbal communication skills, and the ability to prioritize multiple work projects and tasks. Exceptional data entry and data management skill sets are required with an expected high degree of accuracy. Must be able to work effectively with common office computer software, the Trauma Registry software, the electronic medical records system and databases, spreadsheet and graphical programs. PREFERRED QUALIFICATIONS: Registered Health Information Technologist or Registered Health Information Administrator certification (RHIT or RHIA), Certified Professional Coder (CPC), Certified Specialist Trauma Registry (CSTR) preferred. Past trauma registry experience preferred. Additional related education and/or experience preferred.

Collects required information for all injured trauma victims meeting inclusion criteria by reviewing multiple sources including medical records, EMS records, and various hospital software programs. Abstracts required data elements including basic patient demographics, clinical procedures, clinical and diagnostic results, etc. Enters data accurately related to the trauma patient's history, diagnosis, therapy, and outcome. Uses scaling and scoring tools such as current International Classification of Diseases codes (ICD), the Abbreviated Injury Scale (AIS) developed by the Association for the Advancement of Automotive Medicine (AAAM), and Injury Severity Score (ISS). Codes injuries and procedures for the database as required for clinical care, research, benchmarking and accreditation. Ensures the hospital remains compliant with all applicable standards as they relate the respective State registry, American College of Surgeons, National Trauma Data Bank, Trauma Quality Improvement Program (TQIP) and trauma center accreditation. Maintains the Trauma Registry database in compliance with state regulations and accreditation requirements. Assists team with documentation and management of the registry database as it relates to clinical research, benchmarking and accreditation. Develops and produces timely information/reports as requested and contributes to timely data submission to national and state agencies to ensure accreditation/verification/designation statuses are maintained. Works as an integral part of the trauma quality and performance improvement program by contributing to identification of opportunities for improvement and/or areas of concern commensurate with the level of training/knowledge/experience. Works independently under limited supervision. This position functions at assigned facility and has no budgetary responsibilities. Internal and external customers include physicians, clinical staff, facility employees, trauma team members and state and national agencies. Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.

Central California Alliance for Health

Quality Improvement Nurse PQI (RN)

Posted on:

November 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.

Location: Remote in California We have an opportunity to join the Alliance as a Quality Improvement Nurse PQI (RN) in the QI and Population Health Department. OTHER INFORMATION: We are in a hybrid work environment, and we anticipate that the interview process will take place remotely via Microsoft Teams. While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected. In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process. The full compensation range for this position is listed by location below. The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location). Typical areas in Zone 1: Bay Area, Sacramento, Los Angeles area, San Diego area Typical areas in Zone 2: Fresno area, Bakersfield, Central Valley (with the exception of Sacramento), Eastern California, Eureka area

Desirable Qualifications: Experience in process improvement, practice coaching, or health care quality improvement Experience performing PQI activities Working knowledge of managed care, the Medi-Cal program, and related policy Working knowledge of the methods of conducting and interpreting quantitative and qualitative analysis Some knowledge of NCQA HEDIS abstracting guidelines Some knowledge of CPT and ICD coding principles Knowledge of: The principles and practices of clinical nursing Medical practice operations and healthcare delivery systems Ability to: Participate in and support internal and external audits Identify issues, conduct research, gather and analyze information and data, reach logical and sound conclusions, and make recommendations for action Analyze information and data and prepare oral and written reports Education and Experience: Current, unrestricted license as a Registered Nurse issued by the State of California Bachelor’s degree in Nursing and a minimum of three years of experience as a Registered Nurse in acute care or primary care with an emphasis on preventative care (a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

Reporting to the Clinical Safety Supervisor, this position: Develops, manages, and measures a comprehensive healthcare strategy in alignment with Department of Health Care Services (DHCS) standards of care and in collaboration with internal stakeholders and network providers to promote best evidence-based practices and improve member health outcomes Evaluates patient safety and quality issues and communicates findings to internal stakeholders, network providers and community partners

Compunnel Inc.

Registered Nurse (Claims & Appeals Review)

Posted on:

November 4, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Florida

Compunnel Inc. is where AI-native solutions meet human ingenuity, helping enterprises reimagine talent, technology, and growth. A world where your people and your platforms don’t just coexist — they co-elevate. At Compunnel, we build bridges between intelligent systems and human potential, forging paths to transformation in real time. For over 30 years, we’ve been the quiet force behind digital revolutions. We speak two languages fluently: empathy and algorithm. Our AI-powered infrastructure weaves into human workflows (not over them), enabling clients to scale with agility, adapt with foresight, and compete with confidence. From coast to coast in the U.S. (30+ delivery centers) and across global innovation hubs in Canada, India, and the UK, we serve 200+ clients — including 23% of the Fortune 500. Whether you’re a global enterprise or a public sector agency, you lean on us for recruitment (IT, non-IT, public sector) and future-forward digital capabilities. Twelve times ranked on the Inc. 5000 list for fastest-growing private companies, our core strengths lie in Software Development, Cloud, Data Analytics, AI/ML, and Cybersecurity. But what defines us is how we activate them — turning insights into outcomes, plans into momentum. We’re also proud to be a certified Minority Business Enterprise (MBE) in the U.S. and Canada. Inclusion isn’t just values-speak — it’s baked into our DNA. Our alliances with AWS, Microsoft, UiPath, Google Cloud, and more reflect a commitment to staying at the bleeding edge of AI innovation and co-creating centers of excellence with our clients. Let’s not just build technology. Let’s build a future that’s intelligent, inclusive, and impossible to ignore.

Job Title: Registered Nurse – Claims & Appeals Review Location: Remote (Anywhere in Florida) Duration: 06 Months/Can be Extended Working hours: Day Shift Job Type: Subcon Pay Rate: Negotiable Position Purpose: The Quality Analyst is responsible for ensuring the accuracy, compliance, and timeliness of appeal reviews through both manual and automated reporting mechanisms. This role supports continuous improvement in clinical operations by identifying quality gaps, performing root cause analysis, and recommending corrective actions.

Education/Experience: Bachelor’s degree in healthcare, life sciences, or related field preferred 2+ years of experience in appeals, grievance, or quality assurance in a healthcare setting Experience with audit tools, EMR systems, and reporting platforms Licensure/Certification: Valid RN, LPN, or LVN license in applicable state (Florida) Skills: Strong analytical, leadership and documentation skills Proficiency in Excel and data visualization tools Familiarity with InterQual criteria and CMS guidelines Ability to work independently and manage multiple priorities

Review appeal cases and supporting documentation to ensure completeness and compliance with InterQual and contractual guidelines. Conduct manual audits and reporting to assess quality of appeal decisions and documentation. Analyze operational data and performance metrics to identify trends, errors, and improvement opportunities. Collaborate with clinicians and MD reviewers to validate decisions and escalate complex cases. Maintain dashboards and SLA tracking for appeals turnaround time, audit coverage, and accuracy. Support calibration sessions and feedback loops with transaction monitors and team leads. Document findings and prepare reports for internal and client-facing reviews. Ensure compliance with NCQA, CMS, and state regulations.

Mercor

Advanced Practice RN

Posted on:

November 4, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

California

Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey. Position: Nurse Practitioner Type: Independent Contractor Compensation: $80–$100/hour Location: Remote Duration: 3–4 weeks Commitment: 30–40 hours/week

Must-Have: 4+ years professional experience in the nursing domain. Excellent written communication with strong grammar and spelling skills. Start Date: Immediately Compensation & Legal: Hourly compensation, paid weekly via Stripe Connect. Payments based on services rendered; contractors maintain full control over their work schedule and methods. Application Process (Takes 20–30 mins to complete) Upload resume AI interview based on your resume Submit form Resources & Support: For details about the interview process and platform information, please check: https://talent.docs.mercor.com/welcome/welcome For any help or support, reach out to: support@mercor.com PS: Our team reviews applications daily. Please complete your AI interview and application steps to be considered for this opportunity

Create deliverables addressing common requests in the nursing domain. Review peer-developed deliverables to enhance AI research. Diagnose and solve real issues in machine learning systems. Contribute expertise to cutting-edge AI research. Work independently and asynchronously to meet deadlines.

NPHire

Work From Home Nurse Practitioner | Telehealth | Georgia NP | $200/hr

Posted on:

November 4, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

NP/APP

State License:

Georgia

A respected telehealth group is hiring Nurse Practitioners to provide acute care and wellness-focused virtual consultations. This position is perfect for new graduates and experienced providers who want to practice modern, patient-first telemedicine while maintaining complete control of their schedule. What’s Offered: $120–$200/hr (hourly contract) Flexible scheduling with full autonomy Malpractice insurance provided 100% remote telehealth model Expanding nationwide patient base Supportive clinical and admin teams

Active NP license in any U.S. state (all 50 accepted) FNP certification required GEORGIA licenses in high demand Strong clinical assessment & independent decision-making skills Excellent communication & EMR documentation abilities Telehealth experience preferred (not required) DEA registration a plus (for prescribing controlled medications) Comfortable with GLP-1, TRT, or peptides—or willing to train

Conduct acute care telehealth visits (UTI, sinus, ear infections, etc.) Offer on-demand consultations for weight loss, longevity, peptides, and ED Provide functional medicine care, including TRT and CIRS support Work with both synchronous (live) and asynchronous (messaging) consults Collaborate with a professional virtual care team across multiple states

Joint Commission

Surveyor - Home and Hospice Care Registered Nurse

Posted on:

November 4, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

Illinois

Joint Commission enables and affirms the highest standards of healthcare quality and patient safety for all. Founded in 1951, it is the nation’s oldest and largest standards-setting and accrediting body in healthcare, evaluating more than 23,000 healthcare organizations and programs across the United States. As an independent, nonprofit organization, Joint Commission inspires healthcare organizations across all settings to excel in providing safe and effective care of the highest quality and value.

Nationwide Search for a Home Health and Hospice Care Registered Nurse Surveyor Seeking Registered Nurses located anywhere in the United States for this remote opportunity. Seeking Candidates with Home Health and Hospice Care experience.

Requirements: Qualified candidates must be a graduate of approved school of nursing and hold a Master’s degree in appropriate discipline. Current professional license in discipline required at time at time of hire and must be maintained throughout the duration of employment. Certification requirement: You must hold a CPHQ certification (Certified Professional in Healthcare Quality) through National Association for Healthcare Quality (NAHQ) at time of hire or attain by 12/31/28. Candidates must have five years of recent healthcare experience, including 3 years of direct clinical experience in the appropriate health care settings, and 2 years of accreditation or certification leadership or senior management experience. Qualified candidates must have knowledge of Joint Commission standards with direct involvement in two Joint Commission surveys. Previous experience in Home Healthcare and Hospice care required. Experience working in a Medicare Certified home health agency is required. Ideal candidates will have experience in a culturally diverse work environment; fluency in Spanish is a plus. The team players we select to take on these highly visible, challenging roles will have strong interpersonal, communication and problem-solving skills, expertise in interviewing, and PC proficiency. Physical Abilities: Must be able to observe, in real time and without slowing or otherwise interrupting the progress of, all applicable types of ongoing health care treatment (e.g., including emergency treatment, treatment during weather and other extreme situations, etc.). Standing for long periods of time, walking lengthy distances, lifting, climbing, stooping, pulling, and pushing in order to adequately inspect and observe all medical facilities, equipment and procedures, such as emergency exit procedures, remote storage facilities, any areas where cleanliness may affect the possibility of infection, medical equipment, etc., including the following activities: walking up and down stairways (e.g., to test escape routes, assess safety of emergency exits, regulatory compliance, etc.); removing obstructed covers or impediments to equipment or other mechanical areas; examining small and often dirty printed labels and print on equipment; Must be able to engage in extensive travel as set forth above, including driving a car to remote locations, flying on small airplanes and into small airports, traveling in all types of weather conditions, etc. Candidates interested in part time positions must be available to work two or three weeks per month, and must provide three or four weeks of availability for the purpose of scheduling. All positions require 100% nationwide travel (paid). We offer a full benefits package including medical, dental, vision, 401k, pension and a generous paid time off (PTO) package. Full time - 1.0 FTE requires 4 weeks out of the month with 100% travel.

The RN Field Representative surveys hospice and home care organizations throughout the United States. Applies systems analysis skills and inductive reasoning skills to determine health care organizations' degree of compliance with applicable standards and functionality of care delivery systems. Engages health care organization staff in interactive dialogues on standards based issues in health care in order to assess compliance and to identify opportunities for improving compliance. Prepares management reports that clearly link individual standards deficiencies with potential systems vulnerabilities and related organization risk points. Effectively communicates this information to health care organization leadership in a constructive and collegial style. Participates in other Joint Commission activities as assigned by supervisor.

Performant Healthcare, Inc.

Manager, Itemized Bill Review (Hospital Bill Pay Review) - RN/Medical Coder

Posted on:

November 4, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Florida

At Performant, we’re focused on helping our clients achieve their goals by providing technology-enabled services which identify improper payments and recoup or prevent losses due to errant billing practices. We are the premier independent healthcare payment integrity company in the US and a leader across several markets, including Medicare, Medicaid, and Commercial Healthcare. Through this important work we accomplish our mission: To offer innovative payment accuracy solutions that allow our clients to focus on what matter most – quality of care and healthier lives for all. If you are seeking an employer who values People, Innovation, Integrity, Fun, and fostering an Ownership Culture – then Performant is the place for you!

The Itemized Bill Review Manager is a key member of the medical review audit group and supports building a world class healthcare services organization. The leader in this role directs the timely delivery of high-quality Itemized Bill Review (IBR) audits for our business, ensuring organizational goals are met. This position may provide direct oversight of multiple departments and individual contributors, including Nurse Auditors and Coding Auditors. As such, the qualified individual for this role will be a “Nurse Coder”, holding an active RN license and Coding certification(s) in addition to having experience with IBR (also known as hospital bill pay review) audits. Hiring Range: $95,000 - $115,000

Possess a broad and comprehensive understanding of IBR standards and hospital bill pay review, policies and regulations, applies a broad and comprehensive knowledge in areas including medical chart reviews. Thorough working knowledge of CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding and demonstrated capability in developing and implementing effective coding audit strategies. Strong project management and interpersonal skills, makes sound decisions, exhibiting initiative and intuitive thinking. Consulted often by others for advice and opinions and recognized as a leadership role model. Problem solving, strong analytical skills, people skills, teamwork, people management, and managing processes. Strong interpersonal skills for interfacing with all levels of internal and external audit teams and management. Ability to prioritize and multitask. Must be a strong effective communicator, both orally and in writing, with an energetic, charismatic and approachable style. Proven experience in managing high performing, dynamic teams. Ability to work in a diverse and fast paced environment. Strong general technical skills, including, but not limited to Desktop and MS Office applications (Excel Skills required), application reporting tools, and other system/tools to review and document findings Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools. Acts as a change champion by being flexible and adaptable in a highly dynamic and rapidly changing environment. Able to ideate around how to work more efficiently (when necessary) and views work with a long-term vision. Consistently delivers on promises and deadlines. Skill in analyzing information, identifying trends and presenting solutions. Ability to independently organize, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively. Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions. Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives. Required and Preferred Qualifications: Registered Nurse with an unrestricted nursing license Certification as a CPC, CPC-H, CPC-P, RHIA, RHIT, CCS, or CCS-P; other relevant coding certification may be considered Must have sufficient depth and breadth of outpatient and/or inpatient coding experience BA/BS degree or 10+ years of business experience in healthcare with increasing levels of responsibility At least 7 years relevant clinical audit experience in the Health Care industry; IBR experience is required At least 3 years relevant experience managing staff in a healthcare related industry Experience in developing, documenting and implementing process and procedures

Performs, Develops and executes on itemized bill review (IBR) plans, in accordance with internal audit standards and relevant statement of work. Prepares reports and manages IBR activities for assigned clients. Applies in depth level of expertise in performing IBR audits and development of policies and procedures and workflows processes to review claims, and identify processing, procedural, systemic and billing errors and practices leading to claims inaccuracies; also applies in-depth expertise in both outpatient and inpatient medical coding to the development of policies, procedures, guidelines, coding issues/refining coding parameters, workflow and tools. Manages team members performing IBR activities to identify trends, determine root cause of payment inaccuracies, and to recommend process and systems improvements. Proactively identifies opportunities for process improvement, efficiency, resolving problems, preparing and completing action plans. Manages and trains team leaders and staff. Supports staff recruitment, develops auditors and builds effective teams. Supports subcontractor communication, oversight and reporting. Establishes accountability for performance monitoring (productivity/quality), communicates job expectations, trends, documentation, and ensures timelines are met. Supports strategy by conducting needs assessments, capacity planning, cost/benefit analyses, preparing staffing models, establishing productivity and quality standards. Maintains professional and technical knowledge by tracking emerging trends in IBR management; this may include attending educational workshops, reviewing professional publications, establishing personal networks, benchmarking state-of-the-art practices and participating in professional societies. Develops effective relationships with leaders in the organization and has a strong understanding of the business. Applies in-depth understanding of the inter-relationships of the business and support units throughout the organization. Accomplishes organizational goals by accepting ownership of requests; exploring opportunities to add value. Participates in business initiatives and pro-actively advises and assists the business on initiatives. Builds value and credibility with internal and external clients and represents the organization in meetings with the client, provider organizations, contractors, subcontractors and vendors. Uses excellent communication skills to influence a wide range of internal and external audiences. Provides timely response to escalated inquiries from the client and providers. Supports other departments in problem resolution as necessary. Completes required reports and ad hoc requests for information. Inspires trust and credibility; delivers on commitments; acts as IBR subject matter expert. Facilitates meetings as necessary. Performs other duties as assigned.

The Judge Group

Precertification RN

Posted on:

November 4, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

The Judge Group is an international leader in business technology consulting, talent solutions, and learning and development. With over 30 locations across the U.S., Canada & India, Judge is proud to partner with the best and brightest companies in business today, including over 60 of the Fortune 100. We serve organizations in financial services, healthcare, life sciences, insurance, government, aerospace & defense, manufacturing, and technology & telecommunications. Judge has always been committed to doing what’s right – for our colleagues, our client partners, and our communities. At Judge, we cultivate an inclusive environment that empowers our employees to produce their best work. As a family-owned business, we’re not just a high-performing team, but a high-performing family. Through building relationships and our cultural commitment to caring, we support one another.

Our client is currently seeking a Precertification RN: Precertification RN – PT/OT/ST & Bariatric Reviews Location: Remote (Must reside in PA, NJ, or DE) License Required: Active PA RN or LPN (Compact licenses not accepted) REQUIRED Contract Duration: Ongoing (3+ months) Join our dynamic Precertification team, where your clinical expertise will help ensure members receive medically necessary care in a timely and compliant manner. As a Precertification RN, you will conduct thorough reviews of medical records—including history and treatment plans—to determine the appropriateness of services such as physical therapy (PT), occupational therapy (OT), speech therapy (ST), and bariatric procedures. You’ll apply clinical criteria, collaborate with providers, and advocate for members navigating the healthcare system.

Must reside in Pennsylvania, New Jersey, or Delaware Active PA RN or LPN license (Compact licenses not accepted) Minimum 2 years of acute care experience in a hospital or healthcare setting Clinical background in orthopedic unit, outpatient ambulatory surgery center, or surgical unit Prior experience in medical management, precertification, or prior authorization Proficiency in Microsoft Word, Outlook, Excel, SharePoint, and Adobe InterQual experience highly preferred

Clinical Review & Determination: Evaluate healthcare service requests using advanced clinical knowledge and independent judgment Apply established guidelines (e.g., InterQual, Medical Policy) to assess medical necessity for inpatient admissions, procedures, and ancillary services Collaborate with providers to clarify clinical details and ensure alignment with criteria Refer cases to the Medical Director when services fall outside standard guidelines Care Coordination & Referral: Identify members early for discharge planning and coordinate appropriate transitions Refer cases to Case Management, Disease Management, or Quality Management as needed Compliance & Documentation: Confirm service coverage under member health plans Ensure all decisions meet federal, state, and accreditation standards Meet regulatory turnaround times and productivity goals Maintain accurate documentation and data integrity Utilization Management Monitor and report utilization trends Recommend process improvements to enhance efficiency and care quality

The Judge Group

Precertification RN

Posted on:

November 4, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

The Judge Group is an international leader in business technology consulting, talent solutions, and learning and development. With over 30 locations across the U.S., Canada & India, Judge is proud to partner with the best and brightest companies in business today, including over 60 of the Fortune 100. We serve organizations in financial services, healthcare, life sciences, insurance, government, aerospace & defense, manufacturing, and technology & telecommunications. Judge has always been committed to doing what’s right – for our colleagues, our client partners, and our communities. At Judge, we cultivate an inclusive environment that empowers our employees to produce their best work. As a family-owned business, we’re not just a high-performing team, but a high-performing family. Through building relationships and our cultural commitment to caring, we support one another.

Are you a compassionate and experienced RN with a background in NICU care? Do you thrive in a remote work environment and enjoy making a meaningful impact through utilization management? We’re looking for a dedicated Registered Nurse to join our clients team in a part-time remote role supporting hospital admission reviews and discharge planning. If you live in the tri-state area (PA, NJ, DE) and meet the qualifications below, we’d love to hear from you! Part-Time Work Schedule (Post-Training) Week 1: Monday & Tuesday Week 2: Wednesday, Thursday & Friday Repeats every two weeks Approximate weekly hours: 18 hours Position Summary: Under the direction of a designated Manager, the RN will perform telephonic reviews of hospital admissions, recommend alternative levels of care when appropriate, and promote efficient, high-quality healthcare delivery. The role includes early discharge planning, collaboration with hospital staff and physicians, and referral to case management when needed.

Training Requirements: Must be available Monday through Friday during regular business hours Training duration: 2–3 weeks Full-time hours required during training period Active RN license in PA or Compact license including PA Minimum 3 years of acute care hospital experience NICU experience required Prior utilization management and/or discharge planning experience BSN preferred

Conduct telephonic utilization management for inpatient admissions Assess medical necessity using established criteria Collaborate with attending physicians and hospital case managers Facilitate discharge planning and transitions of care Refer cases to Case Management and Disease Management Identify and report quality of care issues Maintain accurate documentation and compliance Provide exceptional customer service and provider education

VITALE NURSING INC

Licensed Vocational Nurse- Private Duty

Posted on:

November 4, 2025

Job Type:

Part-Time

Role Type:

License:

LPN/LVN

State License:

California

VITALE NURSING INC is a company based out of 8549 WILSHIRE BLVD SUITE #813, BEVERLY HILLS, California, United States. Providing compassionate care with a gentle touch. We know it isn’t just bodies that need care, it’s hearts and minds as well. We listen to our clients with a tender ear so they feel completely heard and understood. All services are provided in luxurious comfort and with complete confidentiality. We provide caregiving services for patients in any length of required care. Caregivers are available from 8-24 hours a day, 7 days a week. A wide spectrum of hospitals, doctors, and insurance companies all trust Vitale Nursing, Inc. to provide excellent care, often for patients with special circumstances who require in-home services.

Private Duty Licensed Vocational Nurse (LVN) Vitale Nursing, Inc. – Beverly Hills, Bel-Air, Brentwood, Santa Monica, Pacific Palisades Vitale Nursing, Inc. is seeking compassionate, skilled, and professional Licensed Vocational Nurses (LVNs) to join our concierge-level home health team. Our LVNs provide direct, one-on-one patient care in private homes and recovery settings, ensuring the highest standards of safety, professionalism, and compassion.

