argenx

Nurse Case Manager (Central Time Zone)

Posted on:

December 21, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Massachusetts

Join us as we transform immunology and deliver medicines that help autoimmune patients get their lives back. argenx is preparing for multi-dimensional expansion to reach more patients through a rich pipeline of differentiated assets, led by VYVGART, our first-in-class neonatal Fc receptor blocker approved for the treatment of gMG, and with the potential to treat patients across dozens of severe autoimmune diseases. We are building a new kind of biotech company, one that maintains its roots as a science-based start-up and pushes our commitment to innovate across all corners of our business. We strive to inspire and grow our company, our partnerships, our science, and our people, because when we do, we deliver more for patients.

The Nurse Case Manager (NCM) is the single point of contact for patients and their caregivers. They are aligned regionally and are responsible for educating patients, caregivers and families affected by generalized Myasthenia Gravis (gMG) and CIDP about the disease and argenx’s products and support services. The NCM may provide resources to help patients better manage their disease and coordinate their treatment. The NCM is responsible for participating in one-on-one communications with patients and their caregivers. *MUST LIVE IN THE CENTRAL REGION. SEVERAL OPENINGS AND THIS POSITION IS REMOTE.

Skills and Competencies: Demonstrated effective presentation skills; ability to motivate others; excellent interpersonal (written and verbal) skills – with demonstrated effectiveness to work cross-functional and independently Demonstrated ability to develop, follow and execute plans in an independent environment Demonstrated ability to effectively build positive relationships both internally & externally Demonstrated ability to be adaptable to changing work environments and responsibilities Must be able to thrive in team environment and willing to contribute at all levels with flexibility and a positive attitude Fully competent in MS Office (Word, Excel, PowerPoint) Flexibility to work weekends and evenings, as needed Participate in and complete required pharmacovigilance training Comply with all relevant industry laws and argenx’s policies Travel requirements less than 50% of the time Education, Experience and Qualifications: Applicants must live in the desired Time Zone Current RN License in good standing Bachelor’s degree preferred 5+ years of clinical experience in healthcare to include hospital, home health, pharmaceutical or biotech 2-5+ years of case management 2+ years of experience in pharmaceutical/biotech industry a must Reimbursement experience a plus Must live in geographically assigned territory Bilingual or multilingual a plus

Provide direct educational training and support to patients and caregivers about gMG, CIDP and prescribed argenx products Communicate insurance coverage updates and findings to the patient and/or caregiver Review and educate the patients and/or caregivers on financial assistance programs that they may be eligible for. Coordinate logistical support for patient to receive therapy and manage their disease Collaborate with argenx Patient Access Specialist, Case Coordinator, and Field Reimbursement Manager teams to troubleshoot and resolve reimbursement-related issues Engage with patients and provider case coordinators to ensure appropriate support is being given on an individualized basis Provide patient-focused education to empower patients to advocate on their behalf Develop relationships and manage multiple and complex challenges that patient and caregivers are facing Ensure compliance with relevant industry laws and argenx’s policies Aligned regional travel will be required for patient education to support patient programs Must be an excellent communicator and problem-solver Demonstrated time management skills; planning and prioritization skills; ability to multi-task and maintain prioritization of key projects and deadlines

Wellmark Blue Cross and Blue Shield

Utilization Management Nurse I (Remote eligible)

Posted on:

December 21, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Iowa

Wellmark Blue Cross and Blue Shield and its subsidiaries provide health coverage to more than 2 million members in Iowa and South Dakota. And through the Blue Cross Blue Shield Association, Wellmark is part of a trusted national network that insures more than 100 million people. That's nearly 1/3 of all Americans. Wellmark offers flexible benefit designs, competitive prices, and a large selection of providers. Nearly all physicians and hospitals in Iowa and South Dakota participate with Wellmark, and the Blue Cross and Blue Shield Association provides extensive national and international coverage. *Wellmark Blue Cross and Blue Shield is An Independent Licensee of the Blue Cross and Blue Shield Association serving Iowa and South Dakota.

Are you a dedicated, compassionate and detail-oriented health care professional with the ability to adapt to change and anticipate needs? Are you organized, inquisitive, and thrive in a collaborative setting, while exhibiting independent and critical thinking where resourcefulness is key? Are you motivated and inspired by the opportunity to utilize your clinical expertise in a fast-paced production environment with quality goals? Do you enjoy a team-centric environment where relationship building and strong communication skills are crucial to success? If so, apply today!

Candidates located in Iowa or South Dakota preferred. Top candidates will have prior health plan and/or UM experience along with a diverse clinical background. Prior remote work experience a plus!