Preferred Clinical Experience: IV therapy and blood draws (if certified) Post-operative recovery and wound care G-tube and stroke patient support Tracheostomy and ventilator care (experience strongly preferred) Medication administration and monitoring Hospice and palliative care support Minimum Requirements: Valid California LVN License Current BLS Certification (ACLS preferred) Reliable transportation Strong communication and clinical skills Professional, punctual, and trustworthy demeanor Three professional references Proof of Malpractice Insurance Successful completion of a background check Required Documentation: Valid California LVN license Two forms of identification (Driver’s License/Passport and Social Security card) Signed employee agreement (provided during hiring) Completed application (provided during hiring) Physical exam and TB test (within 1 year) Current CPR/BLS certification Proof of COVID-19 vaccination and booster (or plan to obtain) Proof of Malpractice Insurance

Provide direct nursing care to patients in private residences or hotel recovery suites Assist patients with ADLs (Activities of Daily Living) such as bathing, dressing, grooming, toileting, feeding, and mobility support Administer and oversee medication management, including reminders, administration (within LVN scope), and monitoring for safety and effectiveness Provide post-operative care, wound care, and recovery support under RN or physician guidance Assist with long-term in-home assignments and palliative care patients Monitor vital signs, patient status, and promptly report changes to supervising RN or physician Conduct documentation in compliance with Vitale Nursing, Inc. standards and state requirements Assignments are available in Beverly Hills, Bel-Air, Brentwood, Santa Monica, and Pacific Palisades.

Performant Healthcare, Inc.

Medical Review Clinical QA Auditor (RN) - Home Health & Hospice

Posted on:

November 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Florida

At Performant, we’re focused on helping our clients achieve their goals by providing technology-enabled services which identify improper payments and recoup or prevent losses due to errant billing practices. We are the premier independent healthcare payment integrity company in the US and a leader across several markets, including Medicare, Medicaid, and Commercial Healthcare. Through this important work we accomplish our mission: To offer innovative payment accuracy solutions that allow our clients to focus on what matter most – quality of care and healthier lives for all. If you are seeking an employer who values People, Innovation, Integrity, Fun, and fostering an Ownership Culture – then Performant is the place for you!

The Medical Review Clinical Quality Auditor (RN) is responsible for conducting Quality Assurance (“QA”) reviews of medical review audit work completed by the medical review audit team members to ensure the accuracy of claim findings and applicable documentation for our clients both Government and Commercial payors.

Knowledge, Skills and Abilities Needed: Experience in conducting medical audits, investigations, reviewing and researching post service claims for aberrant billing patters, thorough review of the medical record documentation preferred. Demonstrated ability to perform claim payment audits with high quality and production results, as well as successful application of skills to conduct quality assurance review of audit work completed by others. Must be able to manage multiple assignments effectively, create documentation outlining findings, QA review results and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members. Thorough working knowledge of CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding. Proficiency with CMS 1500/UB 04 forms Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules and regulations. Working knowledge of encoder Proven ability to review, analyze, and research coding issues. Reimbursement policy and/or claims software analyst experience. Familiarity with interpreting electronic medical records (EHR) Basic understanding of accounting principles for accounts payable and receivable as it relates to medical billing. Independent, out-of-the-box thinker; Performs successfully against work given in the form of objectives and projects; leads by example. Understands processes, procedures, and workflow; and demonstrated ability to identify areas of opportunity. Demonstrated ability to consistently apply sound judgment and good effective decision making. Understands Medical Review Audit and Quality Assurance objectives, activities, and key drivers in achieving operational goals. Strong communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal external. Demonstrated ability to collaborate effectively in a variety of settings and topics. Excellent editing and proofreading skills. Ability to independently organization, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively. Excellent time management and delivers results balancing multiple priorities. Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data. Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues. Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures. Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions. Ability to create documentation outlining findings and/or documenting suggestions. Strong general computer skills, including, but not limited to Desktop and MS Office applications (Intermediate Excel Skills), application reporting tools, and case management system/tools to review and document findings. Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools. Ability to be flexible and thrive in a high pace environment with changing priorities. Adaptable to applying skills to diverse operational activities to support business needs. Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives. Serves as a positive role model; and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams. Capability of working in a fast-paced environment, flexibility with assignments and the ability to adapt in a changing environment. Required and Preferred Qualifications: Current active unrestricted Nursing license in good standing required (RN required for government contract focused positions) Not currently sanctioned or excluded from the Medicare program by OIG 3+ years diversified nursing experience providing direct care in an inpatient or outpatient setting. 2+ years of performing medical record audits in a provider setting, or in a payer setting for a health insurance company. 5+ years in health care claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required. (less than 5 yrs. may be considered for internal candidates based upon demonstrated skills and results)

Conducts quality assurance reviews on medical review audit work completed by the audit team members, maintaining productivity and quality standards as defined by department policy. Objectively and accurately documents quality review results in accordance with department quality policies and procedures, scoring and reporting all QA results in an approved QA tracking system and routes record appropriately within audit platform based upon how QA review resulted in concurrence with audit finding or identified corrections required. Reviews audit documentation and conducts research, analyzes claims data, applies knowledge of client SOW, applicable concept guidelines, policies, and regulations as necessary to determine if audit result is accurate and includes complete details to support findings. Provides correction to narrative rationale to correspond with audit determination and flags patterns of concern to audit leadership for real-time intervention, preventing an accumulation of improper findings Contributes to the continuous improvement feedback process and suggests or makes any edits, documentation, next steps, and reporting as may be necessary in accordance with department process and audit leadership direction. May support findings during the appeals process, if needed. May perform primary audit activity as assigned by management. Monitors, tracks, and reports on all work conducted in accordance with QA process and management direction. May prepare QA reports for management that includes a variety of data and trends at the individual, department, and client program level, as well as date range or concept based/trended, or other characteristic that will provide valuable business insights. Consults with internal resources as necessary. Become subject matter expert for assigned business segment(s). Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation, and business trends. Participates in and contributes to applicable department meetings. Successfully completes, retains, applies, and adheres to content in required training as assigned that includes but not limited to information security, anti-harassment and other compliance and policy/procedures training applicable for position. Proactively contributes to continuous improvement of activities and sets positive example Contributes collaboratively to identifying opportunities for improvement of audit results and continuous improvement initiatives. May support training material/tools and best practices development. May identify/make recommendations to management for supplemental team/concept type training. May support training activities for new audit staff or provide supplemental training for existing staff as needed. Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results. Receives feedback and adjusts work priority as necessary. Serves as positive role model and example for other audit staff and conducts work in accordance with company policies, government regulations and law. Performs job duties with high level of professionalism and maintains confidentiality Perform other incidental and related duties as required and assigned to meet business needs.

Wellbox Health

(LPN) Remote Chronic Care Management

Posted on:

November 4, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Compact / Multi-State

Wellbox is a fast-growing healthcare company on a mission to empower people to lead healthier lives. Through comprehensive, preventative care solutions delivered by an exceptional team of nurses, we help patients manage chronic conditions from the comfort of their homes. If you're a compassionate, tech-savvy LPN who thrives in a remote care setting, we’d love to meet you!

As a Patient Care Coordinator, you’ll play a vital role in our patients’ health journeys by conducting monthly telephonic outreach, assessing their unique needs, and creating individualized care plans Schedule & Compensation: Full-time, 40 hours/week | Monday–Friday between 8 AM – 6 PM in the patient's time zone. Orientation + Training (First 2 Months): $20/hr. Monthly Bonus Potential (up to $525). Referral Bonuses: Up to $1,000.

What We’re Looking For: Active Compact LPN license. At least 2 years of clinical experience (care coordination preferred). Tech confidence: you’re comfortable using EMRs, Microsoft Office, and other digital tools. Strong communication and problem-solving skills.

Manage patient care through scheduled phone conversations. Document visits using technology platforms and electronic health records (EHRs). Develop care plans focused on physical, mental, and preventative health. Coach patients through their treatment plans—including wellness, nutrition, and goal setting. Help patients prepare for medical appointments and connect with resources.

Ascend Learning

Nursing Academic Readiness Educator (Part-Time)

Posted on:

November 4, 2025

Job Type:

Part-Time

Role Type:

Coaching

License:

RN

State License:

Kansas

Ascend Learning is a national leader in data driven, online educational solutions for learners, educators and employers in high-growth, licensure-driven professions spanning healthcare, fitness and wellness, skilled trades, insurance, and financial services. We are passionate about accelerating learning while impacting job readiness, employment success and employee retention with the belief that our work changes lives. Our culture is intentionally results-driven and selfless with a relentless focus on our customers. We believe in trust, transparency, freedom, and responsibility with a commitment to meritocracy, inclusion, and diversity of thought. Continual investment in our over 1500 employees is also a core principle realized through ongoing professional development and providing opportunities to grow, develop and lead. Ascend Learning is headquartered in Burlington, MA with additional office locations and remote workers in cities across the U.S. Ascend Learning’s Nursing Segment is fueled by a commitment to excellence in nursing education. Our nursing brands — ATI, APEA, and NursingCE — offer evidence-based solutions designed to develop practice-ready nurses who are prepared for board certification and clinical practice. We use data analytics and engaging learning tools to help nursing students master core content. And we provide nursing education programs and professionals with best-in-class support and expertise from some of the sharpest minds in nursing education. We aid nurse educators in understanding students’ comprehension based on nearly two decades of data — including more than 12 million proctored assessments — that detail student learning and performance. The result is customers who are confident in the advice and guidance we provide with our quality-focused assessments and positive outcomes.

The Client Success Team is responsible for supporting clients purchasing nursing solutions with product training, implementation, integration, and test preparation delivery to achieve client centric outcomes. The team leads the success planning, onboarding, ongoing proactive and reactive client support, and the delivery of ATI NCLEX products. The Client Success team is accountable for delivering quality services that will lead to key business performance indicators for client success including, client satisfaction, product adoption and usage, NCLEX pass rate, institutional and student retention. Do you have a passion for education and providing students support for success? We are now hiring experienced secondary-level educators with knowledge and expertise in Math, Science, English, and Reading to join our Assessment Technologies Institute (ATI) team. We are seeking an Educator for Nursing Success to work remotely and provide part-time one-on-one online guidance and support to entry-level nursing students.

Education & Experience Master’s or higher degree in education with teaching certification (preferred) Master’s or higher degree in Nursing (considered) Preferred instructional technology experience Knowledge at secondary education level of math, science (including anatomy and physiology), English, and reading Minimum of 2 years recent teaching experience, 5+ years preferred Current secondary-level teaching experience; experience teaching in an online environment, preferred Skills & Abilities Communicate professionally and clearly in the online environment Comfortable navigating in an online environment Demonstrate technological competence with a variety of application Respond to customers twice daily via online interaction Apply best practice guidelines and follow process to service customers Ability to work remotely from a home office Guide students to identify their personal learning needs Create a collaborative atmosphere with faculty and students Analyze student performance to individualize study plans

Provide one-on one-instruction using a distance learning platform to support entry-level nursing students to engage in review of content for math, science (including anatomy and physiology), English, and reading Learn and maintain understanding of ATI products and solutions to assist customers Demonstrate analytical skills with the ability to interpret participant outcomes Implement consistent process to optimally deliver high-quality support in an online, asynchronous environment Collaborate with team members and faculty to promote excellence in delivery, discuss students’ outcomes and be a player in supporting product development Provide scheduled virtual student office hours, weekly Have access to dependable computer with reliable internet access

Conifer Health Solutions

Clinical Appeals Nurse - Remote - $10K Sign On Bonus

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

For over 35 years, Conifer Health has partnered with health systems, hospitals, physician groups, and employers to deliver tailored, technology-enabled revenue cycle and value-based care solutions that improve financial performance, enhance the care experience, and reduce the cost to collect. Supporting more than 600 clients and managing over $32 billion in NPR annually, we operate with a “by operators, for operators” mindset — combining deep operational expertise with intelligent automation, advanced analytics, and a mature global delivery model. Our commitment is simple: deliver on client goals with full transparency and measurable outcomes at every step.

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

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

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

UnitedHealth Group

RN Concurrent Review - Kelsey Seybold Clinic - Remote

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.

Required Qualifications: Associate Degree in Nursing or higher Texas RN License 5+ years of nursing experience in concurrent review Managed Care knowledge Preferred Qualifications: Certification in area of specialization, BSN ACP certification Case Management Certification 2+ years in area of specialization, 2+ years of Case Management/Utilization Review experience Proven program development skills Proven communication and problem-solving skills; Computer literate

The Concurrent Review Case Manager is responsible for telephonic monitoring and the documentation of medical treatment and comparing it to established criteria to determine if treatment meets established guidelines. In addition, the Concurrent Review Case Manager monitors patients progress toward recovery for early identification of continuing care needs in an attempt to facilitate discharge for specified populations. This position works closely with Medical Management Physician leadership and various internal departments You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Sutherland

Contract Clinical Appeals RN

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

We are One Sutherland — a global team where everyone is working together to create great breakthrough solutions. Our workforce has thrived in an environment of diversity of thought, experience and background. We celebrate our diversity and embrace it whole-heartedly. Sutherland is an equal opportunity employer. We promote a positive work environment by conducting ourselves professionally and helping each other achieve our goal of One Sutherland Team, Playing to Win.

This role is contract and does not offer an hourly rate. Payment is a 1099 paid bi-weekly upon Reviews. We will pay $50 per Appeal, and $25 per Review if cannot be appealed. You will also be paid $25/hour for any IT/ Compliance trainings that require completion of your time. The Appeals Nurse will review medical records to construct compelling clinical appeals in order to overturn managed care denials based upon clinical nursing judgment and the medical necessity of services delivered.

Licensed RN. 5 years experience working in acute hospital setting. Knowledge of managed care and utilization review process. Knowledge of Interqual criteria and/or Milliman Guidelines. Knowledge of DRGs. Excellent written skills. Proficient computer skills including Microsoft Office, with access to high-speed internet. Experience as a Case Manager or UR nurse who has written appeals is required.

Review of medical records to evaluate the validity of 3rd party denials. Assess strength of completed appeal to predict favorable outcomes. Ability to detect issues resulting in denials and constructively report on issue to assist in resolution. Construct 1st and 2nd level appeals by applying clinical rationale. Manage assigned workload of accounts so appeals are submitted timely in accordance with payer timeframes.

Ensemble Health Partners

RN Clinical Appeals

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

Ensemble Health Partners is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country. Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference! O.N.E Purpose: Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results.

CAREER OPPORTUNITY OFFERING: Bonus Incentives Paid Certifications Tuition Reimbursement Comprehensive Benefits Career Advancement This position pays between $56,800.00 – $108,900.00 based on experience This individual will be responsible for reviewing denials and performing root cause analysis while partnering with the Denial Prevention Nurse Manager to improve process and reduce denials. The RN Clinical Appeals performs all appeals for clinically related claim denials across Ensemble Health Partners, or in a role that primarily assists with analyzing and reviewing records to prevent future denials, provide clinical records to payers, and prepare for provider-to-provider (P2P) reviews. Job duties include, but are not limited to, contacting insurance plans to determine reasons claims were denied, analyzing the claims and determining if appeal is necessary, preparing the appeal materials which may include correcting and resubmitting claims, gathering additional information, including reviews of medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner. In addition, the Specialist will work closely with other departments, such as Case Management, HIM, Physician Advisory, Clinical Denials, Denial Prevention, Accounts Receivable, Bedded Inpatient Authorization and Virtual Utilization review, to ensure denial trends and outcomes are communicated in a timely manner. The Specialist will perform these duties while meeting the mission of Ensemble Health Partners, as well as meeting the regulatory compliance requirements.

Employment Qualifications: Current unrestricted license to practice nursing (LPN, RN) CRCR or other approved professional certification required with 9 months of date of hire Job Experience: 1 to 3 Years Desired Education Level: Associates Degree or Equivalent Experience Preferred Area of Study: Nursing Other Preferred Knowledge, Skills and Abilities: 4 year/ Bachelors Degree Preferred Minimum Education - Specialty/Major: Registered Nurse (RN) or relevant discipline Minimum Years and Type of Experience: 2 years of denials, utilization review, or case management experience strongly preferred Other Knowledge, Skills and Abilities Required: Proficient computer skills, including Microsoft Suite Experience in hospital operations, chart audit/review, and provider relations.

Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. ​Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results. ​Contacting insurance plans to determine reasons claims were denied, analyzing the claims and determining if appeal is necessary, preparing the appeal materials which may include correcting and resubmitting claims, gathering additional information, including reviews of medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner. In addition, work closely with the Case Management Department and HIM Department to ensure denial trends and outcomes are communicated in a timely manner. This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Associates may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.

EK Health Services Inc.

Bill Review Nurse Specialist - REMOTE - LVN/LPN/RN

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

License:

LPN/LVN

State License:

Arizona

EK Health Services Inc. is a leading national workers’ compensation managed care organization. EK Health partners with companies, insurers, healthcare professionals, and patients to successfully resolve and simplify the complex issues surrounding work comp healthcare. With a complete line of managed care solutions, EK Health sets the gold standard for early intervention, medical case management, utilization and peer review, medical bill review, network management, clinical specialty programs, preventative ergonomics, interpretation and translation, vocational rehabilitation, and medicare set-aside. Striving to transform the managed care industry, EK Health is focused on restoring quality of life for injured workers through innovative, cost-effective solutions. Clients trust us to provide services with high-touch experiences, customizable and nimble solutions, lower costs, and proven results. Our holistic approach integrates the best people, processes, and technology to facilitate the best medical treatment available for return-to-work possibilities.

Under the direction of the Bill Review Manager, the Bill Review Nurse Specialist is responsible for utilizing clinical acumen and medical review expertise related to reviewing workers’ compensation medical bills, including but not limited to: reviewing medical records, detailed/itemized statements and other documentation and applying medical necessity or payer guidelines to identify billed items and services that do not meet appropriate regulatory and compliance guidelines Position Specifics: Exempt-Full Time, Remote, Business Hours Monday through Friday

US state licensed Nurse (RN, LPN, LVN) Experience in performing Bill audit reviews 3+ years of experience in complex Workers' Compensation Bill Review with customer service exposure (preferred) Knowledge of medical terminology and coding Ability to read, analyze, and interpret technical procedures, medical reports, state laws and fee schedules CPC (Certified Professional Coding) coursework or certification a big plus Excellent Written and Oral Communication Skills Excellent Interpersonal & Organization Skills Experience with computers and computer programs (MS Word, MS Excel, Email) Ability to work independently with minimal supervision Ability to meet deadlines in a high pressure, time sensitive environment Physical Requirements: The candidate must be able to sit the majority of the day. The candidate must be able to keyboard the majority of the day. Candidate must have manual dexterity. Candidate must be able to speak on the telephone intermittently throughout the day. Candidate must be able to read and write English fluently. Candidate must be able to provide and confirm safe home office environment. Home office must be HIPAA compliant. *Requires DSL, fiber, or cable internet connection from home, 100 Mbps preferred or better. *

Accurately and appropriately analyze complex medical bills and make payment recommendations based on claim history, medical notes, usual and customary rates (UCR), statutory regulations including state laws and fee schedules, available MPN/PPO contracts, coding guidelines, client instructions, and company policies and procedures Research and apply applicable guidelines, and document clear and concise notes related to the recommendations along with related rationales Perform coding analysis. e.g. Medically Unlikely Edits (MUEs), Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT), Diagnosis Codes, etc. Engage with medical providers to negotiate medical services on behalf of our clients while creating long lasting relationships Communicate with medical providers to obtain needed information and resolve bill-specific issues Affidavits/Testify – Bill Review expert witness to provide expert testimony in legal cases involving medical billing disputes, or reasonableness of charges, particularly with insurance claims, workers’ compensation, personal injury, and medical malpractice. Review bills with missing Codes. Review corresponding medical documentation and provide appropriate billing. Medical Records – Able to review medical records Explanation of Review (EOR) – Provide EORs that include detailed sources to complete an analysis. Matching Diagnostic Codes with Bills – Able to match diagnostic codes to codes on a bill Respond to issues and drive problem resolution in a quick turn- around time Participate in ongoing training to enhance job skills and knowledge Maintain emphasis on privacy and confidentiality in all review interactions and completions Complete assigned cases accurately, meeting all regulatory and compliance timelines Continuous working knowledge of Ahshay and the BR system Support and assist all levels of the organization Other duties as assigned

Planned Parenthood of Northern New England

Registered Nurse (RN) - Remote Care Team

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Planned Parenthood of Northern New England (PPNNE) is the largest sexual & reproductive health care provider, educator, and advocate in northern New England, with 20 health centers across Maine, New Hampshire, and Vermont. We provide, promote, and protect access to reproductive health care and sexuality education so that all people can make voluntary choices about their reproductive and sexual health

POSITION TITLE: Registered Nurse (RN) – Remote Care Team LOCATION: ME, NH or VT HOURS: Full time, 37.5hrs/week, hourly (Non-Exempt) position UNION MEMBERSHIP: This position is represented by AFT union in NH/VT & MSEA union in ME POSITION PURPOSE PPNNE’s Remote Care Team (RCT) provides both Telehealth clinical care to patients, as well as Centralized Clinical Support to both patients and health center staff at our 16 health centers regarding lab work follow up, patient communications, referral care coordination, and health information management Affiliate-wide. The Registered Nurse for Remote Care Team Nurse may serve as the first point of contact for patients via remote support services, ensuring outstanding customer service and patient satisfaction by collaborating with the team to provide high-quality patient centered care, while also attending to daily administrative centralized support duties Affiliate-wide. JOB PERKS: Work with a group of dedicated professionals Collaborative Work Environment – PPNNE upholds high workplace values and patient service standards, fostering respect, engagement, and teamwork to create the best experience for employees and patients alike. Cost Coverage for State RN licensure renewal Gain experience with a trusted leader in affordable, high quality, health care Gain experience using the Electronic Medical Records program EPIC Make a Difference! - Make a direct impact in your community by providing patients with access to high quality & essential health care services

KNOWLEDGE, SKILLS AND ABILITIES: RN, with associate degree in nursing (bachelor's degree preferred), plus 1-3 years of relevant clinical experience, or an equivalent combination of education and experience from which comparable knowledge and skills are acquired Compact RN license in Vermont, New Hampshire and Maine Ability to work completely remotely and collaborate effectively with remote team members across 3 states Excellent customer service skills and ability to discuss sensitive topics using trauma informed approach to care Experience with telephone and EHR portal triage Ability to navigate multiple digital applications at once including EHR, Microsoft 365 (Excel, Word, Teams, SharePoint), Outlook, RingCentral phones/faxing, and other technologies as needed, or willingness to learn Ability to sit or stand for up to 6-7.5 hours per day

Schedule patients for appointments based on medication, symptom or follow up needs Provide excellent, patient-centered care in collaboration with PPNNE colleagues including licensed and non-licensed staff Counsel/educate patients regarding all services offered by PPNNE including general reproductive health care; all FDA-approved methods of birth control, including emergency contraception; pregnancy options; and other services related to physical and emotional health and wellbeing Assist the Remote Care Team managers with assigned responsibilities, primarily related to follow up of lab results, incoming patient medical questions, and care coordination in collaboration with members of the Remote Care Team Notify patients of results, follow up care plans, and send reminders for care, while completing communications within appropriate timeframes per Medical Standards and Guidelines (MS&G) Triage and respond to incoming patient communications, via telephone and electronic communications Fulfilling prescription treatments based on lab result findings Assist with regular Clinical Quality Assurance initiatives and associated required audits Provide health care that is culturally and linguistically appropriate to PPNNE patient populations Demonstrate approach to sexual and reproductive health care consistent with Planned Parenthood’s philosophy, service standards and fundamental concepts of reproductive justice.

Molina Healthcare

Care Review Clinician LVN

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

California

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

California residents preferred. Candidates who do not live in California must work Pacific business hours permanently Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

At least 2 years health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. Clinical licensure and/or certification required ONLY if required by state contract, regulation or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. Ability to prioritize and manage multiple deadlines. Excellent organizational, problem-solving and critical-thinking skills. Strong written and verbal communication skills. •Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications: Certified Professional in Healthcare Management (CPHM). Recent hospital experience in a medical unit or emergency room. Previous experience in Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. CALIFORNIA State Specific Requirements: Must be licensed currently for the state of California. California is not a compact state. WORK SCHEDULE: Tues - Sat with some holidays. Training will be held Mon - Fri

Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. Processes requests within required timelines. Refers appropriate cases to medical directors (MDs) and presents cases in a consistent and efficient manner. Requests additional information from members or providers as needed. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote the Molina care model. Adheres to utilization management (UM) policies and procedures.