As a Utilization Management (UM) Nurse, you will provide UM services, transition of care and support to members and health care providers. You will utilize clinical knowledge and expertise to interpret and appropriately apply medical policy, medical necessity criteria (InterQual), and benefit information to provide consultation and responses to UM requests. You will proactively assess and assist members to help move them through the continuum of care by utilizing services and resources efficiently. You will be part of a multidisciplinary team to continuously look for ways to improve processes and maximize health dollars for our members.

CVS Health

Appeals Nurse Consultant - Work From Home

Posted on:

December 21, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Conneticut

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

This position will be working from home anywhere in the US. Standard business hours 8a-5p in time zone of residence Monday - Friday.

Required Qualifications: 3+ years of clinical experience required Active and unrestricted RN licensure in state of residence Preferred Qualifications: Managed Care experience Utilization Management experience Appeals experience Pre Certification experience Pre Authorization experience Education: Associates Degree minimum OR Diploma RN required Bachelors Degree preferred

The Appeals Nurse Consultant position is responsible for processing the medical necessity of Medicare appeals for participating providers. Primary duties may include, but are not limited to: Requesting clinical, research, extrapolating pertinent clinical, applying appropriate Medicare Guidelines, navigate through multiple computer system applications in a fast-paced department. Must work independently as well as in a team environment while working remotely. Fast paced sedentary position, talking on the telephone, looking at computer screens, utilizing templates in Word, and typing on the computer.

AssureCare LLC

Telephone Triage Nurse

Posted on:

December 21, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

California

AssureCare is a privately held healthcare technology company that provides innovative care management solutions to commercial and health and human service providers. AssureCare’s flagship software platform, MedCompass, is used by healthcare providers throughout the United States to deliver end-to-end care management for millions of patients daily. MedCompass transforms healthcare management by automating processes and streamlining workflows, thus allowing care professionals to make better decisions that dramatically improve the quality of care and lower costs. AssureCare is considered an industry leader in developing, modular, seamless solutions designed to improve patient outcomes and reduce avoidable costs associated with population health management. AssureCare is a Vora Group company with headquarters in Cincinnati, OH. For more information, please visit https://www.assurecare.com/

Join the future of healthcare with CURIS Connect, where compassion meets innovation. As a Telephone Triage Nurse, you’ll play a vital role in delivering high-quality remote clinical care that makes a real difference in patients’ lives. You’ll be the reassuring voice on the other end of the line—assessing patient needs, refilling medications when appropriate, reviewing lab results, and providing clear, evidence-based guidance to help patients take the next best step in their care. This role combines the art of nursing with the power of technology, giving you the opportunity to make a meaningful impact from anywhere—while collaborating with an incredible team of healthcare professionals dedicated to accessible, patient-centered care.

Active, unrestricted Registered Nurse (RN) license — California license required. Minimum 2 years of clinical nursing experience (primary care, urgent care, or ER preferred). Previous experience in telephone triage or telehealth strongly preferred. Excellent clinical assessment, critical thinking, and communication skills. Comfort with electronic health records (EHR) and digital health tools. Ability to work independently while thriving in a collaborative, fast-paced virtual environment. Located in PST, MST, or CST time zones preferred

Assess and Triage: Conduct comprehensive assessments of patients’ symptoms and concerns via phone using standardized protocols and clinical decision-support tools. Educate and Empower: Provide patients with evidence-based information, guidance, and emotional support to help them understand their conditions and next steps. Medication Management: Process medication refill requests when clinically appropriate, ensuring safe, accurate, and timely coordination with providers and pharmacies. Lab Result Review: Discuss lab results with patients, providing clear education, care recommendations, and follow-up instructions per provider direction. Collaborative Care: Work closely with providers and interdisciplinary team members to ensure continuity, coordination, and patient satisfaction. Emergency Judgment: Determine urgency of care and escalate appropriately when emergency or immediate attention is required. Documentation: Accurately document all patient interactions within the organization’s EHR in compliance with legal, regulatory, and organizational standards. Confidentiality: Uphold strict HIPAA compliance and maintain patient privacy at all times. Follow-Up and Outcomes: Conduct follow-up calls as needed to ensure resolution of patient concerns and reinforce care plans. Professional Growth: Stay up-to-date on best practices, participate in ongoing training, and contribute to a supportive, innovative clinical culture.