NPHire

Remote Nurse Practitioner – Telehealth Consults | ~$60/hr

Posted on:

November 3, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

A growing telehealth group is seeking licensed MDs and Nurse Practitioners to provide brief virtual consultations for adult patients nationwide. This contract role is 100% remote with flexible scheduling—you’re only online when patients are booked, typically 5–6 hours per day. Compensation & Highlights $25–$60 per hour (paid per consultation / monthly payouts) Remote, flexible—set availability around patient demand No controlled substances on formulary; admin & patient coordination provided

Active U.S. license: NP (FNP/AGNP/AGPCNP/ANP/DNP) or MD (multi-state welcomed) Strong clinical judgment, clear communication, and comfort with telemedicine workflows Ability to use modern EHR/video platforms; reliable remote setup Preferred state licenses: New York, California, Texas, Georgia

Conduct short (1–2 minute) phone or video assessments for focused complaints Review patient info on a proprietary EHR and determine appropriate non-controlled prescriptions Complete concise, compliant EMR documentation and coordinate with support staff as needed

Personify Health

Case Manager Nurse

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

We are seeking a Case Manager Nurse, RN to join our team on a part-time basis, working up to 29 hours per week. In this role, you will provide telephonic case management between providers, patients and caregivers to help ensure cost-effective, high-quality healthcare for health insurance plan participants. This position offers flexibility and is ideal for candidates looking for reduced hours while making an impact within the team. Evening and weekend availability may be required.

Graduation from an accredited RN program and possession of a current California RN license. Minimum of five (5) years medical/surgical or acute care experience, including two years’ experience in case management, or an equivalent combination of education and experience. Prefer case management experience, emergency room, critical care background or some other area of clinical care that is pertinent to case management. Knowledge of medical claims and ICD-10, CPT, HCPCS coding. Ability to critically evaluate claims data and determine treatment plan; discharge planning experience.

Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs. Use claims processing tools to review and research paid claim data to develop a clinical picture of a member’s health and identify for participation in appropriate programs. Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals. Monitor interventions and evaluate the effectiveness of the treatment plan in a timely manner; report measurable outcomes that record effectiveness of interventions. Initiate and maintain contact with the patient/family, provider, employer, and multidisciplinary team as needed throughout the continuum of care. Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance. Be able to meet productivity, quality and turnaround time requirements on a daily, weekly and monthly basis. Negotiate and implement cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews and cost avoidance reports. Establish and maintain working relationships with healthcare providers, client/group, and patients to provide emotional support, guidance and information. Evaluate and make referrals for wellness programs. Maintain complete and detailed documentation of case managed patients in Eldorado and UM Web; maintain site specific files ensuring confidentiality; prepare reports and updates at 30-day intervals for high-risk cases and 90 days interval for low risk cases ensuring confidentiality according to Company policy and HIPAA Perform Utilization Review for assigned members. Serve as mentors to LVNs and provide guidance on complicated cases as it relates to clinical issues.

Personify Health

Utilization Review Nurse- RN

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Rhode Island

Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

Current RN license in the United States or U.S. territory. Associate’s degree or diploma (Nursing program) required. 1+ year clinical experience required. Required Knowledge, Skills, and Abilities

Provide professional assessment and review for the medical necessity of treatment requests and plans. Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity; and post claim or post service reviews. Staff are expected to cross train, and provide cross coverage as needed. Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. Refer requests that fall outside of established guidelines to advance review or senior care consultants. Process appeals for non-certification of services, complete non-certification letters when appropriate. Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together programs. Complete documentation for all reviews in appropriate documentation software. Utilize guidelines in appropriate hierarchy. Guidelines include MCG guidelines, internal medical policies, group specific policies, and NCCN. Ability to meet productivity, quality, and turnaround times daily. Ability to pass external audits to include URAC and NCQA. Maintain HIPPA compliance per company’s policy and procedures. Maintain confidentiality and minimum requirement rules. Complete all required yearly training per company’s expected time limit. Complete and pass all annual testing including IRRA at 90% or higher. Ability to meet productivity, quality, and turnaround times daily. Ability to pass external audits to include URAC and NCQA. Maintain HIPPA compliance per company’s policy and procedures. Maintain confidentiality and minimum requirement rules. Complete all required yearly training per company’s expected period

Enlyte

Triage Clinician 2

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

At Enlyte, we combine innovative technology, clinical expertise, and human compassion to help people recover after workplace injuries or auto accidents. We support their journey back to health and wellness through our industry-leading solutions and services. Whether you're supporting a Fortune 500 client or a local business, developing cutting-edge technology, or providing clinical services you'll work alongside dedicated professionals who share your commitment to excellence and make a meaningful impact. Join us in fueling our mission to protect dreams and restore lives, while building your career in an environment that values collaboration, innovation, and personal growth. Be part of a team that makes a real difference.

This is a full-time, remote position at 32 hours a week. The shift will be Monday, Thursday, Friday and Saturday 9am-530pm CST. You must be located in a Compact state and hold a Compact License in the state in which you reside. Bilingual in Spanish is preferred. The Worker’s Compensation Telephone Triage Clinician position provides inbound telephone triage services remotely to injured workers while following the individual state Worker Compensation rules and regulations. Uses clinical expertise and communication skills to triage, consult, and provide recommendations for emergent and non-emergent situations. Focuses on conveying compassion and ensuring service excellence is centered on the injured worker.

Unencumbered RN License in state of residence required, compact state strongly preferred Minimum of three years’ recent RN experience in one of the following adult clinical areas: Telephone Triage, ER, Urgent Care, Medical Surgical Unit, Occupational Medicine Bilingual in Spanish Preferred Ability to obtain other state licenses as required with fees reimbursed Ability to function independently and learn in a virtual work environment Experience using Microsoft Office Suite 24 hour work week, schedules and shifts available dependent on the needs of the business, and schedules may include working every Saturday OR every Sunday This is a remote position and the successful candidate must have a safe and HIPAA compliant home office with high speed internet connection, verified by speed test.

Make safe decisions for appropriate care using critical thinking skills Use departmental evidence-based protocols to triage patients Build and maintain solid interdependent relationships within the team Maintain up-to-date knowledge and skill in professional, clinical, and system areas Demonstrate effective written and verbal communication skills

SPECTRAFORCE

RN Managed Care Coordinator (Remote after training)

Posted on:

November 3, 2025

Job Type:

Contract

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Welcome to SPECTRAFORCE, your gateway to NEWJOBPHORIA™! Established in 2004, SPECTRAFORCE is now one of the largest and fastest growing U.S. staffing firms renowned for its exceptional client service, SPECTRAFORCE’s innovative A.I.-powered talent acquisition platform and proven methodologies set us apart in the industry. We offer a comprehensive range of services including Contingent, Permanent, and Statement of Work (SOW) staffing solutions. Our expertise extends across multiple sectors such as Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities, and Transportation, and we serve over 140 Fortune clients across the U.S., Canada, Puerto Rico, Costa Rica, and India. At SPECTRAFORCE, we celebrate NEWJOBPHORIA —the exhilarating experience of transforming your career and work life. Join our mission to revolutionize the staffing world, one fulfilling placement at a time. AWARDS: Inc. Best Workplaces, Women’s Choice Awards, SIA Diversity, SIA Largest and Fastest Growing US Staffing Firm

Job Title: Managed Care Coordinator Location: Columbia, SC (4 to 6 weeks of onsite training and then remote) Duration: 3-month assignment with possible conversion Pay rate: $38/hr

Active and unrestricted RN license for the state of South Carolina or compact license. Minimum of 4 years of recent clinical experience in specialty areas like oncology, cardiology, neonatology, maternity, rehabilitation services, mental health, orthopedics, or general medicine/surgery.

Evaluate medical eligibility for benefits and clinical criteria, applying clinical expertise and administrative policies. Provide health management program interventions for members managing health, chronic illness, or acute illness. Active case management, assess service needs, develop action plans, and monitor outcomes.

MedStar Health

RN Denials and Appeals Management Specialist

Posted on:

November 3, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

MedStar Health is a not-for-profit health system dedicated to caring for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. MedStar’s 30,000 associates, 6,000 affiliated physicians, 10 hospitals, ambulatory care and urgent care centers, and the MedStar Health Research Institute are recognized regionally and nationally for excellence in medical care. As the medical education and clinical partner of Georgetown University, MedStar trains more than 1,100 medical residents annually. MedStar Health’s patient-first philosophy combines care, compassion and clinical excellence with an emphasis on customer service.

Responsible for coordinating and monitoring the denial management and appeals process. Combines clinical business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Collaborates with physicians Utilization Review RN's Case Managers revenue cycle personnel and payers to appeal denials.

Education: Associate's degree in Nursing required and Bachelor's degree in Nursing preferred Experience: 3-4 years 2 to 3 years clinical experience required and 3-4 years 2 to 3 years UR experience in health care setting preferred and 1-2 years 2 years background/experience in hospital audits preferred Licenses and Certifications RN - Registered Nurse - State Licensure and/or Compact State Licensure RN license in the District of Columbia or the State of Maryland depending on work location Upon Hire required and Certification in Utilization review case management and health care quality Upon Hire preferred and If MFM maternal fetal medicine (MFM) coding and billing yearly seminars Upon Hire preferred Knowledge Skills and Abilities Excellent verbal and written communication skills. Persuasive writing skills required. Working knowledge of Office Suite software applications preferred.

Completes appeal process for denied days for medical necessity that meets Interqual criteria or appear to be clinically justified. Completes evaluation of all external denials for medical necessity received by the hospital and coordinates decision making regarding the feasibility of initiating an appeal for each external denial for medical necessity. Develops medical summaries of denied cases for review by hospital administration and for possible legal/Maryland Insurance Administrative (MIA) action where indicated. Identifies and implements strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials. Identifies system delays in service to improve the provision of efficient and timely patient care. Identifies process issues related to the concurrent Case Management system including appropriate resource utilization and identification of avoidable days. Maintains records of concurrent and retrospective denial activity in conjunction with Case Management support staff. Monitors and tracks denials and appeal results and coordinates information with Patient Financial Services (PFS). Reports data to the Director and Operations Review Committee. Meets with attending physicians and Physician Advisor as appropriate to clarify or collect information in the process of development of appeal letters. Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required. Participates in the educational process for physicians and hospital staff to address issues that impact the number and type of denials. Serves as a resource to all staff in areas of utilization review/management. Utilizes and analyzes current medical/clinical information as well as medical record information to complete appeal letters. May interact with and assist third party payer reviewers to facilitate appropriate care and ensure payment of services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources. May utilize research methods to collect tabulate and analyze data in collaboration with the medical staff and hospital performance improvement initiates. Implements strategies to correct or modify trends seen through data analysis and outcome monitoring. May serve as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services staff meetings orientation and formal educational offerings. Assists in the orientation of new staff regarding the denials and appeals process. May manage the department in the Managers absence. Keeps Manager informed about issues related to staffing and problem areas. Keeps Manager informed about issues related to quality risk patient/family issues and concerns allocation of resources and vendor/payer issues. Assists the Manager in monitoring performance issues. Contributes to the performance evaluation process by providing feedback to the Manager and assisting the creation of professional development plans for UR Coordinators. Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.

NPHire

Work From Home NP | Short Video Visits | Flexible | Nationwide

Posted on:

November 2, 2025

Job Type:

Contract

Role Type:

Primary Care

License:

NP/APP

State License:

Compact / Multi-State

A growing telehealth group is seeking licensed MDs and Nurse Practitioners to provide brief virtual consultations for adult patients nationwide. This contract role is 100% remote with flexible scheduling—you’re only online when patients are booked, typically 5–6 hours per day.

Active U.S. license: NP (FNP/AGNP/AGPCNP/ANP/DNP) or MD (multi-state welcomed) Strong clinical judgment, clear communication, and comfort with telemedicine workflows Ability to use modern EHR/video platforms; reliable remote setup Preferred state licenses: New York, California, Texas, Georgia

Conduct short (1–2 minute) phone or video assessments for focused complaints Review patient info on a proprietary EHR and determine appropriate non-controlled prescriptions Complete concise, compliant EMR documentation and coordinate with support staff as needed

NPHire

Work From Home Nurse Practitioner - Telehealth Women’s Health - Flexible Schedule - Nationwide Openings

Posted on:

November 2, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Massachusetts

A leading nationwide telehealth group is expanding its clinical team and seeking Nurse Practitioners to provide virtual women’s health and wellness care across the U.S. This fully remote opportunity offers competitive pay, structured scheduling, and meaningful work supporting women’s health during midlife and beyond. If you’re passionate about women’s health, hormonal management, and preventive care, this flexible role allows you to make a real impact—from anywhere in the country.

Active Nurse Practitioner license (MA license strongly preferred) FNP, WHNP, or AGNP certification required At least 3 years of NP experience in women’s health, OBGYN, or primary care Proficiency in telehealth and EMR systems Strong communication skills and a patient-first approach

Conduct telehealth consultations for women’s health and midlife wellness Provide education, lifestyle coaching, and medication management Work with a supportive virtual care team and established clinical pathways Participate in ongoing clinical education and mentorship Enjoy a structured remote schedule with the flexibility to balance your life

TAMMIRA

Nurse Practitioner Wellness Program Director- Part-time, Remote

Posted on:

November 2, 2025

Job Type:

Part-Time

Role Type:

Behavioral Health

License:

RN

State License:

California

We are an innovative telehealth platform providing youth-focused mental health and wellness services in partnership with school districts across California. Our team includes registered nurses focused on supporting early intervention, healthy identity exploration, and mental health. We empower all young people to choose their own path and thrive by supporting them across the pillars of wellness, relationships, nutrition, communication, fitness, and beauty with a strong foundation of evidence-based behavioral health interventions. What You’ll Gain: A flexible, remote work opportunity with a mission-driven team The chance to shape care delivery for underserved youth across California and, in the future, nationwide Participation in clinical innovation, quality improvement, and educational programming Mentorship and leadership opportunities in a collaborative care model

We are currently seeking a Remote, Part-Time California-licensed Psychiatric Mental Health Nurse Practitioner or a Nurse Practitioner with a Psychiatric/Mental Health license or compassionate, dedicated Pediatric Nurse Practitioner to join our telemental health app-based startup, dedicated to transforming youth behavioral health. Through a personalized, strengths-based app, we connect nurses and youth in group and one-on-one (1:1) settings in livestream settings to assess for mental health issues, promote healthy identity and well-being, and counteract the negative impact of social media on youth. You’ll work remotely with a multidisciplinary team of registered nurses (RNs), schools and community referral partners to deliver culturally responsive, evidence-based care for youth and emerging age individuals aged 10- 22. You will provide supervision to licensed pediatric/mental health RNs, offer clinical support (e.g., program evaluation, quality improvement initiatives), co-create psychoeducational programs, and help design interventions for research with a dynamic team and an active youth council. Your primary role is to supervise our nurses and review mental health screeners (PHQ-9, ASQ: Ask Suicide Questions, Columbia, GAD, AUDIT, and CRAFFT), and psychoeducational group notes before submitting insurance claims. Bonus if paneled with Medi-Cal (individually or through an agency). This is a fully remote, contract role with flexible hours and the opportunity to shape the future of mental health early prevention screenings, assessment, psychoeducation, and interventions. Ideal for NPs who are passionate about integrated care, health equity, and digital health innovation. There is no full psychiatric assessment for diagnosis, treatment or medication management in this role. Role Details Type: 1099 Contractor Setting: 100% Remote Schedule: Flexible (you set your hours) Population: Youth ages 10–22 Compensation: $75–$80/hour, depending on licensure, experience, and location

Have an active Nurse Practitioner, unrestricted California license with Board Certification in PMHNP, FNP, or a related field. A Medical degree in child psychiatry and successful completion of residency and fellowship. A certification in general psychiatry and licensure in child psychiatry. Experience supervising NPs or RNs At least 3 years of clinical experience post-licensure, with a strong focus on Behavioral Health and/or adolescent behavioral health Strong clinical documentation and review skills Experience working collaboratively in multidisciplinary teams Tech-savvy and comfortable with EMRs Familiarity with HIPAA and California-specific requirements Preferred Qualifications: Background in school-based or pediatric behavioral health Experience in telehealth care delivery models Familiarity with trauma-informed and culturally responsive care practices

Supervise RNs licensed in California. Collaborate with Advanced Practice Nurses, RNs, and a multi-disciplinary team Review adolescent records to support nursing plan decisions and provide guidance on care as needed (possible duties include chart reviews, including psychoeducational notes and mental health screeners) Participate in interdisciplinary case discussions and provide guidance to ensure that each adolescent is getting the highest-quality individualized care possible. Ensure our community referral protocols are appropriate and comprehensive. Ensure documentation and oversight practices meet California-specific requirements for supervision. Provide evidence-based and community-appropriate education and knowledge to others in terms understandable to the intended audience Make timely and appropriate referrals for second opinion reviews when appropriate or required according to current guidelines and best practices Maintain HIPAA compliance and adhere to TAMMIRA’s security protocols Work with a collaborative care team including mental health and wellness coaches, other therapists, nurse practitioners, registered nurses, and possible external care providers (e.g., school district administrators, school nurses, counselors, social workers, therapists, parents, etc.), which may include participating in weekly all-team meetings Supervise (and potentially deliver) empathetic, high-quality care to students via telehealth, specializing in Behavioral Health. Utilize individualized treatment approaches tailored to each student's specific needs, incorporating evidence-based practices for these conditions. Maintain high ethical standards and ensure strict compliance with all relevant laws, regulations, and guidelines applicable to telehealth services for Behavioral Health, including maintaining patient confidentiality and professional conduct Perform other duties as assigned Clinical Oversight & Consultation: Provide supervision for licensed RNs Review mental health documentation for clinical accuracy and completeness as needed Support diagnosis, treatment planning, and case review with NPs and RNs Participate in interdisciplinary case discussions and care planning rounds Ensure clinical documentation meets California compliance standards Program & Process Development and Schedule Management: Collaborate on quality improvement and program evaluation efforts Help define and improve treatment protocols and workflows Provide input on tools and technology that enhance care delivery Education & Mentorship: Mentor and support NPs and RNs Contribute to clinical education Offer guidance on best practices in adolescent behavioral health and integrated care Oversee psychoeducation and screening as appropriate to support adherence and engagement Team-Based Collaboration: Contribute to weekly case reviews and team huddles Provide real-time guidance and ongoing support to the RN care team Collaborate as needed with external stakeholders (school and community referral partners)

w3r Consulting

Utilization/Quality Review RN

Posted on:

November 2, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Illinois

w3r Consulting is an award-winning, best-in-class IT consulting and management company that delivers enterprise solutions at the intersection of innovation and ingenuity. Organizations throughout the healthcare payor, financial services, and professionals and business services sectors turn to w3r for a strategic, IT-fueled advantage that elevates their stature and capabilities in competitive global markets. As a minority-owned business, w3r brings diverse and multifaceted people from across different backgrounds and life experiences to the table, unlocking the power of unique perspectives and inventive ideas to help clients achieve their evolving goals.

Job Title: Nurse Liaison I UM & QR Location: Onsite in Naperville, IL for training, then fully remote Contract Duration: 8 Months Schedule: Monday to Friday | 8:00 AM – 5:00 PM Job Summary: The Utilization Management & Quality Review Nurse is responsible for ensuring compliance with Utilization Management (UM) and Quality Review (QR) functions across Medical Groups and Independent Practice Associations (IPAs) within HMO networks. This role involves conducting audits, developing corrective action plans, and providing education and support to improve care quality and compliance with HMO standards.

Active Registered Nurse (RN) license in Illinois (unrestricted). Minimum 3 years of clinical experience, including 2 years in utilization review, quality assurance, or data analysis. Strong understanding of managed care principles and UM/QR processes. Excellent analytical, written, and verbal communication skills. Proficient in Microsoft Office applications.

Review and evaluate UM/QR plans for Medical Groups/IPAs. Conduct UM/QR audits and prepare detailed reports on findings. Monitor compliance with UM policies and quality review standards. Develop and implement corrective action plans for non-compliance. Provide training and educational support to Medical Group/IPA staff. Assist with benefit determinations, transplant requests, and special cases. Collaborate with Network Consultants to enhance performance and care outcomes. Maintain compliance with NCQA, BCBSI, and other regulatory requirements.

Compassus

Compliance Registered Nurse

Posted on:

November 2, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Tennessee

Compassus is a national leader in providing high-quality, compassionate, person-centered care to individuals wherever they call home. Our continuum of integrated home-based care, including home health, home infusion, palliative and hospice care ensures patients and their families have the support they need to address current and future health needs. Partnering with Compassus brings peace of mind to patients, caregivers, and health care providers. Our team members work collaboratively to manage patient conditions and meet goals of care alongside referring physicians, health systems, long-term care partners, and family members. Our value is in the compassion and expertise of our teams, which act as an extension of patients’ existing care teams. We believe everyone who interacts with us should experience our individualized 'Care for who I am’ philosophy, from the care services we provide to patients and families to how we interact with our partners and one another.

The Compliance Registered Nurse is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Compliance Registered Nurse functions as an extension of the Regional clinical team to provide routine and non-routine compliance reviews. S/he assists the Regional Clinical Directors and agencies to recognize areas of improvement.

Education And/or Experience: Bachelor of Science in Nursing degree required. Minimum of five (5) years of nursing practice required. At least two (2) years of hospice experience required. Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage. Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, colleagues, investors, and external parties. Strong written and verbal communications. Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy. Certifications, Licenses, and Registrations: Active and unencumbered Registered Nurse license in the state(s) of employment required.

Audits and monitors specific clinical documentation to ensure compliance with applicable statutory and regulatory requirements and organizational policies. Executes elements of the annual audit plan. The audit plan shall include, but not be limited to, clinical and billing audits for all Company locations. Responsible for performing specified audit start-up procedures and the analysis of the audit results. Furnishes monthly reports of audit findings to the Director of Compliance Audit. Communicates identified needs and potential solutions to supervisor. Completes routine and non-routine compliance chart reviews as requested every month. Provides education in the form of verbal and written regarding findings of the compliance reviews. Performs other duties as assigned.

nTech Workforce

HEDIS Medical Review Nurse (RN or LPN)

Posted on:

November 2, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Maryland

At nTech Workforce, we specialize in providing comprehensive staffing and recruiting solutions tailored to meet the unique needs of our clients. Our approach is rooted in understanding industry dynamics and leveraging our extensive network to connect top-tier talent with leading organizations. We emphasize quality placements through rigorous testing and personalized recruitment strategies, ensuring both client satisfaction and candidate success. Our commitment extends beyond mere staffing; we foster long-term partnerships by continuously adapting to industry trends and client requirements. By prioritizing candidate training and professional development, we empower individuals to excel in their roles and contribute effectively to organizational growth.

Role: HEDIS Medical Review Nurse W2 Contract: 6 Months Location: Remote Primarily remote with candidates being required to reside in MD, DC, PA, VA, or DE. There will be a 3-day training period onsite in Canton, MD - MUST Infrequent travel required to onsite provider offices Full-Time, M-F, 8:00 am to 5:00 pm Pay Rate: $39/hour on W2 - All inclusive Overview & Key Responsibilities: Our client is seeking a HEDIS Medical Review Nurse to play a vital role in their annual Healthcare Effectiveness Data and Information Set (HEDIS) project. This is a critical seasonal assignment that directly impacts healthcare quality scores and regulatory compliance. The ideal candidate is a highly organized and clinically knowledgeable professional with extensive HEDIS abstraction experience. The role involves the thorough review and abstraction of medical records, close collaboration with provider offices, and utilization of advanced technology skills to ensure data accuracy and quality measure compliance. This is an excellent opportunity for an experienced nurse to leverage their clinical knowledge and critical thinking skills in a fast-paced, team-focused environment.