AssureCare LLC

Utilization Management Nurse

Posted on:

December 21, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Ohio

AssureCare is a privately held healthcare technology company that provides innovative care management solutions to commercial and health and human service providers. AssureCare’s flagship software platform, MedCompass, is used by healthcare providers throughout the United States to deliver end-to-end care management for millions of patients daily. MedCompass transforms healthcare management by automating processes and streamlining workflows, thus allowing care professionals to make better decisions that dramatically improve the quality of care and lower costs. AssureCare is considered an industry leader in developing, modular, seamless solutions designed to improve patient outcomes and reduce avoidable costs associated with population health management. AssureCare is a Vora Group company with headquarters in Cincinnati, OH. For more information, please visit https://www.assurecare.com/

Active, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the state of practice. Minimum of 3 years of clinical nursing experience in an acute care, outpatient, or similar healthcare setting. Experience in utilization management, case management, or healthcare insurance is highly preferred. In-depth knowledge of medical terminology, clinical practices, and healthcare regulations. Familiarity with utilization management software and medical review tools (e.g., InterQual, Milliman). Strong critical thinking, decision-making, and problem-solving abilities. Ability to work collaboratively with diverse teams and communicate effectively with healthcare providers, patients, and insurance carriers. Proficient in Microsoft Office Suite and electronic health record (EHR) systems. Strong attention to detail and organizational skills. Ability to manage multiple tasks and prioritize effectively in a fast-paced environment. Excellent interpersonal and communication skills, with a focus on customer service. Ability to work independently and make decisions based on established clinical guidelines.

Conduct reviews of medical records, treatment plans, and authorization requests to determine the medical necessity, appropriateness, and efficiency of healthcare services. Evaluate the clinical appropriateness of inpatient, outpatient, and other healthcare services in accordance with established guidelines and criteria. Collaborate with healthcare providers to discuss treatment plans, recommending alternatives when necessary to ensure the best possible care. Assist in the coordination of care for patients, ensuring that the treatment provided is medically necessary and delivered in the most appropriate setting. Participate in interdisciplinary team meetings to discuss complex cases and develop care plans that align with best practices. Ensure timely and accurate documentation of all utilization management decisions, maintaining confidentiality and compliance with HIPAA regulations. Utilize evidence-based clinical guidelines (such as InterQual, Milliman) to assess and determine medical necessity for various treatments and services. Work with healthcare providers to clarify requests and ensure they meet criteria for coverage and authorization. Serve as a liaison between healthcare providers, patients, insurance companies, and other stakeholders to facilitate the appropriate utilization of services. Communicate decisions effectively and explain the rationale for approvals, denials, and modifications of requested services. Provide education and guidance to healthcare providers and patients regarding utilization management policies and procedures. Ensure that utilization management practices comply with regulatory standards, accreditation requirements, and company policies. Assist with audits, quality improvement initiatives, and data collection efforts related to utilization management performance. Stay current on industry trends, healthcare regulations, and emerging clinical guidelines. Review and process appeal requests related to denials of service or coverage, working to resolve issues in a timely and thorough manner. Communicate with providers and insurance representatives to address denials and assist in resolving any disputes.

Integrated Resources, Inc ( IRI )

Registered Nurse

Posted on:

December 21, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Illinois

Integrated Resources Inc. (IRI) is a professional staffing firm specializing in contract, consulting & full time positions in the area of Information Technology, Life Science and Allied Healthcare. Since its inception in 1996, IRI has continued to grow in size, opportunities, service and quality. Our expert team of highly trained counselors work hand in hand with every candidate and client forming a partnership of understanding and commitment.

Title: Medical Management Specialist I (RN) Location: REMOTE (with some local nearby field visits as per need) Duration: 6+ months (contract to hire) NOTE: Looking for support in below areas- Chicago zip code or Kankakee/Kankakee area Belleville, IL DuPage County, IL 60018, 60031, 60053, 60077, 60176, 60601, 60602, 60603, 60604, 60605, 60606, 60607, 60608, 60609, 60610, 60611, 60612, 60613, 60614, 60616, 60622, 60630, 60632, 60642, 60646, 60647, 60654, 60657, 60661, 60706, 60714 (Zip code)

Job Qualifications: Registered Nurse (RN), with 3 years direct clinical care to the consumer in a clinical setting or Licensed Professional Counselor (LPC), or Licensed Master Social Worker (LMSW), which includes 2 years of clinical practice to obtain their LPC or LMSW license. Current, valid, unrestricted license in the state of operations (or reciprocity). 3 years wellness or managed care experience presenting clinical issues with members/physicians. Knowledge of the health and wellness marketplace and employer trends. Verbal and written communication skills including discussing medical needs with members and interfacing with internal staff/management and external vendors and community resources. Analytical experience including medical data analysis. Current driver's license, transportation and applicable insurance. Ability and willingness to travel within assigned territory. PC proficiency includes Word, Excel, and PowerPoint, database experience and Web based applications. Preferred Job Qualifications: 3 years clinical experience. Patient education experience. Condition Management experience. Bilingual in English and Spanish. Transition of Care experience. Experience in managing complex or catastrophic cases. Certification in Case Management, Training, Project Management or nationally recognized health care certification.

This position is responsible for conducting medical management and health education programs for customers on government health care programs. This role will include gathering, analyzing and providing data for regulatory reports. This position will represent the company to members.