Active Registered Nurse (RN) or Licensed Practical Nurse (LPN) license. A minimum of three (3) years of clinical experience with a strong clinical knowledge base and understanding of medical terminology, such as blood pressure (BP) and A1C. o In lieu of an Associate's or Bachelor's degree in Nursing, ten (10) years of recent HEDIS abstraction/overread experience on the payer/health insurance side or with a HEDIS vendor is required. A minimum of five (5) years of HEDIS experience, which is mandatory for this project. Advanced proficiency in the Microsoft Office Suite, including Excel, Word, PowerPoint, Teams, and Outlook. Experience working with Electronic Medical Record (EMR) systems, particularly Epic, eClinicalWorks, and Cerner. Demonstrated critical thinking and strong analytical skills with the ability to "think outside the box" to interpret ambiguous medical records and apply complex HEDIS definitions. Exceptional attention to detail and ability to follow complex, step-by-step instructions and proper procedures accurately. Strong organizational and time management skills to manage a heavy workload and strict seasonal deadlines. Excellent written and verbal communication skills for both internal team communication and external interaction with provider offices. Strong interpersonal skills and the ability to work effectively as an independent contributor and as a member of a team. Must reside within the District of Columbia, Maryland, or Virginia (DMV) area and have reliable transportation for the required in-person training and travel to provider offices. Required attendance for the entire six-month contract; no time-off requests will be authorized due to the critical nature of the HEDIS season. Preferred Skills & Experience: Associate's Degree (AA) or Bachelor's Degree (BSN) in Nursing. At least two (2) recent, consecutive HEDIS seasons with the same employer.

Conduct thorough medical record reviews to collect and validate data against HEDIS performance measures. Abstract relevant clinical data from electronic and paper medical records and accurately enter findings into HEDIS electronic database software. Retrieve medical records via Electronic Medical Record (EMR) systems or fax requests, ensuring strict compliance with HIPAA and member confidentiality requirements. Travel to provider offices in the DMV area (DC, Maryland, Virginia) as needed to retrieve medical records, and potentially travel between multiple offices in one day. Perform outreach to provider offices, primarily outbound phone calls, to request records, validate facility/provider addresses, and clarify documentation discrepancies, with the expectation of receiving call-backs. Utilize extensive knowledge of HEDIS measures to facilitate medical record abstraction for gap closure and additional data gathering. Document all outreach and follow-up efforts and maintain established daily productivity and accuracy levels. Collaborate with the Quality Improvement team to identify trends in abstraction and resolve documentation issues, providing feedback to abstractors as needed. Maintain a flexible approach to problem-solving and be able to quickly adapt to changing priorities and processes during the HEDIS season.

Sunshine Health

Care Manager (RN) - Child Welfare

Posted on:

November 2, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Florida

Headquartered in Broward County, Sunshine Health is among the largest healthcare plans in Florida. Offering coordinated care and a network of support for its more than 2 million members, Sunshine Health is transforming the health of the community, one person at a time. Sunshine Health is a wholly owned subsidiary of Centene Corporation, a diversified, multi-national healthcare enterprise focusing on under-insured and uninsured individuals. Sunshine Health offers government-sponsored managed care through Medicaid, Long Term Care, Medicare and Florida’s Health Insurance Marketplace. Additionally, our specialty plans include the Child Welfare Specialty Plan serving children in or adopted from the state's Child Welfare system; the Serious Mental Illness Specialty Plan for people living with serious mental illness; and the Children's Medical Services Health Plan, operated by Sunshine Health on behalf of the Florida Department of Health for children and adolescents with special healthcare needs. For more information, visit www.SunshineHealth.com or follow us on Facebook and Twitter @SunHealthFL.

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. Applicants for this role have the flexibility to work remotely from their home anywhere within the state of Florida. This role supports children and requires a Florida RN license and at least 2 years of pediatrics experience. The work schedule is Monday - Friday, 8am - 5pm.** 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.

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

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.

CVS Health

Telehealth Registered Nurse

Posted on:

November 2, 2025

Job Type:

Full-Time

Role Type:

Telehealth

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.

••work from Home- Candidate may reside in Texas or AZ•• At CVS Health, we believe we can change the world by improving patient lives, one call at a time. Our Telephonic Registered Nurses (RN) have patient contact in the uniqueness of a telephonic practice setting, where they are impacting lives across the country. You will continue to experience the reasons you became a nurse without having to be in a bedside patient care environment. Shift and Hours for our Telehealth Registered Nurse role: ****This is a Monday-Friday role with hours starting from 10:30am -7:00 pm (CST) These are set hours, and this is a fulltime hourly position. Learn more about us: https://protect-us.mimecast.com/s/cA1pCG6o9qf0q467ZS7DW0y?domain=vimeo.com RN, Registered Nurse, Case Manager, Nurse, Home Health, Autoimmune, Oncology, Telehealth, Telephone, Telephonic, Health Management, Assessment, Education, Training

A Registered Nurse with an unrestricted current compact license in their state of residence and the ability to be licensed in multiple states A Registered Nurse must hold an unrestricted license in their state of residence, with multi- state/compact privileges and have the ability to be licensed in all non-compact states, territories and the District of Columbia based on the needs of the business. Many states’ licensing bodies have their own specific state requirements. Nursing boards may add more requirements from time to time and our nurses are required to meet such requirements. A Registered Nurse with an unrestricted current compact license in Texas or Arizona and the ability to be licensed in multiple states Candidate must be based in TX or AZ for this particular requisition 3+ years of clinical RN experience Experience using Microsoft Office, including Word, Excel and Outlook COVID Vaccine Required: N/A COVID Requirements: N/A Preferred Qualifications: Previous Telephonic Nursing experience EPIC systems experience Bachelor’s degree preferred Licensure in multiple states preferred Education: RN Diploma, Associates or Bachelors in Nursing

Working from home, you will be part of a specialized team on the cutting edge of patient care. Working collaboratively with health care professionals, you will provide a meaningful patient experience, while using your critical thinking skills to develop, implement, and evaluate comprehensive plans of care for multiple disease state patients. As a Telephonic Registered Nurse, you will a profound effect on the lives of the patients and caregivers via each outbound call, providing education and support for their new medication. Along with the Compliance and Persistency team, you are the continuity of care supporting defined patient populations through the use of our state-of-the-art telecommunications nursing outreach programs. To be successful in this Registered Nurse position, you must have excellent written and verbal customer service skills, as well as advanced computer skills in order to interact with patients. Our Registered Nurses redefine the way health care is delivered every day. When you join our team, you'll play an integral role in educating patients with medication adherence and disease state training. As a national leader in the healthcare industry and a Fortune 7 company, we seek special RNs who not only possess strong clinical expertise with innovative ideas, but who have the deep compassion and sensitivity it takes to treat our patients.

The Judge Group

Inpatient Medical Coder- Registered Nurse

Posted on:

November 2, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

The Judge Group is an international leader in business technology consulting, talent solutions, and learning and development. With over 30 locations across the U.S., Canada & India, Judge is proud to partner with the best and brightest companies in business today, including over 60 of the Fortune 100. We serve organizations in financial services, healthcare, life sciences, insurance, government, aerospace & defense, manufacturing, and technology & telecommunications. Judge has always been committed to doing what’s right – for our colleagues, our client partners, and our communities. At Judge, we cultivate an inclusive environment that empowers our employees to produce their best work. As a family-owned business, we’re not just a high-performing team, but a high-performing family. Through building relationships and our cultural commitment to caring, we support one another. Our People-powered Business Solutions Talent & Executive Search From temporary consultants to C-level executives, The Judge Group works across all industries and domains to find exceptional talent. IT Consulting We take an end-to-end approach to technology, working alongside your teams to design, build, implement, and manage all of your organization’s IT resources. Our enterprise IT consulting services and solutions encompass the full technology spectrum, from IT and business transformation, and cloud migration to digital strategies and execution, strategic roadmaps and delivery, process and governance optimization, and IT infrastructure and wireless solutions. Learning Solutions As a leading provider of corporate learning services for companies of all sizes and industries, Judge employs a strategic approach to learning that meets organizational training goals while strengthening business outcomes. Regardless of when, where, or how you want to train your team, our solutions are engineered to engage and support employees throughout their learning journey.

Perform MS-DRG and APR-DRG coding audits to ensure accurate DRG assignment and identify potential overpayments. Review ICD-10-CM/PCS code assignments, sequencing, POA indicators, and discharge dispositions in compliance with CMS guidelines and official coding standards. Apply clinical knowledge and documentation requirements to validate code accuracy and support audit findings. Utilize ICD-10 Official Coding Guidelines and AHA Coding Clinic references to develop clear, concise audit rationales. Leverage proprietary audit tools and encoders to manage workflows and document determinations efficiently. Stay current with coding updates, reimbursement trends, and client-specific requirements. Maintain high-quality standards while managing daily case review volumes in a fast-paced, matrix-driven environment. Collaborate with investigative and analytical teams by providing clinical coding expertise.

Blue Cross and Blue Shield of Kansas City

Clinical Nurse, Case and Disease Management - High Cost Claims

Posted on:

November 2, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Kansas

Blue Cross and Blue Shield of Kansas City (Blue KC) is an independent licensee of the Blue Cross Blue Shield Association and a not-for-profit health insurance provider serving more than one million members in 32 counties in greater Kansas City and northwest Missouri and Johnson and Wyandotte counties in Kansas. Blue KC's mission is to provide affordable access to healthcare and to improve the health of our members. Blue KC was named one of the “Best Companies to Work For” in 2012 and 2019 in the large company category by Ingram’s Magazine.

Utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote optimal, cost-effective outcomes. Transplant only: Provides prior authorization for, coordinates, and individually manages all member transplants. Acts as an internal and external customer resource for interpretation of transplant benefits and transplant-related claim adjudication. Serves as a company expert on current and future transplant types. The candidate for this position must reside in the Kansas City metropolitan area.

Associate degree in nursing 3 years full-time direct patient care clinical experience in either of the following: transplant, oncology or medical/surgical Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public. Ability to define problems, collect data, establish facts, and draw valid conclusions. Thorough knowledge of URAC and NCQA® guidelines and state and federal regulations. Valid and active Registered nurse (RN) in Missouri and Kansas. Case Management Certification within 3 years of hire date or within 3 years of transfer to Case Management role/department. Preferred Qualifications: Bachelor’s degree in nursing with minimum of 5 years' experience, including at least three years' of case management and clinical transplant experience Valid and active Registered nurse (RN) licensure in all 50 states and the District of Columbia initiated within 6 months and completed within 15 months of hire date. Intermediate level keyboarding skills Intermediate level knowledge of FACETS UM, CM and claims applications. Experience in working with Health and Wellness and programs or an understanding of wellness principles Thorough knowledge of NCQA® guidelines and state and federal regulations Intermediate level knowledge of Milliman guidelines .

Completes member assessments by collecting and analyzing information across the seven domains of health and develops and implements individualized care plans with appropriate interventions in a culturally sensitive way. Uses standardized tools to complete assessments in the areas of clinical, functional, financial, support system, psychosocial and cognitive and environmental realms. Monitors effectiveness of plan of care by gathering sufficient information from relevant sources in order to intervene, as appropriate, to improve health outcomes. Determines appropriate intervals for monitoring plan of care. Utilizes internal, community and other healthcare resources to maximize outcomes. Acts as liaison between member, employer, providers, support system and BlueCross BlueShield of Kansas City. Works with multiple members of the healthcare team to foster continuity and coordination of care. Prioritizes interventions based on clinical need and readiness to change. Educates and works with members at different educational and health literacy levels. Utilizes clinical knowledge and critical thinking skills to individualize evidence based interventions. Assesses the member’s need for education and tailors teaching to the member’s knowledge level and learning style. Meets individual quality performance standards and annual targets for program performance as mutually agreed to by management team to maximize program value. Ensures compliance with applicable URAC and NCQA guidelines and state and federal regulations. Meets targets for program performance, such as monthly productivity and annual caseload requirements as mutually agreed to by management team to maximize program value. Schedules time effectively. Works with minimal supervision. Handles multiple projects simultaneously. Prioritizes work appropriately. Additional duties for Transplant only: Provides prior authorization of the transplant and manages individual member cases. Reviews transplant evaluation and authorizes in accord with medical policy. Opens case and follows NCQA case management standards. Documents transplant authorization, issues authorization letters, and follows in FACETS UM system in accord with UM concurrent review guidelines. Consults with Medical Director on cases outside medical policy, notifies providers and members, if transplant benefits are denied, and explains appeal rights. Educates members, providers, and other customers regarding transplant benefits. Directly educates the transplant financial coordinator of the transplant center, member and/or family members, brokers, group and marketing reps, and other providers. Directly educates internal customer service reps regarding individual transplant benefits and the transplant network. Ensures proper payment of pre-transplant, transplant, and post-transplant claims. Sets up transplant pre-pay review for each individual claim. Reviews transplant billing packets and reconciles with transplant centers if necessary. Continuously reviews FACETS claim history to determine if claim has been paid or if adjudication problems are occurring. Follows up with member and transplant center during the global payment process to ensure accurate payment. Responds to claims inquiries. Accurately reports potential high cost members and tracks costs on members currently undergoing transplants. Serves as transplant information source for other departments of the company (e.g., marketing department, senior management, steering committee, contracting department, etc.).

Trice Healthcare Staffing

Performance Improvement Nurse

Posted on:

November 1, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

California

Trauma Performance Improvement (PI) Nurse to support our trauma program. This position will be fully remote with normal business hours availability.

BSN or higher Minimum of 3 years of Emergency/Critical Care/Trauma experience required Minimum of 1 year of performance improvement experience preferred Current Valid California RN License. Trauma Nursing Core Course (TNCC) is required. Emergency Nursing Pediatric Course (ENPC) is preferred but not required.

Commence

Clinical Review Coordinator

Posted on:

November 1, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Nevada

Ignite a new era of impactful health outcomes with data that drives answers, technology that advances performance, and expertise that builds trust. Commence develops human-centered, clinically-relevant, value-based solutions that power more efficient process for better program and patient health.

The Clinical Review Coordinator conducts all mandatory case review and quality assurance activities as stipulated by contracts and maintains the required timeliness and accuracy within the review process. The Clinical Review Coordinator conducts all mandatory case review and quality assurance activities as stipulated by contracts and maintains the required timeliness and accuracy within the review process. The role is remote work, but you must reside in the Las Vegas, NV area.

Essential Knowledge: Individuals must be detailed oriented and clinically knowledgeable of medical terminology. Essential Education: Graduation from an accredited school of nursing and current unrestricted licensure as a Registered Nurse (RN) or Licensed Practical Nurse (LPN). License must be recognized in the jurisdiction(s) relevant to the work assigned. For example, for a federal contract the license must be issued by a body within the United States. A degree in a healthcare-related field with a professional clinical background and experience with Medicare QIO. Quality of care review experience or medical review experience in support of Medicare Administrative Contractor (MAC) or Recovery Audit Contractor (RAC) appeals. Experience performing pre- and post-pay claims reviews, and utilization reviews may also qualify. Minimum of two to four years of experience in clinical decision-making relative to Medicare patients. This position requires notifying a Livanta HR Manager in writing within five calendar days if there is any status change or disciplinary proceeding relating to any of Employee’s licenses or certifications, including, but not limited to, (1) restrictions on an employee’s license or certification, (2) changes to the states in which Employee can practice (3) revocation or expiration of any license or certification, and (4) any potential or actual disciplinary action against Employee by a certifying or licensing body. Essential Skills: Ability to organize and coordinate multiple simultaneous tasks in a team environment. Ability to follow complex written and oral instructions. Ability to collect data, distinguish relevant material, and exercise sound judgment. Ability to apply problem-solving skills and maintain objectivity. Strong computer keyboarding skills. Ability to work independently with minimal supervision. Ability to communicate accurately, consistently, timely, clearly, empathetically, respectfully, and effectively with beneficiaries, representatives, and providers, both verbally and in writing.

Maintains responsibility for assuring an efficient case review process through the production system. Identifies and corrects problem areas on a case-by-case and system-wide basis. Interprets and applies coverage and payment policies, standards of care, and utilization review criteria applicable to a specific position. Communicates with and supports physician reviewers by summarizing case facts, preparing case questions, and resolving physician input issues. Informs Medicare beneficiaries, health care providers, and other partners of the activities and responsibilities of the Quality Improvement Organization (QIO). Edits documentation for internal and external dissemination to beneficiaries, providers, and other medical personnel. Protects the confidentiality of patient information through compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). Performs desktop medical reviews. Attends annual security awareness, rules of conduct, and conflict of interest training. Performs other duties as assigned. Depending on departmental assignment, this position may also have some or all of the following duties: Acts as a neutral liaison for beneficiaries and their representatives. Navigates beneficiaries through the health care system. Provides education, advocacy, resource access, and targeted support to decrease the likelihood of readmission to acute inpatient care. Develops and maintains working relationships with community agencies. Assists beneficiaries with an understanding of their diagnoses. Informs beneficiaries and other interested parties of their rights and responsibilities as patients covered by the Medicare program. Schedules staff for the Medicare Beneficiary Helpline during work hours. Collaborates with internal and external QIO staff on the development and implementation of health care improvement projects.

Commence

Nurse Reviewer

Posted on:

November 1, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Virginia

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care. With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.

The Nurse Reviewer position is responsible for supporting and conducting reviews and determinations for independent dispute resolutions at both the Federal and State levels. This role involves analyzing medical records, ensuring proper documentation, and providing quality assurance checks to support the final determination. IDRE Nurse Reviewers must ensure that their decisions are well-supported with robust rationale and comply with Federal or State guidelines. This position will be responsible for resolving claim disputes submitted by various parties, such as physicians, hospitals, institutions, pharmacies, and other licensed healthcare providers. Additionally, responsibilities will include resolving disputes submitted to the Federal Independent Review (IDR) process. IDRs conduct impartial reviews of healthcare services to resolve disputes between healthcare providers. facilities and payers. IDRs provide objective assessments of billing, coding, and other issues related to disputed claims. The role requires conducting all job duties efficiently, promptly, productively, consistently, and courteously while maintaining a high level of professionalism.

Maintain an active license in nursing ( at a minimum, RN required) Five years of full-time equivalent experience providing direct care to patients Hold a non-restricted nursing license in any state in the US. Ability to analyze clinical documentation and apply appropriate guidelines. Strong oral and written communication skills with excellent customer service. Ability to multitask and adapt to a fast-paced environment. Strong organizational skills and attention to detail Knowledge of claim review processes includes billing, Current Procedural Terminology (CPT) coding, and Explanation of Benefits. Familiarization with navigating electronic documents like PDFs, Microsoft Excel, Microsoft Word, and experience using Microsoft Outlook. Familiarization with electronic data repositories such as SharePoint and/or ShareFile. Exceptional skills in managing sensitive and confidential information. Strong organizational abilities, written, and verbal communication skills in English. Ability to work both independently and collaboratively with other team members to include clinical reviewers, physicians, and attorneys. Skilled in prioritizing tasks to align with business needs and assignments. Appeal and/or claim dispute-related experience. Medical Coding Certification preferred Experience with Utilization Review preferred

Conduct an initial assessment of documentation from both the initiating and responding parties. Review submitted documentation to identify missing documents and determine what is required to resolve the dispute. Follow procedures to obtain the appropriate documentation. Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder or a physician. Prepare documents for the arbitrator reviewer assigned and provide instructions as needed. Collaborate with the legal team to facilitate resolution of disputes. Draft professional determination correspondence. Perform quality assurance checks on determinations according to Federal or State guidance. Audit and analyze patient records to ensure appropriate determination. Stay current with regulation changes and perform research on a case-by-case basis. Deliver high-quality, professional determinations free of grammar and spelling errors. Amend reports with additional clinical information when necessary. Participate in an interdisciplinary health care team to achieve positive outcomes.

Pacer Group

Registered Nurse Home Health/Reviewer

Posted on:

November 1, 2025

Job Type:

Contract

Role Type:

License:

RN

State License:

California

Founded in 2008, PACER is a Minority Woman-owned Global Staffing firm serving Fortune 500 Clients with customized and scalable workforce solutions. With our Account Management integrated into our service delivery processes, we provide our clients with staffing solutions that are transparent and robust irrespective of the industry they function in.

Home Health RN – Remote (CA License Required) Facility: Compassus Providence Home Health – LA County South Location: Torrance, CA (5315 Torrance Blvd, Ste 169-B) Role Type: Remote Reviewer RN – Back Office Chart Review Schedule: 4x8-hour days (08:00 AM – 04:00 PM) | Must work 1 weekend day (Sat or Sun) Start Date: 11/03/2025 Duration: 13 Weeks Pay: $43–$47/hr Job Overview: Review and process chart tasks 3–4 (back office) HCHB (Homecare Homebase) & OASIS documentation review Virtual training provided (3 hours) 32 hours/week

Active CA RN License 1+ year of Home Health experience OASIS & HCHB experience required BCLS certification Reliable transportation (if field visits are needed)

BestView Elite Group

Healthcare RN/NP Financial Professional

Posted on:

November 1, 2025

Job Type:

Contract

Role Type:

License:

RN

State License:

California

At BestView Elite, we are a team of driven financial professionals dedicated to empowering individuals and families through financial education and leadership. We believe that financial literacy is the cornerstone of true financial independence—and our mission is to equip our clients with the knowledge, tools, and confidence they need to take control of their financial future.

Are you a Registered Nurse or Nurse Practitioner who's passionate about helping families - but seeking a career that offers freedom of time, less burnout and long term financial stability? You're not alone. You'll be trained and supported by a team made up primarily of fellow medical professionals. This is a fully remote, work-from-home opportunity as a Financial Professional—ideal for Nurses (RNs/NPs) looking to transition or diversify. Flexible Schedule | Part-Time or Full-Time | Not a Nursing Position | 1099 Contract High Income Potential | Full Training Provided & Mentorship

Nurses are naturally positioned to succeed in the financial industry because of the qualities and skills they already possess: Empathy & Care – Just like in healthcare, financial services require deep care for people’s well-being. Nurses already lead with heart, making them trusted advisors in both health and wealth. Strong Communication – Nurses are trained to explain complex medical information clearly to patients. That same skill translates powerfully into breaking down financial concepts for clients. Problem Solvers – Nurses are trained to assess, analyze, and respond quickly. In financial services, they use those same instincts to guide clients toward solutions that protect and grow their assets. Service-Driven Mindset – The profession is rooted in service—and that doesn’t change. Nurses find deep fulfillment helping families not just heal, but thrive financially. Respected & Trusted – Nurses hold one of the most trusted roles in society. That reputation carries into financial services, where trust is everything. If you see yourself in these qualities, we’d love to welcome you into this fast-growing industry. Your experience and heart for service are exactly what the financial world needs — let’s help more families together from Healthcare to Wealthcare!

Educate individuals and families on key financial concepts such as income protection, retirement planning, debt management, and wealth building Guide clients through life’s transitions—whether it’s protecting a new baby, preparing for college, or planning for retirement Build genuine, trust-based relationships with clients through empathy, education, and integrity Collaborate with a team of professionals (many with medical backgrounds like yours) for ongoing training, mentorship, and support Maintain and grow your own client base with flexible scheduling—full-time or part-time

Included Health

Utilization Management (UM) Integration Nurse

Posted on:

November 1, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included.

The UM Integration Nurse will work as part of the Care and Case Management team, focusing on projects and work that integrate Utilization Management (UM) with Care and Case Management (CCM). This role is ideal for a nurse who can effectively bridge these two critical areas.