Farmers Insurance DDHQ

Nurse Consultant

Posted on:

December 21, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Colorado

We are Farmers! We are… more than just your favorite commercials.  At Farmers, we strive to deliver peace of mind to our customers by providing protection and comprehensive advice and delivering in the moments of truth. That means having people who can help us meet changing customer and business needs. Farmers high-performance culture is focused on results and the people who achieve them. We hold ourselves and others accountable for sustainably growing the business and each other. We seek solutions, own our actions, and grow through discomfort. We see setbacks as opportunities while continuously asking ourselves how we impact our customers. Farmers is an award winning, equal opportunity employer, committed to the strength of an inclusive workforce. We are dedicated to supporting the well-being of our people through our extensive suite of benefits, as well as the well-being of the communities we serve through employee volunteer programs and nonprofit partnerships. Helping others in their time of need isn’t just our business – it’s our culture!  To learn more about our high-performance culture and open opportunities, check out www.Farmers.com/careers/corporate and be sure to follow us on Instagram, LinkedIn, and TikTok.

Workplace: Remote The Senior Nurse Consultant is accountable for reviewing the medical aspects of claim files which are considered complex in nature (e.g. litigated Claims, multiple injuries, traumatic brain and/or spinal damage, etc.) for multiple lines of business and for the development of chronological reports which analyze case files relating to bodily injury, treatment received, and future medical treatments. In addition to composing formal written analyses and conducting file reviews, also generates medical opinions on an informal basis, performs research and provides consultation to the Claims team on medical issues frequently encountered in the Claims review process and provides ongoing education/training to Claims staff on the medical aspects commonly seen in various claims. Additional responsibilities include participating in, as well as leading certain assignments and taking part in project teams within the line of business and at the enterprise level. Projects could include maintaining and updating the SharePoint site, leading or participating in large scale medical training initiatives, piloting new processes, participating in local office efforts such as inclusion or engagement champion, and acting as a medical expert representative on enterprise level project teams. In addition, also acts as a resource to other Nurse Consultants by serving as a mentor and performing onboarding and new hire training.

Education Requirements: High School diploma or equivalent required. Registered Nurse license required. Bachelor of Science in Nursing preferred. Experience Requirements: Two years legal nurse consultant experience required. Prior leadership experience and demonstrated project management skills. Special Skill Requirement: Legal Nurse Consultant or a Nurse Case Manager certification by a nationally established and accredited testing organization or Juris Doctorate degree preferred. Advanced knowledge of general industry trends relating to the area of liability claims, medical/legal insurance experience preferred, or at least 5 years working within the insurance industry focusing on multiple disciplinary backgrounds like Casualty, Liability, MED/PIP and/or Workers Compensation claims preferred. Excellent written and oral communications skills, including exceptional presentation skills, required along with prior training/mentoring experience. Advanced proficiency with technological equipment and systems needed to complete, monitor, and track work products (e.g. SharePoint and Excel) along with the proven ability/willingness to learn new systems as needed required. Physical Actions & Environment: Primarily a sedentary job that may require travel, up to 10% of the time and carrying up to 25 lbs. Required job duties are normally performed in a climate-controlled office environment, but with exposure to some or all of the following environments when in the field: Uncontrolled outside environmental conditions Excessive noise levels Chemicals/biological conditions Moving mechanical parts Areas considered dangerous which could affect the respiratory system or skin, such as fumes, odors, dust mists, gases, oils, smoke, soot, or poor ventilation.

Receives requests from the Claims Adjusters, Farmers Claims handlers, and/or Legal representatives to determine file review needs of complex Claims from various lines of business. This includes addressing medical questions, assessing time sensitive deadline demands by which the requestor may need medical reports, reviewing as well as analyzing medical records and other relevant documents (e.g. deposition transcripts, accident reports, photographs etc.) and conducts necessary research in order to properly assess injuries alleged for each claimant involved. In addition, also completes the review of Claims as it relates to alleged injury, treatment of injury and future treatment to provide claims handler and/or defense attorney with medical analysis/medical explanation of injury. Provides litigation support to Farmers Claims handlers and/or Legal representatives through the review of complex Claims files for multiple lines of business in order to properly assess alleged injuries from claimants involved. This includes, but is not limited to, reviewing disposition transcripts, accident reports and photographs, analyzing expert witness reports and deposition testimony, as well as preparing questions for independent medical examinations. Additional responsibilities include preparing deposition questions for the plaintiff or treating physician, providing discovery and expert retention recommendations to Claims or Legal and attending mediations/depositions for the purpose of being called upon to support Farmers by providing explanations related to medical issues or clarifying medical aspects of the claim file. May also offer medically appropriate suggestions to the claims handler and/or defense attorney in order to obtain additional medical records or to consider obtaining a medical expert. Conducts new hire orientation for recently onboarded Nurse Consultants and assists new employees and peers with report writing, conducting medical analyses and file reviews. Sets priorities and leads projects and/or actively participates on teams relating to various initiatives which includes maintaining and updating the SharePoint site, piloting new processes, leading or participating in a large scale medical training initiative, and acting as an inclusion or engagement champion for the department. May also act as a representative on enterprise level project teams. Develops as well as delivers training and education to Claims professionals via one-on-one, online, or in classroom type settings on various medical topics commonly seen in claims. Examples include traumatic brain injury, spinal injections, soft tissue damage, knee and shoulder injuries. Also researches and monitors developments in the area of medical treatment options and technologies to keep updated on the most current trends and changes. Performs other duties as assigned.

argenx

Nurse Case Manager (Eastern Time Zone)

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Massachusetts

Join us as we transform immunology and deliver medicines that help autoimmune patients get their lives back. argenx is preparing for multi-dimensional expansion to reach more patients through a rich pipeline of differentiated assets, led by VYVGART, our first-in-class neonatal Fc receptor blocker approved for the treatment of gMG, and with the potential to treat patients across dozens of severe autoimmune diseases. We are building a new kind of biotech company, one that maintains its roots as a science-based start-up and pushes our commitment to innovate across all corners of our business. We strive to inspire and grow our company, our partnerships, our science, and our people, because when we do, we deliver more for patients.

The Nurse Case Manager (NCM) is the single point of contact for patients and their caregivers. They are aligned regionally and are responsible for educating patients, caregivers and families affected by generalized Myasthenia Gravis (gMG) about the disease and argenx’s products and support services. The NCM may provide resources to help patients better manage their disease and coordinate their treatment. The NCM is responsible for participating in one-on-one communications with patients and their caregivers.

Skills and Competencies: Demonstrated effective presentation skills; ability to motivate others; excellent interpersonal (written and verbal) skills – with demonstrated effectiveness to work cross-functional and independently Demonstrated ability to develop, follow and execute plans in an independent environment Demonstrated ability to effectively build positive relationships both internally & externally Demonstrated ability to be adaptable to changing work environments and responsibilities Must be able to thrive in team environment and willing to contribute at all levels with flexibility and a positive attitude Fully competent in MS Office (Word, Excel, PowerPoint) Flexibility to work weekends and evenings, as needed Participate in and complete required pharmacovigilance training Comply with all relevant industry laws and argenx’s policies Travel requirements less than 50% of the time Education, Experience and Qualifications: Applicants must live in the Eastern Time Zone Current RN License in good standing Bachelor’s degree preferred 5+ years of clinical experience in healthcare to include hospital, home health, pharmaceutical or biotech 5+ years of case management 2+ years of experience in pharmaceutical/biotech industry a must Reimbursement experience a plus Must live in geographically assigned territory Bilingual or multilingual a plus

Provide direct educational training and support to patients and caregivers about gMG and prescribed argenx products Communicate insurance coverage updates and findings to the patient and/or caregiver Review and educate the patients and/or caregivers on financial assistance programs that they may be eligible for. Coordinate logistical support for patient to receive therapy and manage their disease Collaborate with argenx Patient Access Specialist, Case Coordinator, and Field Reimbursement Manager teams to troubleshoot and resolve reimbursement-related issues Engage with patients and provider case coordinators to ensure appropriate support is being given on an individualized basis Provide patient-focused education to empower patients to advocate on their behalf Develop relationships and manage multiple and complex challenges that patient and caregivers are facing Ensure compliance with relevant industry laws and argenx’s policies Aligned regional travel will be required for patient education to support patient programs Must be an excellent communicator and problem-solver Demonstrated time management skills; planning and prioritization skills; ability to multi-task and maintain prioritization of key projects and deadlines

Unified Women's Healthcare

Quality Performance Liaison

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Florida

Unified is accelerating meaningful change in women’s health by building innovative, mission-driven businesses to meet the comprehensive needs of women across the entirety of their health journey. Founded in 2009, Unified’s affiliates support nearly 3,000 providers across more than 20 North American markets and are an indispensable source of business expertise in the industry. Its businesses remain top in their field, including the largest ObGyn physician practice management platform in the United States, the global pioneer in fertility treatment and science (CCRM Fertility), the leading women’s maternity analytics platform that is directly improving birth outcomes (Lucina), and the nation’s leading virtual menopause and lifestyle care provider (Gennev). For more information, visit unifiedwomenshealthcare.com.

We are seeking a Quality Performance Liaison (QPL) to work as a liaison between the Florida Woman Care’s “Lead with Quality” program, as well as Florida Woman Care’s laboratory, and our care centers’ clinical staff. This team will collaborate with Managed Care Contracting, Clinical Transformation Manager, and Market Performance Partners for Quality metrics. Responsibilities include educating clinical staff on Lead with Quality, supporting the women’s healthcare quality metrics, educating on laboratory tests within our compendium, supporting proper test utilization and ordering, training clinical staff to perform phlebotomy services and providing customer support for the satisfaction of our care centers. Problem-solving and strong investigative skills are required to resolve customer concerns. The position is also directly responsible for support, training, successful onboarding of new care centers, and laboratory testing/ordering. A successful candidate must be a Registered Nurse with a passion for clinical quality, customer focused, demonstrate strong communication skills, be genuinely empathetic to concerns of our care center partners and patients and be willing to travel to care center locations across the state of Florida and Georgia.