Bachelor of Science in Nursing (BSN) Must reside in a compact NLC state. Active Compact RN license in good standing with the nursing board of their state. 5+ years of experience in nursing 2+ years working in Utilization Management (UM) Case management experience preferred. Complex discharge planning experience preferred. Willingness to become (and maintain) licensure in multiple states. Skilled in using multiple technology platforms and reporting systems for data analysis, performance tracking, and report creation. Demonstrate strong organizational skills and comfort in reading and interpreting plan documents. Excellent organizational skills and attention to detail required. Ability to be agile and balance multiple priorities while maintaining a positive and professional attitude. Demonstrates professional, appropriate, effective, and tactful communication skills, including written, verbal, and nonverbal. Strong ambition and internal drive are essential to this position. Comfortable discussing different medical conditions. Experience with technology and an understanding of digital tools and EMR platforms. Strong empathy and commitment to patient-centered care. Flexibility and comfort in an evolving environment. Strictly follow security and HIPAA regulations to protect patient medical information. Be pleasant, responsive, and willing to work with and learn from the team. Collaborate well across diverse teams with clinical and non-clinical members to deliver a seamless, top-quality care experience to patients. Translate medical information into clear, accessible, and patient-friendly language. Strict adherence to security and HIPAA regulations. Physical Requirements: Prompt and regular attendance at assigned work location Ability to remain seated in a stationary position for prolonged periods Requires eye-hand coordination and manual dexterity sufficient to operate keyboard, computer and other office-related equipment No heavy lifting is expected, though occasional exertion of about 20 lbs. of force (e.g., lifting a computer / laptop) may be required Ability to interact with leadership, employees, and members in an appropriate manner. This position requires frequent communication with patients and physicians; must be able to exchange accurate information during these patient encounters Occasional overnight business travel

Communicate and coordinate with facilities when a member is discharging to a lower level of care. Perform benefit verification and pre-determination benefit decisions based on member plan documents. Conduct care coordination calls with our UM vendor partner to support identifying and solutioning for barriers to discharge. Work on transplant coordination with Center of Excellence (COE) vendors and clients. Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general. Partner with the members' local providers to ensure coordinated care. Coordinate with internal and external resources to support the development and execution of the utilization management program. Establish and maintain communication and relationships with key cross-functional stakeholders. Serve as an escalation point for workflow questions/clarifications and complex cases. Assist the clinical team with day-to-day work and direct patient care, when needed. Display focus towards continuous improvement, suggest alternative solutions, as well as new ideas that improve team productivity, workflows, member experience, and efficiency, aligning directly with company values and goals. Comfort with telephonic and video visits Responsibilities may shift over time depending on CCM and/or UM program needs. Other duties as assigned.

DataAnnotation

Nurse Specialist

Posted on:

November 1, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

New York

We are looking for a Nurse Specialist to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model. Physicians & Advanced Practice Clinicians In this role you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include: Physicians of all specialties (e.g., Internists, Cardiologists, Oncologists), Physician Assistants, Nurse Practitioners, Certified Nurse-Midwives, Certified Registered Nurse Anesthetists, Clinical Nurse Specialists, Registered Nurses. Therapists Physical Therapists, Occupational Therapists, Speech-Language Pathologists, Respiratory Therapists, Athletic Trainers, Massage/Recreational Therapists. Diagnostic & Laboratory Professionals Radiologic Technologists, Sonographers, MRI & Nuclear Medicine Technologists, Medical Laboratory Scientists, Phlebotomists, Histology & Genetics Technicians. Public Health & Specialized Roles Dietitians/Nutritionists, Genetic Counselors, Epidemiologists, Public Health Nurses. Benefits This is a full-time or part-time REMOTE position You’ll be able to choose which projects you want to work on You can work on your own schedule Projects are paid hourly starting at $50-$60 USD per hour, with bonuses on high-quality and high-volume work

Fluency in English (native or bilingual level) A current or in progress medical degree Notes: Payment is made via PayPal. We will never ask for any money from you. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contract position.

Give AI chatbots diverse and complex healthcare related problems and evaluate their outputs Evaluate the quality produced by AI models for correctness and performance Ensure the medical accuracy of model performance

Wellbox Health

(LPN) Virtual Nurse Coordinator

Posted on:

November 1, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

Wellbox is a fast-growing healthcare company empowering people to lead healthier lives. We provide preventative care solutions and support patients in managing chronic conditions from home.

Schedule & Pay: Full-time, 40 hrs/week | Monday-Friday, 8 AM-6 PM (patient’s time zone). Orientation/Training (first 2 months): $20/hr. Monthly bonus potential up to $525. Referral bonuses up to $1,000. Benefits: Health, dental, and vision insurance. 401(k) + matching. Paid time off & flexible schedule. Life insurance & employee assistance program. Referral program. Application Process: 2-3 week hiring timeline. Timed assessment to evaluate computer literacy, basic math, and clinical knowledge. Virtual interviews with the Recruiting Manager and the Clinical Director.

Active Compact LPN license. 2+ years clinical experience (care coordination preferred). Comfortable with EMRs, Microsoft Office, and other digital tools. Strong communication and problem-solving skills. Must use a desktop or laptop for assessments and work (tablets/phones not compatible).

As a Patient Care Coordinator, you’ll guide patients through their health journeys via monthly phone outreach, individualized care plans, and coaching on wellness, nutrition, and treatment goals.

Elevance Health

Telephonic Nurse Case Manager II (CA)

Posted on:

November 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 Nurse Case Manager II Sign on Bonus: $5000. Location: 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. Must reside in California. 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 9:00am to 5:30pm with 1-2 late evenings 11:30 am to 8:00 pm PST. *****This position will service members in different states; therefore, Multi-State Licensure will be required. The Telephonic Nurse Case Manager II is responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically.

Minimum Requirements: 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: Case Management experience is preferred. Certification as a Case Manager is preferred. Minimum 2 years' experience in acute care setting is preferred. Managed Care experience is preferred. Ability to talk and type at the same time is preferred. Demonstrate critical thinking skills when interacting with members is preferred. Experience with (Microsoft Office) and/or ability to learn new computer programs/systems/software quickly is preferred. Ability to manage, review and respond to emails/instant messages in a timely fashion is 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.

Blue Cross and Blue Shield of Nebraska

Medical Review Specialist - RN: Post Service

Posted on:

November 1, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Nebraska

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve. Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there’s no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you’ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

Candidates applying to this remote nursing position can live in one of the following states: Florida, Iowa, Kansas, Missouri, Nebraska, North Dakota, and Texas. This position is accountable for performing medical review to ensure correct dispositions according to all contracts, related endorsements, government regulations and BCBSNE medical policies

To Be Considered For This Position, You Must Have: Associate degree in nursing or Certified Practical Nurse and three (3) years clinical experience in a health care setting. Must hold a current, unrestricted Registered Nurse or Licensed Practical Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates. The Strongest Candidates For This Position Will Also Possess Bachelor’s degree in healthcare field. Certification in Managed Care. Clinical experience in multiple levels of care. Experience in medical review or utilization management. Knowledge of accreditation standards and regulatory requirements.

Responsible for meeting all State and Federal regulations as well as BCBSA and BCBSNE mandates related to claims and preauthorization processing. Responsible for accurate and timely medical review of claims and preauthorization's. Responsible for accurate and timely medical review of Customer Service inquiries about claims and preauthorization's. Responsible for determining availability of benefits according to company contracts, endorsements and medical policy. Responsible for determining member eligibility prior to medical review. Responsible for fostering a constructive relationship with all departments within BCBSNE. Responsible for maintaining professional licensure and practicing within the scope of licensure. Responsible for collaborating and consulting with healthcare providers, members, and internal team of clinical support specialists, nurses, physicians, medical directors and pharmacists to ensure medically appropriate, high quality, cost-effective care, promote positive member outcomes, effective use of resources, optimize member benefits, and support business initiatives.

Comagine Health

Clinical Reviewer

Posted on:

November 1, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Washington

Comagine Health is a national, nonprofit, health care consulting firm. We work collaboratively with patients, providers, payers, and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system. As a trusted, neutral party, we work in our communities to address key, complex health, and health care delivery problems. In all our engagements and initiatives, we draw upon our expertise in quality improvement, care management, health information technology, analytics, and research. We invite our partners and communities to work with us to improve health and redesign the health care delivery system.

Comagine Health is looking for a remote RN Clinical Reviewer to support our growing team. This role will support a variety of patient populations across the organization, providing utilization management and care planning as needed.

Competencies: Professional curiosity and lifelong learner mindset--we cover many contracts with this team and there is always something new! Excellent written and oral communication Ability to document critical thinking and develop questions for providers regarding decision-making and plan of care Strong MS Office Suite proficiency and familiarity with database software programs Strong organizational skills Excellent interpersonal and problem-solving skills Ability to organize and coordinate multiple simultaneous tasks in a team environment Required Qualifications: A degree or diploma in nursing. Current, active, unrestricted RN licensure in good standing. 3 years of clinical (direct patient care) work experience that includes critical care, ED, and/or intensive care. Desired Qualifications: 1+ years of utilization review (or other medical management experience)

Participate in a multi-disciplinary team to improve the quality of healthcare for individuals and populations. Apply nationally-recognized clinical criteria and guidelines to determine the medical necessity of inpatient admissions, outpatient procedures, and other healthcare services. Consult with physicians or refer cases to others, when indicated.

Blue Cross Blue Shield of Arizona

Health Manager - Diabetes Certification - 1 (Remote AZ)

Posted on:

November 1, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Arizona

Blue Cross ® Blue Shield ® of Arizona (AZ Blue) is committed to helping Arizonans get healthier faster and stay healthier longer. With a mission to inspire health and make it easy, AZ Blue offers health insurance and related services to more than 2 million customers. AZ Blue, a non-profit company, is an independent licensee of the Blue Cross Blue Shield Association. The company and its subsidiaries employ more than 3,200 people in its Phoenix, Flagstaff, and Tucson offices.

This remote work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOB: Responsible for supporting members in achieving self-efficacy in managing their health condition(s) through a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates self-management strategies and care services available to members through their benefit plan that meet the individuals' health care needs while promoting quality, cost effective outcomes.

Required Work Experience: 2 years of experience in full-time equivalent of direct clinical care to the consumer Required Education Associate’s Degree in general field of study or Post High School Nursing Diploma Required Licenses: Active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN, or active registration as a Registered Dietician (RD) or Registered Dietitian Nutritionist (RDN). Required Certifications: Diabetes Care and Education Specialist (DCES) (formerly Certified Diabetes Educator (CDE)) PREFERRED QUALIFICATIONS Preferred Work Experience: 3 years of experience in full-time equivalent of direct clinical care to the consumer 1-2 years of experience working in a managed care organization Experience working with individuals living with chronic conditions such as: Diabetes, CHF, COPD, CAD, CKD, and asthma Preferred Education: Bachelor's Degree in Nursing or Health and Human Services-related field of study Preferred Licenses: N/A Preferred Certifications: Certified Lifestyle Medicine Professional Certified Health Coach Case Management Certification Required Job Skills: Intermediate PC proficiency Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones Intermediate skill in word processing, spreadsheet, and database software Required Professional Competencies: Maintain confidentiality and privacy Advanced and current clinical knowledge, particularly as it relates to common chronic conditions including asthma, coronary artery disease, chronic kidney disease, chornic obstructive pulmonary disorder, congestive heart failure, and diabetes Practice interpersonal and active listening skills to achieve customer satisfaction Knowledge of health and/or patient education and behavior change techniques Interpret and translate policies, procedures, programs, and guidelines Capable of investigative and analytical research Demonstrated organizational skills with the ability to priortize tasks and work with multiple priorities Follow and accept instruction and direction Establish and maintain working relationships in a collaborative team environment Apply independent and sound judgment with good problem solving skills Navigate, gather, input, and maintain data records in multiple system applications Required Leadership Experience and Competencies: Conflict Resolution Represent BCBSAZ in the community PREFERRED COMPETENCIES Preferred Job Skills: Advanced PC proficiency Knowledge of CPT 2018 and ICD-10 coding Preferred Professional Competencies: Knowledge of condition management, managed care, utilization management, and quality management Working knowledge of McKesson InterQual, MCG, ASAM, or other nationally recognized criteria Knowledge of a wide range of matters pertaining to the organizations services and operations Preferred Leadership Experience and Competencies: N/A

Perform assessments, condition management education, training, and other clinically based activities to coordinate care among providers, members, and family to implement the care plan. Conduct member-centered planning, including shared goal setting and member-tailored education and interventions to support the member in achieving self-efficacy for condition management. Identify holistic member needs considering whole-person health, to include condition-specific needs, behavioral health needs, and social drivers of health needs. Recommend and refer services and resources to members based on their individualized needs, specific health plan, and community and cultural preferences. Make and answer a diverse and high volume of condition management-related member calls on a daily basis. Explain to members a variety of information concerning the organization’s services, including but not limited to contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc. Analyze medical records, claims data, and other information sources. Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director. Consult and coordinate with other Health Managers, various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of member inquiries. Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines. Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other applicable accreditation requirements. Maintain complete and accurate records per department policy. Demonstrate ability to apply plan policies and procedures effectively. When indicated to assist with team/project functions: Collaborate with team to distribute workload/work tasks Monitor and report team tasks Communicate team issues and opportunities for improvement to supervisor/manager Support/mentor team members. Participate in continuing education and current development in the field of medicine, disease self-management, social drivers of health, behavioral health and managed care. Represent BCBSAZ and the Health Management Program at member events up to 5% of the time. Volunteer within the community to help BCBSAZ give back. The position has an onsite expectation of 0 days per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements Perform all other duties as assigned.

Blue Cross Blue Shield of Arizona

Initial Clinical Reviewer- RN (Remote - AZ)

Posted on:

November 1, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Arizona

Blue Cross ® Blue Shield ® of Arizona (AZ Blue) is committed to helping Arizonans get healthier faster and stay healthier longer. With a mission to inspire health and make it easy, AZ Blue offers health insurance and related services to more than 2 million customers. AZ Blue, a non-profit company, is an independent licensee of the Blue Cross Blue Shield Association. The company and its subsidiaries employ more than 3,200 people in its Phoenix, Flagstaff, and Tucson offices.

This position is Remote within the state of AZ only. This remote work opportunity requires residency, and work to be performed, within the State of Arizona. Purpose of the job: Responsible for identifying, researching, processing, resolving, and responding to inquiries from internal and external customers with emphasis on excellence, privacy, compliance, and versatility within the health insurance industry.

Required Work Experience: 2 years of experience in clinical field of practice, health insurance, or other health care related field Required Education: Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program Required Licenses Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LPN, LPT, LPC, LBSW, LMSW, or LCSW. Required Certifications: N/A PREFERRED QUALIFICATIONS: Preferred Work Experience 3 years of experience in clinical field of practice, health insurance, or other health care related field Preferred Education: Bachelor's Degree in Nursing or related field of study Preferred Licenses: Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse Preferred Certifications: N/A

Assist with transplant admissions, pre-transplant authorizations, care management/coordination, and regulatory reporting Identify, research, process, resolve and respond to customer inquiries and correspondence via telephone, written communication and/or in person. Answer a diverse and high volume of health insurance related customer calls or correspondence daily. Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests. Maintain complete and accurate records per department policy. Meet quality, quantity, and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations. Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc. Demonstrate ability to apply plan policies and procedures effectively. Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries. When indicated to assist with team/project functions: Collaborate with team to distribute workload/work tasks. Monitor and report team tasks. Communicate team issues and opportunities for improvement to supervisor/manager. Support/mentor team members. Participate in continuing education and current developments in the fields of medicine and managed care. Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements The position has an expectation of 5 days per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned.

Blue Cross Blue Shield of Arizona

Prior Authorization Nurse - Remote - AZ

Posted on:

October 31, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Arizona

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

This remote work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOB Under the direction of the Prior Authorization Management (PA), ensures prospective review/prior authorization requests are completed in a timely fashion to meet contractual requirements and ensures all reviews are conducted using nationally recognized and evidence-based standards.

2 years of clinical experience 1 year of Medicaid/Medicare experience 1 year of experience managing multiple projects Required Education: Associate degree in Nursing Required Licenses: Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN or LPN. Required Certifications: N/A PREFERRED QUALIFICATIONS: Preferred Work Experience 1 year of experience in managed care 1 year of experience in prior authorization/utilization review Preferred Education: Bachelor's Degree in Nursing Preferred Licenses: N/A Preferred Certifications: N/A Required Job Skills Computer skills Ability to use electronic medical management systems Analytical problem solving skills Required Professional Competencies: N/A Required Leadership Experience and Competencies: N/A PREFERRED COMPETENCIES: Preferred Job Skills: N/A Preferred Professional Competencies: N/A Preferred Leadership Experience and Competencies: N/A

Ensures prior authorization requests are completed accurately, thoroughly, and in a timely fashion to meet contractual requirements. Coordinates and follows the established preauthorization review process for pre-service requests. Ensures all reviews are conducted using nationally recognized and evidence-based standards. Utilize clinical skills, chart review, physician communication and appropriate criteria for approval of pre-service requests; escalate pre-service request to the Medical Director for determination when criteria is not met. Clearly define and document review rationale to support approval, Medical Director Review and/or Notice of Action document. Initiates interdepartmental coordination to ensure quality and timely care for members. Participates in Quality Improvement Projects as directed. Assists the management team and others in preparation for audits and other regulatory activities. Assists with other departments and special projects as needed RN: Performs audits of case files and staff documentation as directed Assists with orientation and training of all staff Assists with annual criteria review Assists with implementation of process changes as needed Each progressive level includes the ability to perform the essential functions of any lower levels. Perform all other duties as assigned. The position has an onsite expectation of 0 days per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements

Optum

Senior Clinical Administrative Coordinator RN - Remote in MST

Posted on:

October 31, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

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.

There’s an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn’t for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. *** The hours/schedule for this position will be, Monday – Friday, from 8:00 am – 5:00 pm MST, with occasional Saturday coverage *** You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. The Clinical Administrative Consultant RN (CAC, Clinical Coordinator) is responsible for providing expertise as a clinical interface or liaison within the company to resolve and prevent issues concerning initiation and delivery of patient care. The CAC applies their field experience, expertise and clinical nursing assessment skills to: assess new patient referrals for appropriateness of home or AIS treatment; verify physician orders for therapy; determine administration method and patient supply requirements with the pharmacy team; determine nursing care needs and source for these services; and execute all tasks with a focus on patient-specific needs. You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Current, unrestricted Compact RN license 2+ years of experience in Infusion Therapy and Home Health with specific proficiency in infusion therapy Willing and/or able to obtain additional RN licensures in the states of: AK, CA, HI, IL, MA, MI, MN, NV, NY and OR if licensure is not currently active Advanced interpersonal communications, both written and verbal Knowledge of and experience with Microsoft Office and electronic medical records (EMR) programs Willing and able to work with an interdisciplinary team of professionals including pharmacists and technicians, physicians and other licensed prescribers, registered dietitians, home health agencies (HHAs), sales representatives, and others as needed to provide comprehensive care and support of patients and caregivers Ability to maintain confidentiality in all aspects of patient, staff and agency information Ability to assume a flexible work schedule Ability to meet attendance, overtime, on-call, and other reliability requirements of the job Ability to work independently in home or alternate site settings Ability to work under pressure with clinical emergencies if required Preferred Qualifications: CRNI (Certified Registered Nurse Infusion) 3+ years of experience in Infusion Therapy and Home Health with specific proficiency in infusion therapy Knowledgeable and/or experience in HIPAA; OSHA; JCAHO Knowledge of the Infusion Nursing Society (INS) standards of practice, policies and procedures Experience within a healthcare organization providing coordination and navigation of patient care between providers

Receives, evaluates, accepts and executes the initial patient intake process to assure that patient verification, assessment, teaching and the ongoing scheduling of nursing services occur in a timely manner Reviews patient chart for admission criteria, assessing patient’s needs will be met, therapy is appropriate and environment is safe Assures timely communication with other company personnel, and outside providers, especially physicians and other agencies, to assure the quality and continuity of patient care Ability to establish and maintain positive clinical rapport with all patients and their families, representing Optum Infusion Pharmacy including working directly with patients and their families, maintain contact as per company policy and protocol and clinically monitor all patients providing direct infusion therapy services Communicates coordination of care with alternate providers (AIS, hospice) and documents communication Collaborative relationships involving agencies delivering services on behalf of/or in conjunction with Optum Infusion Pharmacy, including nursing agencies in a contracted relationship, patient, families, significant caregivers, and other healthcare team members Utilizes Electronic Medical Record (EMR) and documentation systems to clearly communicate patient status during clinical review, coordination of care and ongoing support of patients Maintain current nursing licensure in all states in which patients are serviced, as required by the respective State Boards of Nursing and/or Department of Health Assist in securing and maintaining licensure and accreditations warranted by Optum Infusion Pharmacy, including required Home Health Licensure, JCAHO, and any other licensure or credentialing as necessary Compliance and adherence to State and Federal regulations and laws, JCAHO, HIPAA, CPR, and infusion pharmacy and nursing licensure accepted standards of practice Participates in staff meetings with nursing and pharmacy Maintain all mandatory education required upon hire and annually per policy May be required to represent the company in clinical interactions as requested May provide education regarding Optum Infusion Pharmacy services, for both internal and external customers Function as clinical educator, and resource Represents self in a professional and ethical manner at all times, while representing Optum Infusion Pharmacy, complying with all applicable company policies and procedures May be asked to participate in cross training of the various clinical functions in order to function in multiple roles as required Other duties as requested

NPHire

Work From Home Nurse Practitioner / Remote Care / Flexible Hours / Nationwide

Posted on:

October 31, 2025

Job Type:

Contract

Role Type:

Primary Care

License:

NP/APP

State License:

Georgia

A growing telehealth group is seeking licensed MDs and Nurse Practitioners to deliver brief, focused virtual consultations for adult patients nationwide. This fully remote, contract role is ideal for clinicians who want flexible, on-demand hours (typically 5–6 per day) and streamlined workflows with no follow-ups or in-person visits.

Active U.S. license: MD or NP (FNP/AGNP/AGPCNP/ANP/DNP) Strong clinical judgment and clear patient communication Comfortable with telemedicine platforms and virtual workflows Experience: 4+ years (per posting)

Conduct short (1–2 minute) video or phone assessments Review patient info in the EHR and approve prescriptions for non-inflammatory medications Complete concise, compliant EMR documentation Coordinate with an admin team that manages scheduling and patient communication

Quest Diagnostics

Nurse, Health Screener- Pennington NJ

Posted on:

October 31, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

New Jersey

Quest Diagnostics (NYSE: DGX) empowers people to take action to improve health outcomes. Derived from the world's largest database of clinical lab results, our diagnostic insights reveal new avenues to identify and treat disease, inspire healthy behaviors and improve health care management. Quest annually serves one in three adult Americans and half the physicians and hospitals in the United States, and our 47,000 employees understand that, in the right hands and with the right context, our diagnostic insights can inspire actions that transform lives. The company offers physicians the broadest test menu (3,000+ tests), is a pioneer in developing innovative new tests, is the leader in cancer diagnostics, provides anatomic pathology (AP) services, & interpretive consultation through its medical & scientific staff of about 900 M.D.s & Ph.D.s. The company reported 2020 revenues of $9.44 billion. Quest Diagnostics offers the most extensive clinical testing network in the U.S., with laboratories in most major metropolitan areas, & in Mexico, the UK & India. The company also operates four esoteric laboratories, 40 outpatient AP laboratories, & 160 smaller, rapid-response laboratories. Patients may have specimens collected in any of the company’s approximately 2,250 patient service centers. On a typical workday, testing is performed for about 550,000 patients. Quest Diagnostics empowers healthcare organizations & clinicians with state-of-the-art connectivity solutions. The company is the leading provider of pre-employment drugs-of-abuse screening for employers & risk assessment services for the life insurance industry. It is the world’s 2nd largest provider of clinical trials testing for new pharmaceuticals.

The primary responsibility of the Health Screener is to provide coverage in the field ensuring that health screenings are completed accurately and on time.  Maintain a safe and professional environment for clients and employees; perform with confidence all aspects of a health screening, including specimen collection and processing duties following established practices and procedures. Pay Range: $33.51 - $41.08 / hour Salary offers are based on a wide range of factors including relevant skills, training, experience, education, and, where applicable, certifications obtained. Market and organizational factors are also considered. Successful candidates may be eligible to receive annual performance bonus compensation.