Registered Nursing degree required, bachelors preferred Active Florida Nursing License in good standing Minimum 1 year of outside sales/service experience in the healthcare/clinical laboratory/medical device industry is preferred Ideal candidates to live in South FL, Central/Northeast FL or the West Coast of FL Account management and/or customer service experience is desirable Self-motivated Strong communication skills; both written and verbal Ability to deliver results in a fast-paced, competitive market Proficient in Microsoft Office Experience with using Salesforce preferred Ability to multitask and provide prompt problem resolutions for all customers Must have a Valid Driver's License, clean driving record and reliable automobile transportation (business related travel expenses are reimbursable) Acknowledgement of possible exposure to blood-borne pathogens Strong independent time management and organization skills Ability to travel up to 85% Able to meet the physical and time demands of care center visits

Act as a liaison between the Florida Woman Care’s “Lead with Quality” program, as well as Florida Woman Care’s laboratory, and our care centers’ clinical staff Collaborate with Managed Care Contracting, Clinical Transformation Manager, and Market Performance Partners for Quality metrics Provide support and education on the organization’s Lead with Quality program Educate and support on quality metrics Provide laboratory account management support for clinical operations Provide education and educational material to the customer base Resolve any customer related issues in a timely manner Actively provide oversight for all assigned care center sites Think outside the box to solve problems and to escalate when appropriate Handle care center inquiries by onsite visits, telephone and by tickets created in the portal regarding status of reports, concerns of service failures and other duties to provide customer satisfaction Triage concerns appropriately based upon protocols Provide information to care center customers regarding collection requirements of laboratory testing Create and distribute quality reports Together with the Laboratory Customer Service team, manage our onboarding process for new care centers as well as maintenance of relationships including site visits to Florida and Georgia care centers on a frequent basis Continuously evaluate operational procedures and workflows and recommend changes as needed Identify and pursue opportunities to expand laboratory services with care centers Initiate, develop and grow relationships to drive awareness and build additional utilization Recognize opportunities for expanding business within assigned care centers Develop, maintain, and grow laboratory utilization through relationship building and responsive customer service Other duties as assigned

Vynca

LVN Case Manager

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

LPN/LVN

State License:

California

Join the dynamic journey at Vynca, where we're passionate about transforming care for individuals with complex needs. We’re more than just a team; we're a close-knit community. Our shared commitment to caring for each other and those we serve is what sets us apart. Guided by our unwavering core values: Excellence, Compassion, Curiosity, and Integrity, we forge paths of success together. Join us in this transformative movement where you can contribute to making a profound difference every day. At Vynca, our mission is to provide comprehensive care for more quality days at home.

We're seeking an exceptional Clinical Lead Care Manager (CLCM) to join our team. Under the direction of the ECM Clinical Manager, the CLCM serves as the client’s primary point of contact and works with all their providers such as doctors, specialists, pharmacists, social services providers, and others to make sure everyone is in agreement about the client’s needs and care. The CLCM manages client cases, coordinates health care benefits, provides education and facilitates member access to care in a timely and cost-effective manner. The CLCM collaborates and communicates with the client’s caregivers/family support persons, other providers, and others in the Care Team to promote wellness, recovery, independence, resilience, and member empowerment, while ensuring access to appropriate services and maximizing member benefit. This is a critical role that we're looking to fill as soon as possible.

Active California Licensed Vocational Nurse (LVN) license required Willing and able to work Monday-Friday 8:30am-5:00pm Pacific Time, with the possibility of evenings and weekends 2+ years of experience as a care manager, care navigator, or community health worker supporting vulnerable populations Working knowledge of government and community resources related to social determinants of health Excellent oral and written communication skills Positive interpersonal skills required Must have general computer skills and a working knowledge of Google Workspace, MS Office, and the internet Bilingual (English/Spanish) preferred At this time we are only considering applicants in the following states: California, Georgia, Texas, Arizona, Colorado, Florida, Illinois, Nevada, North Carolina, Oregon, and Washington.