Required Work Experience: N/A Preferred Work Experience: At least 1 year of healthcare experience in a professional setting preferred. Physical And Mental Requirements: Lift light to moderately heavy objects. The normal performance of duties may require lifting and carrying objects. Objects in the weight range of 1 to 15 pounds are lifted and carried frequently; objects in the weight range of 16 to 40 pounds may be lifted and carried occasionally. Objects exceeding 41 pounds are not to be lifted or carried without assistance Requires use of phone and PC Fine dexterity with hands/steadiness Handling stress & emotions Concentrating on tasks Making decisions Adjusting to change Examining/observing details Sitting or standing for long periods at a time Position requires travel Knowledge: Must be knowledgeable of required regulations and comply with them Skills: Proficient with finger sticks and manual blood pressure. Ability to understand and perform complex procedures and techniques and work with complex instrumentation (Cholestech and/ or Cardio Check experience preferred). Skills required for proper specimen and reagent handling, labeling, processing, preparation, transportation, and storage necessary. Excellent customer service internally and externally Possess good written and verbal communication skills Ability to read, understand and follow detailed procedures Basic computer skills necessary including access to internet / email Strong communication skills both written and verbal Proficient in Microsoft Office Suite, specifically Word, Outlook, and Excel

Perform biometric screening at client sites including finger stick blood collection, BMI, Blood Pressure and other health screening services based on service package Performs basic waived testing technical procedures on blood samples and completes required quality control. Provide exceptional customer service at all health screenings. Maintains accurate, complete, and legible records. Participates in training/retraining and continuing education programs as necessary. Complies with all designated safety policies and procedures in the work area, including the use of applicable protective equipment when necessary to prevent exposure to potentially infectious agents. Understands and complies with applicable federal, state and local laws.  Adheres to quality assurance procedures and good manufacturing practices. Maintain all HIPAA and OSHA standards while on events. Performs other related duties as necessary.

Acentra Health

Clinical Assessor, Mid - RN - Full-time (Remote U.S.)

Posted on:

October 31, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact. Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra Health is looking for a Clinical Assessor, Mid to join our growing team. Job Summary: The purpose of this position is to complete needs-based level of care (LOC) determinations and exception requests for service authorizations for members applying for Medicaid Waiver services. This position also assesses level of care (LOC) to allow targeted individuals to remain in or return to a home and community-based setting.

An active, unrestricted Registered Nurse (RN) License in South Carolina or Compact Licensure, per contract requirements. 1+ years of experience working with Members with Intellectual and Related Disabilities, Autism Spectrum Disorder (ASD), Traumatic Brain Injury (TBI) or Spinal Cord Injury (SPI), or 1+ years of Case Manager experience.

Conduct assessments to determine whether the beneficiary meets the conditions and criteria for Waiver eligibility, using state-approved standardized assessment tool(s). Ensure the privacy and dignity of individuals receiving assessment for Waiver services is maintained at the highest standards. Ensure that new, expedited, annual, change of status, mediation/appeals, reconsideration review, and derivative assessments are conducted within established timeframes. Conduct service plan reviews as needed. Submit the completed assessments using state-approved interface. Participate in the Member's mediation and appeal processes, as requested. Respond to state inquiries regarding assessments conducted. Attend and actively participate in staff meetings and conduct case consultations/peer reviews/internal auditing as assigned. Provide assessments for initial eligibility determinations for an applicant to participate in a 1915(c) HCBS program, and, when applicable, annual and change of status assessments for participants currently participating in a 1915(c) HCBS program, using state-approved standardized assessment tool(s). Consult, when necessary, with the Member's selected Case Management entity to generate an approvable service plan. Ensure that the selected service plan completed by the Member's assigned Case Manager is appropriate to the Member's need for services, based on the severity of their medical condition, functional disability, physical, or cognitive impairment. Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

Medix™

HEDIS Nurse - 247521

Posted on:

October 31, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

New York

Medix provides workforce solutions to clients and creates opportunity for talent in the Healthcare, Life Sciences, Engineering and Technology fields. Through our core purpose of positively impacting lives, we have earned our reputation as an industry leader by providing unsurpassed customer service and top quality professionals to our clients.

Duration: 3-6 Months Hours: Mon - Fri: 8:30am to 5:00pm Location: Remote

RN/LPN required (open to any state license) Recent experience with HEDIS Medical Record abstraction and data entry Working knowledge of different EMR systems Able to navigate Microsoft Office – Word and Excel Be able to commit to the entire project Strong attention to detail and administrative skills

Mercalis

Patient Support Nurse

Posted on:

October 31, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Valeris is an integrated life sciences commercialization partner that provides comprehensive solutions that span the entire healthcare value chain. Backed by proven industry expertise and results-driven technology, Valeris helps navigate the complex life sciences marketplace by providing commercialization solutions to accelerate value and enhance patient lives. Valeris fosters a culture that encourages individuality and provides opportunities for creativity, growth, and success while fostering a team environment. We are a diversity-driven organization with an inclusive approach to delivering patient-centric solutions that, eliminate barriers for patients, and increase patient access to life altering medications.

The Patient Support Nurse is a blended role to 1) facilitate a successful patient journey to and while on therapy by providing care coordination, education, and psychosocial support, 2) provide medication and disease state education, and 3) provide clinical feedback to enhance the clinical portion of patient support programs.

AD or Bachelor’s Degree in Nursing (BSN, RN) with a valid nursing license in one or more states Four or more years of nursing experience; prior telephonic experience a plus Two or more years of Nephrology experience preferred Knowledge of medical insurance terminology and reimbursement/insurance, healthcare billing, physician office, health insurance processing or related reimbursement experience a plus Ability to communicate clearly and effectively orally and in writing-may be asked to submit a written test sample Proficient with Microsoft products Experience and comfort with a digital CRM required Attention to detail and committed to following through in communication with patients and providers Empathetic listening skills in order to interact effectively with patients and providers Willingness to work in a fast-paced environment and have the ability to multi-task and pivot with ease Strong customer service experience and skills Must be eligible to obtain licensure in all 50 states!! #LI-JK1 #LI-REMOTE

Provide education and support to patients, caregivers and health care providers regarding assigned therapeutic areas and maintain accurate record of activity per program setup Establish relationships, develop trust, and maintain rapport with patients, caregivers, and healthcare providers in a 100% telephonic setting Counsel and educate new/existing patients on the use of products, dosing and administration, use of devices, drug insurance coverage/reimbursement challenges in a telephonic, or virtual setting Evaluate and contribute to development of program resources Coordinate and utilize resources to share and secure financial options for those with financial need. Follow program guidelines and escalate complex cases according to program policy and procedures. Receive and make calls to patients and/or caregivers regarding assigned disease states, products, and patient needs to include discussions regarding insurance coverage and available financial support options for the particular therapy Accurately maintain, constantly update, and successfully navigate patient account records in a digital CRM (Customer Relationship Management System) Support health care provider offices regarding questions, concerns, or challenges with prescription Report and document adverse events and product/safety complaints as per program SOPs Participate in program specific customer meetings and training sessions Participate in program specific orientation meetings and demonstrate clinical and program competency on written, evaluated tests Serve as an advocate to patients and health care providers regarding insurance coverage, medical billing, reimbursement process, and general access for complex pharmaceuticals. May be asked to perform related job duties that are not specifically set-forth in this job description.

Evergreen Triage

Telephone Triage Nurse (RN)

Posted on:

October 31, 2025

Job Type:

Contract

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Evergreen Triage is a nurse-led after-hours triage service aimed at providing clinics and senior living facilities with peace of mind. We partner with healthcare organizations to deliver safe, timely, and compassionate patient support while offering providers trusted relief outside of business hours. Our nurses follow evidence-based protocols to assess symptoms, guide next steps, and ensure patients receive appropriate care. Every call is documented, tracked, and reported back, giving administrators clear insights and providers confidence that their patients are supported. By reducing provider burnout and minimizing unnecessary ER visits, Evergreen Triage helps healthcare organizations save costs, protect their teams, and strengthen patient trust.

We’re on the lookout for skilled registered nurses to join our team and support our after-hours triage services. The best part? You get to choose your own schedule! You can decide how much or how little you want to work. This is a 1099 contract position where nurses pick their available four- or eight-hour coverage windows and get paid for each call they answer during that time. As a nurse, you’ll be answering patient calls, following evidence-based protocols (like Schmitt-Thompson), and documenting the outcomes of each call for our partnered medical offices. Compensation is on a per-call basis. Average call volume varies based on client coverage and shift demand.

Proficiency in working autonomously as a nurse Experience in Telephone Triage and Triage protocols Ability to document and manage accurate medical records Excellent communication and interpersonal skills Ability to work efficiently in a HIPAA safe space Experience in providing compassionate care and support A Registered Nurse (RN) license from Minnesota is mandatory. A Compact State Registered Nurse (RN) license would be an additional advantage. Minimum of 2 years of nursing experience

Receive and triage incoming patient calls during designated after-hours coverage periods. Use Schmitt-Thompson protocols to guide patient decisions and next steps. Escalate urgent calls per client-specific instructions. Complete accurate documentation in the EMR or designated system.

By The Bay Health

Remote - Per diem Hospice Aide Scheduler

Posted on:

October 31, 2025

Job Type:

Part-Time

Role Type:

License:

None Required

State License:

California

By The Bay Health, a non-profit established in 1975, set the standard for hospice in the U.S. by emphasizing the role of the patient in making important medical decisions. Our spectrum of home-based services now includes Skilled Home Health Care, Palliative Care, Adult Hospice Care and Pediatric Care. Our team approach strives to address practical, social, emotional and spiritual aspects of care, with the goal to maximize quality of life for our patients, caregivers and families.

We are seeking a Hospice Aide Scheduler to work remotely, who will be responsible for assignment of team RN, team LVN and hospice aide services in compliance with organization policies and procedures and applicable laws and regulations. Schedule: Per diem; 8:30am - 5:00pm 2 days a week, every week or 6 shifts a month

By the Bay Health follows all CDPH vaccine requirements for healthcare personnel. High school diploma or general education degree (GED); or one to three months related experience and/or training; or equivalent combination of education and experience Previous experience performing clerical/administrative tasks in a healthcare setting or related position preferred

Schedules and maintains appointments through computerized scheduling program Adjust the team RN, team LVN, and hospice aide assignments whenever indicated to accommodate changing needs Demonstrate an understanding of all By the Bay Health Team RN, Team LVN, and Hospice Aide services Communicate daily with patients, families, and/or RN case managers regarding scheduled visits

Insight Global

Nursing Care Manager

Posted on:

October 31, 2025

Job Type:

Contract

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Insight Global is an international professional services and staffing company specializing in delivering talent and technical solutions to Fortune 1000 companies across the IT, Non-IT, Healthcare, and Engineering industries. Fueled by staffing and talent experts, Evergreen, our professional services brand, brings technical advisors and culture consultants to help customers tackle their biggest challenges. With over 70 locations across North America, Europe, and Asia, and global staffing capabilities in 50+ countries, our teams of tech-enabled recruiters are dedicated to finding the right talent and technical solutions to help our customers thrive. At our core, we are dedicated to empowering people to do great things. That’s why we’re passionate about developing our people personally, professionally, and financially so they can be the light to the world around them. To find out more, visit www.insightglobal.com

Position: Registered Nurse Care Managers Location: Remote (Must be in a Compact License State!) Duration: 6-month C2H Pay Rate: $40/hr Schedule/ Hours: 40 hours per week, 9:00am – 6:00pm (1 hour lunch)

Active, unrestricted RN Compact license (Must reside in the state their license is valid in) 2+ years in case management, care management, or disease management for a health insurance company, a health navigator or a TPA 2+ years of remote care or telephonic case management Bachelor of Science in Nursing (BSN) Plusses: CCM (Certified Case Manager) certification

Insight Global is looking for a Remote Nurse Care Manager to support a virtual care and healthcare navigation company. This individual will act as a clinical partner helping high-risk and rising-risk members through proactive outreach, post-discharge planning, and care coordination. They will collaborate with a multidisciplinary team to develop and execute holistic care plans while ensuring that each member receives the guidance, education, and support they need throughout their healthcare journey. Day-to-day responsibilities include but are not limited to, coordinating communication with hospital care management teams, supporting medication reconciliation efforts, and navigating members to their employee resources. This is an awesome opportunity to join a tech-enabled care integrator and contribute to a growing Care & Case Management team!

Humana

Quality Improvement Senior Clinical Professional (RN)

Posted on:

October 30, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Florida

At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms –when and where they need it. Our employees are at the heart of making this happen and that’s why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first.

The Quality Improvement Senior Clinical Professional (RN) is responsible for the development, implementation and management oversight of the company's Medicare Stars Program in the SouthEast Florida region (West Palm Beach, Stuart, Jupiter - Treasure Coast/Palm Beach Market). Additional Information: Hours for the role are: Monday-Friday 8am-5pm EST This role is currently remote/virtual but candidate may travel to provider offices within region up to 30% in the near future This position will be located in the West Palm Beach, Stuart, Jupiter - Treasure Coast/Palm Beach Market area.

Licensed Registered Nurse (RN) without restriction in applicable state 5+ years' of clinical nursing experience 1+ years' experience in a fast-paced healthcare operational role, including hospital, provider or member facing nursing responsibilities Experience in provider engagement and relationship management Strong understanding of Stars measures and quality improvement initiatives Proven ability to influence clinical practice or provider performance Comprehensive knowledge of Microsoft Office applications, Word and Excel with advanced knowledge of PowerPoint Excellent presentation and communication skills, both oral and written Strong relationship building skills as this is a provider-facing role Strong attention to detail with a focus on process and quality Valid driver's license with reliable transportation and the ability to travel up to 30% within the region Preferred Qualifications: Bachelor’s degree in Nursing 3+ years of managed care experience 3+ years of case management experience Strong knowledge of HEDIS/Stars/CMS Work-At-Home Requirements To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended to support Humana applications, per associate. Wireless, Wired Cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if they provide an optimal connection for associates. The use of these methods must be approved by leadership. (See Wireless, Wired Cable or DSL Connection in Exceptions, Section 7.0 in this policy.) Humana will not pay for or reimburse Home or Hybrid Home/Office associates for any portion of the cost of their self-provided internet service, with the exception of associates who live or work from Home in the state of California, Illinois, Montana, or South Dakota. Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

The Quality Improvement Senior Clinical Professional (RN) develops programs designed to increase the plan quality. Partners with leaders regarding implementation planning. Reviews and communicates results of programs. The Quality Improvement Clinical Professional (RN) (Senior Stars Improvement, Clinical Professional (RN)) represents the scope of health plan/provider relationships across the following areas: Provider facing Zoom virtual/telephonic meetings Weekly metrics for provider outreach, some Zoom telephonic outreach will entail calling to the in-network providers to establish working relationships Quality/clinical management and population health HEDIS and Stars performance Operational improvements Financial performance and incentive programs Data sharing and connectivity Documentation and coding Additional areas related to provider performance, member experience, market growth, provider experience and operational excellence

The Judge Group

Policy Lead Registered Nurse

Posted on:

October 30, 2025

Job Type:

Contract

Role Type:

Leadership / Management

License:

RN

State License:

Pennsylvania

The Judge Group is an international leader in business technology consulting, talent solutions, and learning and development. With over 30 locations across the U.S., Canada & India, Judge is proud to partner with the best and brightest companies in business today, including over 60 of the Fortune 100. We serve organizations in financial services, healthcare, life sciences, insurance, government, aerospace & defense, manufacturing, and technology & telecommunications. Judge has always been committed to doing what’s right – for our colleagues, our client partners, and our communities. At Judge, we cultivate an inclusive environment that empowers our employees to produce their best work. As a family-owned business, we’re not just a high-performing team, but a high-performing family. Through building relationships and our cultural commitment to caring, we support one another.

Title: Claim Payment Policy Lead Location: Remote (must reside in PA, NJ, or DE) Duration: 3+ months, potential temp-to-perm Equipment: Candidate must provide their own

Clinical background: RN preferred, but LPN or allied health professionals (e.g., PT) considered Coding experience: 3–5 years with certifications like CPC, CCS, RHIA, or RHIT Billing knowledge: Physician or facility billing experience Strong communication, analytical, and organizational skills Ability to work independently and manage priorities Preferred Qualifications: Experience in policy development Familiarity with CMS, Medicare, FDA approvals

Develop and maintain claim payment policies aligned with industry standards and payer trends Lead cross-functional teams to identify cost-saving opportunities Monitor regulatory and reimbursement changes (CMS, Medicare, FDA) Present findings and policy bulletins to internal teams Apply coding expertise (CPT, ICD, HCPCS) to policy development Create business requirement documents and support coding initiatives Mentor staff and serve as SME in coding/clinical areas

MedStar Health

Acute Care Nurse Practitioner (ACNP) in Connected Heart Failure Management - MedStar Health - Remote Opportunity!

Posted on:

October 30, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Maryland

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C. region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.

Remote Opportunity! Acute Care Nurse Practitioner in Connected Heart Failure Management Telemedicine - MedStar Health MedStar Medical Group offers a uniquely rewarding career in a major marketplace. Shape your future in health care in the kind of setting that’s right for you and your practice. Become part of an organization that welcomes your experience and input — as a clinician and healthcare expert. We are looking for an Acute Care Nurse Practitioner (ACNP) with cardiology experience, and heart failure as a specialty, to join MedStar Health’s growing telemedicine services. As a Connected Heart Failure Monitoring and Management provider, you will provide on-demand clinical care directly to patients using our telehealth platform (currently MedStar video visit) in compliance with the heart failure clinical guidelines of the program and under the direction of the cardiology physician team. You will effectively transition care of patients from telehealth encounters to in-person care for emergent, urgent, and scheduled follow-up needs. This program improves patient access to a clinician and facilitates care within the MedStar system. We are looking for a provider to join our virtual team that spans Maryland, DC, and northern Virginia regions.

ACNP Certification At least 3 years of Nurse Practitioner experience in cardiology, with heart failure as a specialty, preferred Reside and have (or be able to obtain) tristate licensures (MD, DC, and VA), but only one relevant license (MD, DC, or VA) required at time of hire. This is a full-time remote Monday through Friday position working 8-hour flexible days. There will be an 8-12 week orientation that includes working 1-2 days per week on-site in the facility.

MedStar Health

Connected Transitional Care Opportunity -- MedStar Health

Posted on:

October 30, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Maryland

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C. region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.

MedStar Medical Group offers a uniquely rewarding career in a major marketplace. Shape your future in health care in the kind of setting that’s right for you and your practice. Become part of an organization that welcomes your experience and input — as a clinician and healthcare expert. We are looking for a Nurse Practitioner with inpatient, ER, or primary care experience to join MedStar’s growing telemedicine services in Connected Transitional Care. In this position you will work remotely using our telehealth platform seeing patients for hospital discharge follow up visits. This program promotes a team-based approach to care, working in conjunction with our other primary care team members. This program improves patient access to a clinician and facilitates care within the MedStar system. As a MedStar Medical Group clinician, you can expect: A competitive salary Medical, dental and vision insurance Paid malpractice insurance Generous paid time off CME leave and CME allowance Retirement savings plan – 403(b) with % employer match Be a part of a nationally-recognized health system and the largest provider of health services in the Baltimore/Washington region. With our vast resources and capabilities at your disposal, you can expand your clinical expertise. Enjoy a rich career and a quality of life unique to Baltimore and the Mid-Atlantic region, which features a mix of urban, suburban and rural communities.

Compunnel Inc.

Appeals Nurse

Posted on:

October 30, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Florida

Compunnel Inc. is where AI-native solutions meet human ingenuity, helping enterprises reimagine talent, technology, and growth. A world where your people and your platforms don’t just coexist — they co-elevate. At Compunnel, we build bridges between intelligent systems and human potential, forging paths to transformation in real time. For over 30 years, we’ve been the quiet force behind digital revolutions. We speak two languages fluently: empathy and algorithm. Our AI-powered infrastructure weaves into human workflows (not over them), enabling clients to scale with agility, adapt with foresight, and compete with confidence. From coast to coast in the U.S. (30+ delivery centers) and across global innovation hubs in Canada, India, and the UK, we serve 200+ clients — including 23% of the Fortune 500. Whether you’re a global enterprise or a public sector agency, you lean on us for recruitment (IT, non-IT, public sector) and future-forward digital capabilities.

Serve as a clinical resource within the Medical Management team, responsible for reviewing medical documentation and determining the medical necessity of services. This role ensures compliance with InterQual criteria and contract requirements, and facilitates appeal reviews by either approving cases or escalating to a Medical Director.

Education/Experience: RN with 4+ years of clinical nursing or case management experience OR LPN/LVN with 5+ years of clinical experience Managed care or utilization review experience preferred Licensure/Certification: Valid RN, LPN, or LVN license in applicable state NCLEX certification and active US RN license preferred for offshore roles Skills: Strong understanding of InterQual and Milliman guidelines Familiarity with ICD and CPT codes Proficiency in Microsoft Word, Excel, and EMR systems Effective communication skills, both verbal and written

Review all submitted materials including EMRs and supporting documentation to assess completeness and compliance. Apply InterQual criteria and contract guidelines to determine medical necessity. Make initial determinations on cases; approve or escalate to MD for further review. Prepare and submit appeal letters in accordance with NCQA and state regulations. Coordinate with internal departments and external review organizations for fair hearings and appeals. Maintain accurate logs and documentation for all appeal decisions. Stay current with NCQA, CMS, and state regulatory updates. Support continuity of care and ensure timely resolution of member and provider inquiries.

Berkley Medical Management Solutions (a Berkley Company)

California Workers Compensation Telephonic Nurse Case Manager (Remote)

Posted on:

October 30, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Berkley Medical Management Solutions (BMMS) provides a different kind of managed-care service for W.R. Berkley Corporation. We believe focusing on an injured worker’s successful and speedy return to work is good for people and good for Berkley’s insurance operating units. BMMS was first started in 2014 by reimagining the relationship between medical need and technology to deliver the best outcome for injured workers and Berkley’s operating units. Our goal was clear: combine solid clinical practices, proven return-to-work strategies and robust software into one system for seamless management of workers’ compensation cases. To get it right, we started with a flexible technology platform that allowed for impressive customization without sacrificing the ability for expansion and continued innovation. We deploy integrated systems to give W.R. Berkley Companies recommendations and professional services for managing each individual case in an efficient and appropriate manner. The power of our technology takes medical bill-review services and clinical advisory services to a new level. Our unique marriage of technology, software platforms, data analytics and professional services ensures we provide Berkley’s operating units with reliable results, and reduced time and expenses associated with case management.

As a Telephonic Nurse Case Manager, you will assess, plan, coordinate, monitor, evaluate and implement options and services to facilitate timely medical care and return to work outcomes of injured workers.

Minimum 2 years of experience in workers compensation insurance and medical case management preferred Minimum of 4 years medical/surgical clinical experience required Ability to work standard business hours in the Pacific Time Zone (Monday through Friday, 8:00 AM to 5:00 PM PST). Exhibit strong communication skills, professionalism, flexibility and adaptability Possess working knowledge of medical and vocational resources available to the Workers’ Compensation industry Demonstrate evidence of self-motivation and the ability to perform case management duties independently Demonstrate evidence of computer and technology skills Oral and written fluency in both Spanish and English a plus Education: Graduate of an accredited school of nursing and possess a current RN license. CA RN License RN compact license preferred, CCM preferred, Bachelor of Nursing preferred

Coordinate and implement medical case management to facilitate case closure Timely and comprehensive communication with with employers, adjusters and the injured workers. Assess appropriate utilization of medical treatment and services available through contact with physicians and other specialist to ensure cost effective quality care Review and analyze medical records and assess data to ensure appropriate case management process occurs while providing recommendations to achieve case progress and movement to closure Responsible for assigned caseloads, which may vary in numbers, territory and/or by state jurisdiction Acquire and maintain nursing licensure for all jurisdictions as business needs require Coordinate services to include home services, durable medical equipment, IMEs, admissions, discharges, and vocational services when appropriate and evaluate cost effectiveness and quality of services Document activities and case progress using appropriate methods and tools following best practices for quality improvement Reviewing job analysis/job description with all providers to coordinate and implement disability case management. This includes coordinating job analysis with employer to facilitate return to work. Engage and participate in special projects as assigned by case management leadership team Occasionally attend on site meetings and professional programs Foster a teamwork environment Maintaining and updating evidence based medical guidelines (such as Official Disability Guidelines, MD Guidelines and all required state regulated guidelines) in reference to the injured worker treatment plan and work status. Obtain and maintain applicable state certifications and/or licensures in the state where job duties are performed. Obtain case management professional certification (CCM) within 2 years of hire

Sedgwick

RN Utilization Review

Posted on:

October 30, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance

PRIMARY PURPOSE OF THE ROLE: To utilize evidence-based tools to evaluate the prescribed treatment to ensure patient safety and quality standards are in alignment with best practice standards. ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. Apply your RN clinical knowledge and experience to assist in the management of complex medical conditions, treatment planning and recovery from illness or injury. Work in the best of both worlds - a rewarding career making an impact on the health and well-being of others in a remote work environment. Enjoy flexibility and autonomy in your daily work and your career path while advocating for the most effective and efficient medical treatment for injured employees in a non-traditional setting. Enable our Caring Counts® mission of supporting injured employees from some of the world’s best brands and organizations. Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. Celebrate your career achievements and each other through professional development opportunities, continuing education credits, team building initiatives and more. Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs.