Assess member needs in the areas of physical health, mental health, SUD, oral health, palliative care, memory care, trauma-informed care, social supports, housing, and referral and linkage to community-based services and supports Oversees the development of the client care plans and goal settings Offer services where the member resides, seeks care, or finds most easily accessible, including office-based, telehealth, or field-based services Connect clients to other social services and supports that are needed Advocate on behalf of the client with health care professionals (e.g. PCP, etc.) Utilize evidence-based practices, such as Motivational Interviewing, Harm Reduction, and Trauma-Informed Care principles Conduct outreach and engagement activities in order to facilitate linkage to the ECM program and log activity in the Client Relationship Management (CRM) system Evaluate client’s progress and update SMART goals Provide mental health promotion Arrange transportation (e.g., ACCESS) Complete all documentation, including outcome measures within the timeframes established by the individual care plans Maintain up-to-date patient health records in the Electronic Medical Record (EMR) system and other business systems Complete monthly reporting to ensure program compliance Attend training as assigned

NPHire

Work-From-Home Nurse Practitioner (Telehealth - Flexible Schedule)

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

A leading virtual care organization is seeking Nurse Practitioners to support its expanding national telehealth service lines. This is a fully remote, contract-based + bonus pay role offering flexibility, steady patient volume, and the ability to practice from anywhere.

Conduct virtual visits for common acute issues (fever, cough, infections, minor injuries, etc.) Provide primary care assessments, chronic care follow-ups, and routine check-ins. Pay range and compensation package $120–$185 per hour (contract-based) Flexible scheduling: choose your shifts 100% remote, nationwide openings Malpractice coverage included Consistent appointment flow and ongoing support Onboarding, clinical resources, and operations assistance

Qualifications: Active Nurse Practitioner license in at least one U.S. state Multi-state licensure (preferred but not required) FNP, AGNP, ANP, or similar certification Comfortable managing acute complaints + basic primary care Strong communication and clinical decision-making skills New graduates accepted Required Skills: Active Nurse Practitioner license Strong communication skills Clinical decision-making skills

Review labs, diagnostics, and patient messages through an integrated telehealth platform Develop treatment plans, prescribe when appropriate, and ensure continuity of care Document all encounters thoroughly in the EMR Collaborate with a supportive clinical and operations team as needed

ConcertoCare

Clinical Quality and Performance RN

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New York

At ConcertoCare, we are redefining care and aging for millions of US seniors and other adults with complex care needs by delivering human-first, tech-enabled care in the home. Our care teams leverage our value-based, interdisciplinary care model to address unmet health and social needs and to improve quality of life for our patients. We take a holistic, equitable, and compassionate approach to health and wellness in partnership with our patients and their families, caregivers, and communities. In short, we strive to offer the kind of healthcare that we would want our own loved ones to experience.

The ConcertoCare Clinical Quality and Performance (CQP) RN is an integral part of the ConcertoCare team and is a key driver of our commitment to continually improve the quality of patient care that we provide while ensuring patient safety. This role will primarily provide oversight and direction to the credentialing process for providers and serve as the clinical subject matter expert to monitor and ensure company Occupational Health procedures and protocols are in alignment with CDC guidelines. When applicable, the person will coordinate activities related to contractual requirements for delegated arrangements; and clinical regulatory requirements in support of external interfaces to demonstrate compliance with health plan partners and external regulatory entities regarding clinical audit. When necessary, they will also work with the VP, Clinical Quality & Performance, Population Health Leaders, and market teams to develop and implement programs and operations in support of organization-wide clinical quality, clinical pathway audit, and patient safety programs and organization-wide clinical policies. They will also work closely with the market quality champions/leads and other clinical leaders to ensure coordination and integration of efforts to improve clinical quality and ensure patient safety.

Current RN License in good standing in the state of practice required Bachelor’s degree or equivalent years of related work experience. Master’s degree preferred Four or more years of clinical experience At least 2 years quality, safety, audit and/or clinical policy experience Ambulatory provider-based experience highly preferred Geriatric care experience highly desired Knowledge of Medicare and Medicaid highly desired Clinical Audit experience a plus Training tool development and course delivery experience a plus Strong problem-solving and organizational skills Experience working with third party vendors. Demonstrate the ability to understand, create and evaluate workflows. Ability to communicate effectively in writing and verbally. Demonstrated ability to perform multiple concurrent tasks with minimal supervision and meet deadlines Ability to work in a fast paced, dynamic environment and work well with others on a team Proficient in computer skills to include Microsoft Office Suite (Outlook, Excel, PowerPoint, Word), able to create and analyze data and reports