Active unrestricted RN license in a state or territory of the United States required. Compact licensure preferred. Bachelor's degree in nursing (BSN) from an accredited college or university or equivalent work experience preferred. Certification in case management, pharmacy, rehabilitation nursing or a related specialty is highly preferred. Two (2) years of direct clinical experience as an RN is required. ​TAKING CARE OF YOU BY: Seeks innovative customer solutions Seeks ongoing learning as a professional and a person Thrives when solving challenging problems Seeks clear role expectations Metrics/policies/processes are helpful Seeks to contribute to a larger purpose Thrives when everyone is working towards same vision/goals Strong team and customer service orientation

Performs clinical assessments via information in medical files; assesses injured employee’s situation which may include psychosocial needs. Evaluates patient condition including treatment utilization and compliance. Evaluates need for and recommends alternative treatment. Collaborate effectively with physicians, claims examiners, clients, vendors, supervisors and other parties as needed. Negotiates appropriate level and intensity of care through use of medical and disability guidelines, adhering to quality assurance standards. Acts as a resource in consulting with the client, nursing staff and claims examiners regarding treatment issues. Performs treatment utilization management reviews. Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards. We offer a diverse and comprehensive benefits including medical, dental vision, 401K, PTO and more beginning your first day.

CVS Health

Appeals Nurse Consultant (Remote)

Posted on:

October 30, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

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.

CVS Aetna is seeking a dedicated Appeals Nurse Consultant to join our remote team. In this role, you will play a critical role in ensuring fair and accurate resolution of clinical appeals by applying sound clinical judgment and regulatory knowledge.

Remote Work Expectations: This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications: Must have active and unrestricted RN licensure in state of residence. 3+ years clinical experience. Preferred Qualifications: Appeals, Managed Care, or Utilization Review experience. Proficiency with computer skills including navigating multiple systems. Exceptional communication skills. Time efficient, highly organized, and ability to multitask. Education: Associate's Degree minimum.

Responsible for the review and resolution of clinical appeals. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. This position may support UM (includes expedited), MPO, Coding, or Behavioral Health appeals. This is a full-time telework position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time). Occasional weekend and holiday on-call coverage may be required.

Mercor

RN Fully Remote Nurse

Posted on:

October 30, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

California

Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.

Position: Registered Nurse Type: Independent Contractor Compensation: $60–$110/hour Location: Remote Duration: 3–4 weeks Commitment: 30–40 hours/week

Must-Have: 4+ years professional experience in your domain. Excellent written communication with strong grammar and spelling skills. Start Date: Immediately Compensation & Legal: Hourly contractor, Paid weekly via Stripe Connect. Application Process (Takes 20–30 mins to complete) Upload resume AI interview based on your resume Submit form Resources & Support: For details about the interview process and platform information, please check: https://talent.docs.mercor.com/welcome/welcome For any help or support, reach out to: support@mercor.com

Create deliverables addressing common requests in your professional domain. Review peer-developed deliverables to enhance AI research. Diagnose and solve real issues in AI model training and evaluation. Work independently and asynchronously to meet deadlines. Collaborate with AI research teams to improve model outputs.

Intermountain Health

Registered Nurse Orthopedic Boneline Triage PRN

Posted on:

October 30, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Utah

Headquartered in Utah with locations in six primary states and additional operations across the western U.S., Intermountain Health is a nonprofit system of 34 hospitals, 400+ clinics, a medical group of more than 4,800 employed physicians and advanced care providers, a health plan division called Select Health with more than one million members, and other health services. With more than 68,000 caregivers on a mission to help people live the healthiest lives possible, Intermountain is committed to improving community health, and is widely recognized as a leader in transforming healthcare. We strive to be a model health system by taking full clinical and financial accountability for the health of more people, partnering to proactively keep people well, and coordinating and providing the best possible care. At Intermountain, every caregiver helps us fulfill our mission of helping people live the healthiest lives possible. Interested in joining our team? Check out our career website and apply today at https://intermountainhealthcare.org/careers/.

The Registered Nurse (RN) is a professional caregiver who assumes responsibility and accountability for assessing, planning, implementing and evaluating care of patients. The Clinic RN utilizes the nursing process by use of technology, therapeutic intervention, evidence-based practice and coordination of care with other health team members in an outpatient clinic setting. Clinic RNs are pivotal members of the care delivery team headed by the physician and have specialized knowledge, skills and ability pertinent to ambulatory care patient needs. Scope of performance includes prioritization and triage of care delivery, implementing established standing orders and protocols, performing procedures and therapies consistent with training and licensure.

Current RN License in state of practice. Basic Life Support Certification (BLS) for healthcare providers. Practice specific certification as required by the clinical setting in which they work (i.e., ACLS, PALS, etc.). Ability to communicate effectively both verbally and in writing. RNs with less than 12 months of working experience as an RN prior to joining Intermountain must obtain their BSN within four years of their start date. Preferred Qualifications: Bachelor's degree in Nursing (BSN) from an accredited institution. Physical Requirements: Ongoing need for employee to see and read information, labels, assess patient needs, operate monitors, identify equipment and supplies. - and - Frequent interactions with patient care providers, patients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations. - and - Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, medication preparation, etc. - and - Expected to lift and utilize full range of movement to transfer patients. Will also bend to retrieve, lift, and carry supplies and equipment. Typically includes items of varying weights, up to and including heavy items. - and - Need to walk and assist with transporting/ambulating patients and obtaining and distributing supplies and equipment. This includes pushing/pulling gurneys and portable equipment, including heavy items. Often required to navigate crowded and busy rooms (full of equipment, power cords on the floor, etc). - and - May be expected to stand in a stationary position for an extended period of time.

Assess: Performs appropriate assessment of physical, social and psychological status (including cognitive, communicative and developmental skills as appropriate). Seeks and evaluates information acquired from other members of interdisciplinary team: patient, family, physician, non-nursing disciplines, support staff, others. Plan: Uses assessment information and critical thinking skills to collaboratively develop individualized plan of care. Actively seeks patient, family, team, and physician involvement to develop plan of care including needed education. Collaboratively plans and prepares patients for further support needs once the current episode of care outcomes are met (i.e., teaching, referrals, and follow-up). Implement: Directs the interdisciplinary care team via delegation, coordination and collaboration as appropriate. Provides or delegates care consistent with plan of care, guidelines of care and professional licensure provisions. Demonstrates the ability to set priorities and to coordinate and organize patient care delivery through effectively managing time, supplies, and resources. Evaluate: Evaluates patient response to interventions through review of achievement of goals, clinical outcomes, patient and family satisfaction. Revises plan of care as indicated, and reassesses changes as appropriate. Professionalism: Promotes nursing profession and participate in development of others. Integrates legal and ethical standards into practice: complies with regulatory standards, practices within scope of licensure, provides accurate & timely documentation, and understands legal implications of care delivery.

Intermountain Health

Registered Nurse Auditor

Posted on:

October 30, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Utah

Headquartered in Utah with locations in six primary states and additional operations across the western U.S., Intermountain Health is a nonprofit system of 34 hospitals, 400+ clinics, a medical group of more than 4,800 employed physicians and advanced care providers, a health plan division called Select Health with more than one million members, and other health services. With more than 68,000 caregivers on a mission to help people live the healthiest lives possible, Intermountain is committed to improving community health, and is widely recognized as a leader in transforming healthcare. We strive to be a model health system by taking full clinical and financial accountability for the health of more people, partnering to proactively keep people well, and coordinating and providing the best possible care. At Intermountain, every caregiver helps us fulfill our mission of helping people live the healthiest lives possible. Interested in joining our team? Check out our career website and apply today at https://intermountainhealthcare.org/careers/.

To review medical records retrieved from provider offices and abstract medical information for HEDIS (Health Effectiveness Data Information Set) annual audits. Interprets relevant clinical criteria through review of medical records annotates via Adobe PDF and populates a data collection tool to support compliance with HEDIS, CMS, and STARS performance measures. The schedule for the position is flex-seasonal. Mid-January through the end of April we ask a minimum of 28 hours per week. May through December the flexibility is 0-14 hours per week depending on active projects being active.

Current RN license in state of practice. Current driver's license and access to personal vehicle to be able to travel to multiple local offices. Three years of clinical experience in hospital, and/or physician office. Computer skill in word processing and spreadsheets. RNs with less than 12 months of working experience as an RN prior to joining Intermountain must obtain their BSN within five years of their start date. Preferred Qualifications: Bachelor's Degree in Nursing (BSN) from an accredited institution. Effective organizational skills and written and verbal communication skills. Physical Requirements: Ongoing need for employee to see and read information, assess member needs, and view computer monitors and Frequent interactions with providers, members that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues accurately and Manual dexterity of hands and fingers, this includes frequent computer use and typing for documenting member care, accessing needed information, etc.

Work collaboratively with Select Health’s HEDIS Manager, Quality Consultants, and Data Analyst Responsible for performing accurate and comprehensive medical record reviews using a proprietary abstraction tool and software on an assigned laptop Reviewer will perform remote or offsite medical record reviews with charts collected from provider offices, clinics and hospitals for the purpose of obtaining documentation to support the HEDIS project. Records will be retrieved by third party vendor, fax, remote EMR access and/or mail processes Locate and review all assigned medical charts, perform abstraction, mark-up supporting documentation per audit specifications Proven organizational and time management skills including the ability to meet required deadlines. Work with provider offices as needed to schedule/confirm appointments, and follow up on medical record requests Calls members to gather procedural information on when and where the member received are and verify care was received. Reviewer must pass a medical record abstraction test prior to beginning the project and will need to maintain minimum competency throughout the project Frequent interactions with providers, members that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues accurately

Healthmap Solutions

Remote RN Care Navigator (Texas)

Posted on:

October 30, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Healthmap Solutions is the future of specialty health management that focuses on progressive diseases, with a particular expertise in kidney health populations. Healthmap Solutions uses clinical big data resources and high-powered analytics to power complex specialty health management programs. Healthmap Solutions is a diverse, growing company committed to our clients and our employees. We are champions for better health, for those who need us most.

The Care Navigator will be responsible for case management specific to kidney health management. The Care Navigator will complete activities for the continuum of care to facilitate and promote high quality, cost-effective outcomes for patients and focus on the whole patient and care delivery coordination. Managing a set caseload of mixed acuity members, reviewing and/or obtaining member data and entry in HealthMap’s Care Management documentation system (Compass), completing member health and social determinants of health screenings, medication reconciliation, creation and maintaining member-centric care plans, updates of identified problems, barriers, interventions, and goals and assistance with ongoing case management. The Care Navigator will collaborate with internal and external (physicians, nurses, and other healthcare personnel) to assure positive patient outcomes and care coordination.

Active, unrestricted Compact RN license required Bilingual preferred Bachelor's degree required CCM preferred Three (3) years of experience in case management preferred Experience in a dialysis center or transplant center preferred Experience with Medicare and Medicaid preferred Skills: Advocate and energize a culture of collaboration, positivity, and motivation Strategic thinking and planning Deliver effective communication – verbal and written Succeed in a challenging environment with changing priorities

Handle in and outbound calls delivering world-class service to our members Educate kidney health and related co-morbid conditions as well as optimizing renal replacement therapy by educating members on the types of dialysis and transplant options Engage members into HealthMap’s Kidney Health Program Follow up with members based on complexity and cadence by policy Serve as patient advocate for responding and working to resolve concerns or barriers Utilize community resources and programs in care planning Serve as liaison between the patient, the patient’s support network, treating physician, and other ancillary providers as a member of an interdisciplinary care team to coordinate care, resolve nursing problems and assist patients in meeting individualized goals Notify providers of identified patient needs based on policy Comply with HIPAA privacy laws and all other federal, state, and local regulations Comply with company-defined operational policies and procedures Comply with company security policies Accountable for individual metrics and key performance indicators and identified by the organization Navigate technical applications - Excel, OneNote, Outlook, and Word Support after hours and various time zones based on business need Drive patient and families in their own care and to support self-management

SSM Health

RN-Referral Liaison, Continuum of Care/Remote PRN

Posted on:

October 30, 2025

Job Type:

Part-Time

Role Type:

Case Management

License:

RN

State License:

Illinois

SSM Health is a Catholic, not-for-profit, fully integrated health system dedicated to advancing innovative, sustainable, and compassionate care for patients and communities throughout the Midwest and beyond. The organization’s 40,000 team members and 13,900 providers are committed to fulfilling SSM Health’s Mission: “Through our exceptional health care services, we reveal the healing presence of God.” With care delivery sites in Illinois, Missouri, Oklahoma and Wisconsin, SSM Health includes hospitals, physician offices, outpatient and virtual care services, comprehensive home care and hospice services, a fully transparent pharmacy benefit company, a health insurance company and an accountable care organization. It is one of the largest employers in every community it serves. For more information, visit ssmhealth.com Visit jobs.ssmhealth.com to fulfill your calling with SSM Health. Together – We Care.

The selected individual will be responsible for; Meeting with patients/families in person to discuss continuum of care services. Meeting/communicating with referral sources (case management, social work, clinics, providers, SNF/ALF facilities etc). Care coordination between continuum of care departments, such as branch departments, business development etc. Eligibility/Chart Review to determine appropriateness for continuum of care services **Must live in the ILL Region and be within 1 hour of branch offices. Some coverage onsite. Flexible schedule: Minimum 8 hours /month + weekend shift (Sat & Sun 8-430) Schedule will typically be available 2 months in advance. Pay Range: $32.77 - $52.43 Pay Rate Type: Hourly SSM Health values the skills and talents that each team member brings to our organization. Compensation for this role is based on a variety of components including relevant experience, labor market, and other qualifications. The posted pay range for this position is what SSM Health reasonably expects, in good faith, to offer based on the circumstances at the time of posting. SSM Health may ultimately pay more or less than the posted range as permitted by law. Job Summary: Creates an environment that leads to a positive patient care experience by facilitating problem solving and decision making. Ensures accuracy and timeliness on all functions related to insurance prior authorization, plan benefits, and medical necessity documentation. Serves as a liaison between patients, physicians and all other participants of the health care team.

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

Creates a positive patient care experience by greeting, preparing, exiting and following up with patients for providers according to established competency guidelines, policies and procedures. Creates an atmosphere of teamwork by contributing to opportunities to improve employee and customer satisfaction, including self development, continuing education (personal and technical), and achieving department objectives and goals. Provides support, both expected and directed, and collaborates with physicians and multi-disciplinary care team(s) for best care/results. Ensures accuracy of data collection and reporting for quality Initiatives. Maintains accountability for maximizing revenue capture and growth while optimizing cost savings. Communicates opportunities for organizational growth and improvement. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's Scope of Service. As an SSM Health nurse, I will demonstrate the professional nursing standards defined in the professional practice model. Uses the ANA Code of Ethics for Nurses to guide his/her response to the current and evolving health and nursing needs of our patients and our patient populations. Works in a constant state of alertness and safe manner. Performs other duties as assigned.

Denver Health

RN Registered Nurse, Utilization Coordinator Denver Health Medical Plan - Remote (Must be a Colorado Resident)

Posted on:

October 29, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Colorado

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation. As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year. Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

*Must Be a Colorado Resident Job Summary: Under general supervision the RN, Utilization Coordinator performs initial inpatient or outpatient utilization review activities to determine the efficiency, effectiveness and quality of medical and behavioral health services. In collaboration with the UM Supervisor, serves as liaison between ordering and service providers and the Health Plan. Makes medical determination decisions within defined protocols based on review of the service requests, clinical and non-clinical data, Member eligibility, and benefit levels in accordance with contract and policy guidelines. Convey approval or denial of requested services, identifies and reports on specific cases, and provides information regarding utilization management requirements and operational procedures to members, providers and facilities.

Education: Associate's Degree Completion of a nursing education program that satisfies the licensing requirements of the Colorado State Board of Nursing for Registered Nurses required. Work Experience: 1-3 years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required or 1-3 years experience in care coordination, case management or member navigation required. Medicaid and Medicare Managed Care experience preferred Home care/field-based case management, or working with the needs of vulnerable populations who have chronic medical, behavioral health or social needs preferred Certification in Case Management preferred Licenses: RN-Registered Nurse - DORA - Department of Regulatory Agencies required Knowledge, Skills and Abilities: Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment. Effectively collaborate with and respond to varied personalities in differing emotional conditions, and maintain professional composure at all times. Strong customer service orientation and aptitude. Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action. Ability to communicate verbally and in writing complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.

Performs clinical review of inpatient or outpatient service request using clinical judgment, nationally accepted clinical guidelines, knowledge of departmental procedures and policies within timeliness guidelines for preservice, urgent or concurrent review. (30%) Consults on cases with Supervisor, Manager, Director or Medical Director. Requests additional info from requesting providers, as needed. (20%) Creates correspondence to Members and Providers related to clinical determination; adjusts language to appropriate literacy level to support lay person understanding of medical terminology. (15%) Routes potential denials of service/care are referred to Medical Directors for review in a comprehensive, timely and professional manner. (10%) Support and collaborate with the UM and CM Managers and Supervisors in the implementation and management of UM/CM activities. (10%) Mentors and performs peer reviews. (10%) Participates in ongoing education and training related to health plan benefits and limitations, regulatory requirements, clinical guidelines, inter-rater reliability testing, community standards of patient care, and professional nursing standards of practice. (5%)

Insight Global

Remote RN Care Coordinator

Posted on:

October 29, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Insight Global is an international professional services and staffing company specializing in delivering talent and technical solutions to Fortune 1000 companies across the IT, Non-IT, Healthcare, and Engineering industries. Fueled by staffing and talent experts, Evergreen, our professional services brand, brings technical advisors and culture consultants to help customers tackle their biggest challenges. With over 70 locations across North America, Europe, and Asia, and global staffing capabilities in 50+ countries, our teams of tech-enabled recruiters are dedicated to finding the right talent and technical solutions to help our customers thrive. At our core, we are dedicated to empowering people to do great things. That’s why we’re passionate about developing our people personally, professionally, and financially so they can be the light to the world around them. To find out more, visit www.insightglobal.com

Position: Remote RN Care Coordinator Duration: 3 month contract with extensions, potential for permanent Location: REMOTE Shift: M-F no weekend or holidays (9:30am-6pm) Insight Global is looking to hire a Remote RN Care Coordinator for their long-term care client. The position of Care Coordinator plays a leading role in the insured or member’s assessment process. They provide services to a variety of clients, all that require your deep knowledge of long-term care needs of an aging or chronically ill population. You will be part of a remote team of clinicians that calls claimants or their families and facilities to conduct a short assessment by phone or zoom. In about 20 minutes, the RN collects and updates the claimant’s electronic health record, plan of care and provide a detailed note for any change note. You will be part of a remote team of clinicians that spends their days reviewing clinical assessments completed by field assessors and writing Plans of Care for Long Term Care Insurance and other government sponsored insurance plans.

Compact Registered Nurse License in good standing 2-5 years of experience in home care, case management, hospice and/or rehabilitation setting with an aging population Telephonic nurse care experience Strong knowledge of Microsoft applications to include Outlook and Word. Proficient with workflow management tools and a CRM.

Reviewing clinical assessments completed by field assessors to determine chronic illness status and develop a plan of care with supporting written documentation. Collaborate with field assessors and facility staff via phone to determine if further information is needed on a claimant or member’s health status Call claimants, family members or facility staff to update records on their present health status and provide a new plan of care, as well as handle telephonic assessments Work with new clients to develop processes that meet their insureds’ needs.

Liberty Mutual Insurance

Medical & Disability Nurse Case Manager

Posted on:

October 29, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Arizona

Pay Philosophy: The typical starting salary range for this role is determined by a number of factors including skills, experience, education, certifications and location. The full salary range for this role reflects the competitive labor market value for all employees in these positions across the national market and provides an opportunity to progress as employees grow and develop within the role. Some roles at Liberty Mutual have a corresponding compensation plan which may include commission and/or bonus earnings at rates that vary based on multiple factors set forth in the compensation plan for the role. As a purpose-driven organization, Liberty Mutual is committed to fostering an environment where employees from all backgrounds can build long and meaningful careers. Through strong relationships, comprehensive benefits and continuous learning opportunities, we seek to create an environment where employees can succeed, both professionally and personally. At Liberty Mutual, we believe progress happens when people feel secure. By providing protection for the unexpected and delivering it with care, we help people embrace today and confidently pursue tomorrow. We are dedicated to fostering an inclusive environment where employees from all backgrounds can build long and meaningful careers. By actively seeking employee feedback and amplifying the voices of our seven Employee Resource Groups (ERGs), which are open to all, we create an environment where every individual can make a meaningful impact so we continue to meet the evolving needs of our customers. We value your hard work, integrity and commitment to make things better, and we put people first by offering you benefits that support your life and well-being. To learn more about our benefit offerings please visit: https://LMI.co/Benefits

If you're a registered nurse looking for a new opportunity to work in a fast-paced, professional environment where your talent contributes to our competitive edge, Liberty Mutual Insurance has the opportunity for you. Under general technical direction, responsible for medically managing assigned caseload and by applying clinical expertise ensure individuals receive appropriate healthcare in order to return to work and normal activity in a timely and cost effective manner. Caseload may include catastrophic/complex medical/disability cases, lost time, and/or medical only claims. Also act as a clinical resource for field claim partners. This is a remote position however, you will be required to report into the office twice a month per business requirements if you reside within 50 miles of the following offices: Chandler, AZ, Dove, NH, Suwanee, GA, Rocklin, CA, Indianapolis, IN, Plano, TX, and Westborough, MA. Please note this policy is subject to change.

Ability to analyze and make sound nursing judgments and to accurately document activities. Strong communication skills in order to build relationships with injured employees, medical professionals, employers, field claims staff and others. Good negotiation skills to effectively establish target return to work dates and coordinate medical care. Knowledge of state, local and federal laws related to health care delivery preferred. Personal computer knowledge and proficiency in general computer applications such as Internet Explorer and Microsoft Office (including Word, Excel and Outlook). Degree from an accredited nursing school required (prefer Bachelor of Science in Nursing). Minimum of 3 to 5 years of clinical nursing experience; prefer previous orthopedic, emergency room, critical care, home care or rehab care experience. Previous medical case management experience a plus. Must also have current unrestricted registered nurse (R.N.) license in the state where the position is based and other assigned states as required by law. Must have additional professional certifications, such as CCM, COHN, CRRN, etc., where required by WC law.

Follows Liberty Mutual's established standards and protocols to effectively manage assigned caseload of medical/disability cases and by applying clinical expertise assist to achieve optimal outcome and to facilitate claim resolution and disposition. Effectively communicates with injured employees, medical professionals, field claims staff, attorneys, and others to obtain information, and to negotiate medical treatment and return to work plans using critical thinking skills, clinical expertise and other resources as needed to achieve an optimal case outcome. Utilizes the Nursing Process (assessment, diagnosis, planning, intervention and evaluation) to facilitate medical management to attain maximum medical improvement and return-to-work (RTW) per state jurisdictional requirements. Appropriately utilizes internal and external resources and referrals i.e., Utilization Review, Peer Review, Field Claims Specialists, Regional Medical Director Consults, and Vocational Rehabilitation to achieve best possible case outcome. Follows general technical direction from nurse manager, senior medical and disability case manager and/or CCMU staff to resolve highly complex medical and/or RTW issues and/or successfully manage catastrophic injuries. Documents all RN activities accurately, concisely and on a timely basis. This includes documenting the medical and disability case management strategies for claim resolution, based on clinical expertise. Adheres to confidentiality policy. Appropriately applies clinical expertise to claims and delivers services in an efficient and effective manner. Accurately and appropriately documents time tracking for work performed. Achieves annual time tracking goal. Handles special projects as assigned.

CVS Health

Utilization Management Nurse Consultant - Work From Home

Posted on:

October 29, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

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

Utilization Management is a 24/7 operation and the work schedule may include weekends, holidays, and evening hours. This will be a full-time remote role. Schedule 1: Monday through Friday, 8am to 5pm CST with required occasional weekend, holiday and evening rotations. Schedule 2: Saturday and Sunday 8am-5pm CST with flexible Weekdays Position Summary: Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines for services requiring precertification. The majority of the time is spent at a desk and on the phone collecting and reviewing clinical information from providers. Precertification nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. This position will be working regular business hours with potential for occasional weekend/holiday on-call.

Required Qualifications: Must have active, current, and unrestricted compact RN licensure in state of residence 3+ years of clinical experience required 1+ years of Microsoft Office Suite experience required Position requires proficiency with computer skills which includes navigating multiple systems Ability to work in a fast paced environment Preferred Qualifications: Prior Authorization experience strongly preferred Sedentary work involves periods of sitting, talking, listening and computer use Ability to work in a fast paced environment Education: Associate's degree required BSN preferred

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written

Oscar Health

NP/PA - Oscar Primary Care (100% Remote)

Posted on:

October 29, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

Compact / Multi-State

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

You will manage a panel of members within the states of Georgia, Texas, Florida and other Oscar states where we offer virtual Oscar Virtual Primary Care or expand to (including New York, Oklahoma, Connecticut, Arizona, etc). You'll keep a set patient schedule and will be the primary care provider for your panel. You'll engage with new products and tooling that we're rolling out for the virtual care service lines. Clinic Hours: Monday - Friday, closed on weekends and major holidays We are open 7am - 8pm EST. (Shifts available in all time zones) All providers work 5 8hr shifts per week. You will report into the Medical Director, Oscar Primary Care. Work Location: Oscar Medical Group is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission. This is a remote / work-from-home role. You must reside in one of the following states: Arizona, California, Colorado, Florida, Georgia, Illinois, Massachusetts, Michigan, Nevada, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Texas, or Virginia. Note, this list of states is subject to change. #LI-Remote Pay Transparency: The base pay for this role is: $130,000 - $136,500 per year. You are also eligible for employee benefits, annual vacation grant of up to 18 days per year and annual performance bonuses.

DNP, FNP, ENP, or PA from accredited program Board Certification (NCCPA or AANP or ANCC) Spanish language fluency (read, write, and speak) 3+ years of in person primary care experience 2+ years of experience delivering virtual care Licensed in GA, FL, TX Compact RN license (if an APRN) Bonus points: Experience working with remote diagnostic and home monitoring tools If not licensed in Arizona, has the necessary pharmacology course hour requirement and/or coursework to obtain an Arizona license

Provide care for your panel of patients (18+) virtually (phone, messaging, video) Provide continuity of care to patients with a wide range of acuity from young/healthy to chronic conditions (DM, HTN, COPD, CAD, etc). Collaborate with physicians MD/DO on the Care Team on complex patients / escalated cases. Follow up on labs, imaging, and closed loop communication with patients and other providers. Collaborate with registered nurses, medical assistant and clinical supervisory where applicable Be available on call to answer important lab escalations as they occur. Participate in collaborative care with virtual behavioral health specialists

Oscar Health

Utilization Review Nurse

Posted on:

October 29, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Hi, we're Oscar. We're hiring a Utilization Review Nurse to join our Utilization Review team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

You will perform frequent case reviews, check medical records and speak with care providers regarding treatment as needed. You will make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions. You will report into the Supervisor, Utilization Review. Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; Illinois; Iowa; Kansas; Michigan; Missouri; Nebraska; New Jersey; North Carolina; Ohio; Pennsylvania; South Carolina; Tennessee; Texas; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $35.00 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.

Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) Associate Degree - Nursing or Graduate of Accredited School of Nursing Or Successful completion of Diploma Program in Practical Nursing of Accredited School of Nursing Ability to obtain additional state licenses to meet business needs 1+ year of utilization review experience in a managed care setting 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital) Bonus points: BSN Previous experience conducting concurrent or inpatient reviews for a managed care plan

Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines Obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines Meet required decision-making SLAs Refer members for further care engagement when needed Compliance with all applicable laws and regulations Other duties as assigned

Cognizant

UR Registered Nurse – Clinical Appeals & Denials Specialist - Remote

Posted on:

October 29, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Pennsylvania

Cognizant is one of the world's leading professional services companies, transforming clients' business, operating, and technology models for the digital era. Our unique industry-based, consultative approach helps clients envision, build, and run more innovative and efficient businesses. Headquartered in the U.S., Cognizant (a member of the NASDAQ-100 and one of Forbes World’s Best Employers 2024) is consistently listed among the most admired companies in the world. Learn how Cognizant helps clients lead with digital at www.cognizant.com

Schedule: Monday to Friday - Eastern Time Location: Remote About the role: As a Registered Nurse you will make an impact by performing advanced level work related to clinical denial management and managing clinical denials from Providers to the Health Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a valued member of the Cognizant team and work collaboratively with stakeholders and other teams.

Educational background - Registered Nurse (RN) 2-3 years combined clinical and utilization management experience with managed health care plan 3 years’ experience in health care revenue cycle or clinic operations Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and concurrent reviews Intermediate Microsoft Office knowledge (Excel, Word, Outlook) In-patient and outpatient experience These will help you stand out Epic experience Experience in drafting appeals disputing inpatient clinical validations audits is a plus.

Maintain ownership and responsibility for assigned accounts. Maintain working knowledge of applicable health insurers’ internal claims, appeals, and retro-authorization as well as timely filing deadlines and processes. Review clinical denials including but not limited to referral, preauthorization, medical necessity, non-covered services, investigational/experimental and billing resulting in denials and/or delays in payment. Draft and submit the medical necessity determinations to the Health Plan/Medical Director based on the review of clinical documentation in accordance with Medicare, Medicaid, and third-party guidelines. Effectively document and log claims/appeals information on relevant tracking systems Utilize critical thinking skills to interpret guidelines of internal policies for clinical determination. Medical Necessity Reviews can be based on InterQual, Milliman Clinical Guidelines (MCG), Medicare guidelines, and health insurer specific guidelines. Review retro-authorizations in accordance with health insurer requirements and follow insurer process guidelines. Identify denial patterns with clients to mitigate risk and minimize regulatory penalties. Escalate potential risks to client, client partners and/or leadership. Demonstrates critical thinking skills to interpret guidelines of internal policies for clinical determination We strive to provide flexibility wherever possible. Based on this role’s business requirements, this is a remote position open to qualified applicants in United States. Regardless of your working arrangement, we are here to support a healthy work-life balance though our various wellbeing programs. The working arrangements for this role are accurate as of the date of posting. This may change based on the project you’re engaged in, as well as business and client requirements. Rest assured; we will always be clear about role expectations.

Cognizant

Clinical Registered Nurse - Utilization Management - Remote

Posted on:

October 29, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

New Jersey

Cognizant is one of the world's leading professional services companies, transforming clients' business, operating, and technology models for the digital era. Our unique industry-based, consultative approach helps clients envision, build, and run more innovative and efficient businesses. Headquartered in the U.S., Cognizant (a member of the NASDAQ-100 and one of Forbes World’s Best Employers 2024) is consistently listed among the most admired companies in the world. Learn how Cognizant helps clients lead with digital at www.cognizant.com

Schedule: Monday to Friday - Eastern Time Location: Remote About the role: As a Registered Nurse you will make an impact by performing advanced level work related to clinical denial management and managing clinical denials from Providers to the Health Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a valued member of the Cognizant team and work collaboratively with stakeholders and other teams.

Educational background - Registered Nurse (RN) 2-3 years combined clinical and/or utilization management experience with managed health care plan 3 years’ experience in health care revenue cycle or clinic operations Experience in utilization management to include Clinical Appeals and Grievances, precertification, initial and concurrent reviews Intermediate Microsoft Office knowledge (Excel, Word, Outlook) In-patient and outpatient experience These will help you stand out Epic experience Experience in drafting appeals disputing inpatient clinical validations audits is a plus.

Maintain ownership and responsibility for assigned accounts. Maintain working knowledge of applicable health insurers’ internal claims, appeals, and retro-authorization as well as timely filing deadlines and processes. Review clinical denials including but not limited to referral, preauthorization, medical necessity, non-covered services, investigational/experimental and billing resulting in denials and/or delays in payment. Draft and submit the medical necessity determinations to the Health Plan/Medical Director based on the review of clinical documentation in accordance with Medicare, Medicaid, and third-party guidelines. Effectively document and log claims/appeals information on relevant tracking systems Utilize critical thinking skills to interpret guidelines of internal policies for clinical determination. Medical Necessity Reviews can be based on InterQual, Milliman Clinical Guidelines (MCG), Medicare guidelines, and health insurer specific guidelines. Review retro-authorizations in accordance with health insurer requirements and follow insurer process guidelines. Identify denial patterns with clients to mitigate risk and minimize regulatory penalties. Escalate potential risks to client, client partners and/or leadership. Demonstrates critical thinking skills to interpret guidelines of internal policies for clinical determination We strive to provide flexibility wherever possible. Based on this role’s business requirements, this is a remote position open to qualified applicants in United States. Regardless of your working arrangement, we are here to support a healthy work-life balance though our various wellbeing programs. The working arrangements for this role are accurate as of the date of posting. This may change based on the project you’re engaged in, as well as business and client requirements. Rest assured; we will always be clear about role expectations.

Mercor

Registered Nurse Clinic | Remote $110/hr

Posted on:

October 29, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.

Position: Registered Nurse Type: Independent Contractor Compensation: $60–$110/hour Location: Remote Duration: 3–4 weeks Commitment: 30–40 hours/week

Must-Have 4+ years professional experience in your domain. Excellent written communication with strong grammar and spelling skills. Start Date: Immediately Compensation & Legal: Hourly contractor, Paid weekly via Stripe Connect.

Create deliverables addressing common requests in your professional domain. Review peer-developed deliverables to enhance AI research. Diagnose and solve real issues in AI model training and evaluation. Work independently and asynchronously to meet deadlines. Collaborate with AI research teams to improve model outputs.

Wound Care

Clinical Administrative Nurse Specialist (Remote)

Posted on:

October 28, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Remote! We’re seeking a dynamic RN with strong administrative coordination skills to join Labs as our front-line for incoming facility/clinician calls and diagnostic request workflows. This role ensures smooth communication, scheduling and documentation for our wound-care diagnostics operations, while leveraging your clinical understanding to escalate appropriately and maintain high operational quality. Apply if you: have wound-care or related nursing experience, thrive on managing calls/requests/scheduling, are comfortable working in a fast-paced diagnostic environment, and bring professionalism, accuracy and initiative. Position Summary: As a key member of the Labs team, the Clinical Administrative Nurse Specialist will act as the primary point of contact for incoming clinical calls, provider/facility requests, and wound-care diagnostics coordination. This individual will leverage nursing knowledge (wound care, clinical terminology) together with administrative/secretarial proficiency (call management, scheduling, documentation) to ensure seamless support for clients, patients, and internal stakeholders. The role contributes to operational efficiency, high-quality service, and excellent communication between referring facilities, clinicians, and the lab team.

Current Registered Nurse (RN) license Minimum of 2-3 years clinical nursing experience (preferably in wound care, wound clinic, home health, or related area). Strong administrative/office experience (calls, scheduling, database management, multi-line phones) in a healthcare setting. Knowledge of medical terminology, sample handling, diagnostic lab workflows. Proficiency with electronic health records (EHR) or lab information systems, Microsoft Office (Excel/Word) and database tools. Excellent communication (verbal and written), strong interpersonal skills, ability to prioritize and multi-task in a fast-paced environment. High level of confidentiality, attention to detail, professionalism. Ability to work independently and as part of a cross-functional team. Preferred Qualifications: Experience working with wound-care facilities, home-health, or mobile lab settings. Previous experience in a secretarial/support role in a clinical department. Working Conditions & Physical Requirements: Remote: Ability to work standard business hours; may require flexibility for peak request times.

Receive and triage incoming calls from facilities, referring clinicians, patients and external vendors. Determine urgency, route appropriately, log the call/request, and ensure follow-through. Coordinate and schedule wound-care diagnostic services (lab tests, sample pickups, consultations) with internal and external partners. Prepare and distribute necessary documentation (consent forms, referral forms, billing info, shipping/chain-of-custody forms) related to wound-care diagnostic services. Serve as liaison between nursing/facility staff and the lab operations team: clarify clinical questions, relay test results, escalate concerns. Assist with administrative tasks: ordering supplies (for lab kits or facility packaging), maintaining office/clinical supply inventory, coordinating courier/pickup schedules.

P&T Industries, LLC

Remote Nurse Practitioner

Posted on:

October 28, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

NP/APP

State License:

Texas

We are seeking a Remote Nurse Practitioner to join our healthcare team. The ideal candidate will have a strong background in providing comprehensive care to patients, particularly in outpatient settings, telephone triage and telehealth environments. This role involves working remotely with patients, families, and interdisciplinary teams to deliver high-quality healthcare services. This is an opportunity to work remotely utilizing advanced systems to impact populated and rural communities.

Candidates should possess the following qualifications: Valid license Nurse Practitioner/board certification and DEA license in the state of Texas. Background in Internal, Family Medicine and/or Urgent Care preferred Familiarity with systems related to Telehealth care delivery. Strong assessment skills and ability to utilize Hippa compliant tools to complete health histories. Manage prescription refills and chronic condition management.

Conduct patient assessments and health histories. Develop and implement individualized care plans based on patient needs and preferences. Provide health coaching and education to patients and their families regarding disease prevention and management. Prescribe various medications to manage conditions such as infectious diseases, hypertension, diabetes, obesity, colds, flu, gastrointestinal complications and a host of acute telehealth complications that may present. Order lab values with access to nationwide laboratory services and stat lab access. Order mobile and ambulatory medical imaging to increase access to care. Work on your schedule. Create your own schedule and work when you want, whether that’s evenings, part-time, or full-time. 100% remote. Provide rewarding patient care from the comfort and safety of your home or office. Utilize ICD-9 coding for accurate documentation of diagnoses and treatment plans. Maintain accurate medical records and documentation in compliance with healthcare regulations.

Sentara Health

Nurse Case Manager

Posted on:

October 28, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Sentara is focused on living its mission — to improve health every day. In addition to providing world-class care, Sentara partners with organizations to provide significant support to address social determinants of health and advance the overall quality of life.

Sentara Health Plans is currently hiring an Integrated Nurse Case Manager in Tidewater Virginia Status: Full Time (40 hrs/wk) Shift: Day (8am-5pm) Location: Remote* in Tidewater, VA (Requires Travel) *Position is remote but does require in person face-to-face assessments multiple times throughout the week. Candidates must be able to travel frequently throughout the week to complete in person assessments. Location of assessments include: Virginia Beach, Chesapeake, Norfolk, Suffolk, Portsmouth. May occasionally include Hampton, Newport News, Williamsburg

Preferred: Private duty nursing experience and knowledgeable with ventilators in a facility or home Education: Associates or Bachelors Degree in Nursing (Required) Certification/Licensure: Virginia or Compact RN License (Required) Experience: 3 years experience in Nursing (Required) Experience in Private Duty Nursing or NICU or Experience working with Ventilators (Required) Discharge planning experience (Preferred) Managed Care experience (Preferred)

Responsible for case management services within the scope of licensure; develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum Performs telephonic or face-to-face clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical and behavioral health, social services and long-term services Identifies members for high-risk complications and coordinates care in conjunction with the member and health care team Manages chronic illnesses, co-morbidities, and/or disabilities ensuring cost effective and efficient utilization of health benefits; conducts gap in care management for quality programs Assists with the implementation of member care plans by facilitating authorizations/referrals within benefits structure or extra-contractual arrangements, as permissible Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on care management treatment plans Presents cases at case conferences for multidisciplinary focus. Ensures compliance with regulatory, accrediting and company policies and procedures May assist in problem solving with provider, claims or service issues

Companion Data Services

Stop Loss Registered Nurse

Posted on:

October 28, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

We are currently hiring for a Stop Loss Registered Nurse to join BlueCross BlueShield of South Carolina. In this role as a Stop Loss Registered Nurse, you will evaluate and manage catastrophic episodes of illness for underwriting and claims. Ensures that the insured is receiving the best medical care, but in the most cost-effective manner. Location: This position is full-time (40 hours/week) Monday-Friday, from 8:00am – 4:00pm CST and can be hybrid in Dallas, TX or fully remote.

Required Education: Associates in a job-related field Degree Equivalency: Graduate of Accredited School of Nursing Required Work Experience: 10 years, 5 years clinical plus 5 years medical management experience. Required Skills and Abilities: Working knowledge of word processing software. Excellent verbal and written communication skills. Ability to work independently, prioritize effectively, and make sound decisions. Working knowledge of managed care and various forms of health care delivery systems. Working knowledge of catastrophic claims cost, medical vendors, case management. Demonstrated customer service, communication, and organizational skills. 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 RN licensure in state hired. What We Prefer You to Have: Preferred Education: Bachelor's degree-Nursing Preferred Work Experience: 10+ years as a medical staff nurse, experience working with a stop loss carrier and providing underwriting and claims with medical cost projects.

Facilitates cost estimates to the underwriters for new and renewal stop loss business. Consults with the underwriters on catastrophic episodes of illness. Provides case management oversight of managed care between the TPA and us. Review potential claim notices and excess claims received to determine setting reserves. Reviews potential claims notices from TPAs. Researches as necessary to evaluate cost containment and intervenes with the TPA.

Elevance Health

Med Mgmt Clinician Associate (contract)

Posted on:

October 28, 2025

Job Type:

Contract

Role Type:

Utilization Review

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.

Anticipated Start Date: 12/08/2025 Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date. Responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. Focuses on less complex and potentially higher volume benefit plans and/or contracts, following standard procedures that do not require the training or skill of a registered nurse.

Requires H.S. diploma or equivalent. Requires a minimum of 2 years of clinical experience and/or utilization review experience. Current active, valid and unrestricted LPN/LVN or RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required. Multi-state licensure is required if this individual is providing services in multiple states. Utilization Management experience. Call center experience. Prior-auth experience. Managed care experience. Additional Details: High-Speed Internet. 100% WFM (Remote role). Monday - Friday; 10:30AM -7PM EST Acceptable office space to keep confidential information secure. The candidate must reside 50 miles from any Pulse Point location. There are no OT or weekend requirements.

Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. Work may be facilitated, in part, by algorithmic or automated processes. Handles less complex benefit plans and/or contracts. Conducts and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract. May process a medical necessity denial determination made by a Medical Director. Refers complex or non-routine reviews to more senior nurses and/or Medical Directors. Does not issue medical necessity non-certifications.

Broad River Rehabilitation

MDS Integration Specialist

Posted on:

October 28, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

North Carolina

We are looking for a dynamic and highly motivated Nurse for the MDS Integration Specialist opportunity with BRR. Responsibilities will include facilitating and developing the relationship/coordination between the facility and rehab. This includes aspects of the clinical practice focusing on: optimization of collaboration for therapy services with facility MDS personnel, appropriate functional outcomes, identification of training needs, and implementation of MDS related programs. Objectives will be achieved within the value system of Broad River Rehab and with the ultimate objective of creating value for our patients, our customers and our employees. This position is a remote position. Broad River Rehab is a NC based growing therapy company (providing services in multiple states) which partners with providers across all settings including assisted/ independent and skilled nursing facilities to provide premier physical, occupational and speech therapy services.

COMPETENCIES/REQUIREMENTS: Excellent geriatric clinical knowledge base. Excellent communication and relationship building skills. Able to coach, counsel and serve as a mentor. Good customer and employee problem resolution skills. Ability to maximize contribution as a team. Knowledge of Medicare billing procedures and documentation compliance. Ability to work with minimal direct oversight Bending, stooping, reaching, pushing, pulling, transferring, lifting 50 or more pounds, and assisting adults/children weighing 200 pounds or more with possible use of mechanical devices where applicable. CREDENTIALS: Active LPN/RN license to practice in state(s) employed. 1-3 years MDS experience.

Patient/Caseload Management Participate as effective team member and maximize team effort for facility and patient care excellence. Follow established protected health information (PHI) policies to prevent privacy or security breaches. If breach identified, report to Broad River Rehab Management. Provide / oversee appropriate MDS nursing process collaboration per all pertinent federal and state regulations. Oversee provision of GG coding training for therapy and facility staff per established facility schedule and as needed. Assist facility collaboration between MDS personnel and Rehab Director for Medicaid Case Management and PDPM optimization May be called upon for short durations of time to complete job responsibilities of BRR contracted MDS nurse in facility Customer Relations/Business Development Maintain and manage relationship with facility staff to ensure effective customer relations. Enhance facility profitability through understanding and education of reimbursement issues. Ensure alignment with facility objectives, timely response to facility issues and resolution of problems. Staff Management and Development Assist with new staff orientation and training to ensure understanding of MDS coding principles.

Cohere Health

Lead RN, Concurrent Review

Posted on:

October 28, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Massachusetts

Cohere Health’s clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. Cohere Health works with over 660,000 providers and handles over 12 million prior authorization requests annually. Its responsible AI auto-approves up to 90% of requests for millions of health plan members. With the acquisition of ZignaAI, we’ve further enhanced our platform by launching our Payment Integrity Suite, anchored by Cohere Validate™, an AI-driven clinical and coding validation solution that operates in near real-time. By unifying pre-service authorization data with post-service claims validation, we’re creating a transparent healthcare ecosystem that reduces waste, improves payer-provider collaboration and patient outcomes, and ensures providers are paid promptly and accurately. Cohere Health’s innovations continue to receive industry wide recognition. We’ve been named to the 2025 Inc. 5000 list and in the Gartner® Hype Cycle™ for U.S. Healthcare Payers (2022-2025), and ranked as a Top 5 LinkedIn™ Startup for 2023 & 2024. Backed by leading investors such as Deerfield Management, Define Ventures, Flare Capital Partners, Longitude Capital, and Polaris Partners, Cohere Health drives more transparent, streamlined healthcare processes, helping patients receive faster, more appropriate care and higher-quality outcomes. The Coherenauts, as we call ourselves, who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles. We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone.

Cohere’s Service Operations team is responsible for ensuring that our healthcare partners are supported throughout their lifecycle of using the platform. The Lead RN Reviewer in Service Operations position is a crucial role in our organization. In this role, you are responsible for coaching, mentoring, evaluating and developing the RN team. The Lead RN Reviewer will use established operational tools to ensure all RN staff are meeting or exceeding performance metrics and quality standards established by the leadership team. As a Lead RN Reviewer, you will work closely with the leadership team and report to the Clinical Supervisor of Service Operations. You will be responsible for providing supervision for the RN Reviewers to meet or exceed operational objectives and metrics. You will leverage both your creative skills and communication skills to promote a high performing clinical team. At a growing organization, this is a position that offers the ability to make a substantive mark on the company and its partners with exponential growth opportunities.

5+ years experience in Managed Care, Healthcare or Health Insurance related field 1-2 years previous Supervisory or Lead experience Current RN Licensure required, Bachelor’s degree in related field preferred Able to develop and train large groups and/or one on one Skilled in understanding others’ perspectives and challenges Able to interpret operational reports and drive process improvement initiatives Be kind and patient while demonstrating subject matter expertise Excellent interpersonal skills, oral and written communication skills Able to break down big challenges into organized plans Intellectually curious with a strong desire to understand and constantly improve your work and business processes Able to work cross functionally across remote teams Flexible and agile in ambiguous situations; open to changes in role and scope as the business grows

Gain a deep understanding of Cohere’s product and our health plan partners Provide general supervision over the nursing staff. This includes interviewing new hires, training, coaching, mentoring, quality auditing and oversight of quality improvement plans initiated by the Clinical Supervisor and or Director. Coordinates and provides day-to-day oversight and direction to clinicians Assist in addressing any case escalations or provider issues Other duties as assigned