Ensures new provider welcome letters are sent, provider documentation is uploaded and validated, and maintains the confidentiality of all records. Provides prompt customer services to existing employees and new hires to ensure seamless payer enrollment experience. Serves as the primary contact for third-party credentialing vendor and point of contact for market leaders awaiting credentialing results. Notifies management and/or recruiters of payer enrollment issues; collaborates and advises as appropriate and escalates issues and concerns. Supplies new market updates and provides updates to existing market changes impacting enrollment. Ensures completion of government and state regulatory payer initiation and revalidation i.e., Medicare/Medicaid. Maintains a database file to store, track and maintain credentialing information. Supports clinical quality improvement activities including data review, audits, and reporting Monitors key clinical pathways reports, applicable dashboards and other reports for all markets and products Collaborates with team and market leadership to identify opportunities for clinical quality performance improvement and develops supportive plans to target opportunities using PI/QI improvement methods and tools. Conducts quality audits regarding clinical staff adherence to clinical pathways, tracks and trends, provides recommendations and expertise in improving adherence (e.g., training, focused audits) Conducts patient safety audits in focused clinical areas Tracks and reports safety events and near misses Coordinates root cause analysis and recommends performance improvement activities to address safety events and near misses. Works with the Population Health and Market teams to develop /deploy standardized organizational clinical policies and targeted training to improve patient outcomes. Works with Population Health and IT leaders to develop job aides, workflows, and training programs to support successful implementation of Population Health Improvement initiatives. Implements and conducts both external and internal clinical audits for delegation oversight programs inclusive of facilitating policies and procedures to ensure that all functions meet health plan and regulatory requirements. Collaborates with the VP, Clinical Quality & Performance to communicate audit findings and opportunities for process improvement specific to audit finding consistent with the organization’s vision and strategic long-term goals. Serves as the clinical subject matter expert, in partnership with the Occupational Health team, to monitor and ensure company Occupational Health procedures and protocols are in alignment with CDC guidelines. Responds promptly to Occupational Health concerns, providing expert clinical guidance and support. Collaborates with cross-functional teams to assist in auditing and completing Occupational Health requirements for employees. Contributes to the development and implementation of occupational health initiatives that promote employee wellness such as Occupational Health guidebooks and other materials. Participates in the collection, analysis, and reporting of data relevant to delegation oversight.

Ascension

RN-Case Manager

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

Ascension associates are key to our commitment of transforming healthcare and providing care to all, especially those most in need. Join us and help us drive impact through reimagining how we can deliver a people-centered healthcare experience and creating the solutions to do it. Explore career opportunities across our ministry locations and within our corporate headquarters. Ascension is a leading non-profit, faith-based national health system made up of over 134,000 associates and 2,600 sites of care, including more than 140 hospitals and 40 senior living communities in 19 states. Our Mission, Vision and Values encompass everything we do at Ascension. Every associate is empowered to give back, volunteer and make a positive impact in their community. Ascension careers are more than jobs; they are opportunities to enhance your life and the lives of the people around you.

Department: Mission Integration Schedule:Full-Time, 8-hour day shift, Monday - Friday, Remote with occasional extended hours/weekends based on population needs Facility:Ascension Care Management Insurance Salary:$78,561.60 - $110,905.60 (per year) Must Reside in Texas

Licensure / Certification / Registration: Registered Nurse obtained prior to hire date or job transfer date required. Licensure required relevant to state in which work is performed. Case Manager credentialed from the American Case Management Association (ACMA) preferred. BLS Provider preferred. American Heart Association or American Red Cross accepted. Case Manager credentialed from the Commission for Case Manager Certification (CCMC) preferred. Licensure required relevant to state in which work is performed Education: Diploma from an accredited school/college of nursing OR Required professional licensure at time of hire. Additional Preferences Bilingual: Spanish is required. Registered Nurse license required. Strong clinical and organizational skills, preferred. 1-2 years of telephonic case management and case manager experience, preferred. 1-2 years of Medicaid and Commercial insurance services, required. #LI-Remote

Assess the physical, functional, social, psychological, environmental, learning and financial needs of health plan members Identify problems, goals and interventions designed to meet the member’s needs, including prioritized goals that consider the member/caregivers goals, preferences and desired level of involvement in the case management plan. Create a care plan including objectives, goals and actions designed to meet the member’s needs. Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Assess the member’s formal and informal support systems, including caregiver resources and involvement as well as available benefits and/or community resources. Evaluate member’s progress toward goal achievement, including identification and evaluation of barriers to meeting or complying with case management plan of care, and systematically reassess for changes in goals and/or health status. Communicates with primary care physician and members of the comprehensive care team regarding status of the member Utilize motivational interviewing skills to build patient engagement in case management plan of care Provide education, information, direction and support related to care goals of members Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and meet the needs of the patient, coordinate services to avoid duplication. Maintain accurate member records and confidentiality. Engage in professional development activities to keep abreast of case management practices and patient engagement strategies.

Devoted Health

Bilingual (Spanish/English) Transitions of Care RN Case Manager

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce. At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States. And we've just started. So join us on this mission!

A bit about this role: We want to help patients navigate the healthcare system in a better and safer way, and case management is critical to achieving this for our most vulnerable and complex patients. You'll be responsible for providing telephonic, short-term, interdisciplinary care management in the 30 days post-discharge for patients at high risk for readmission. You'll serve as an advocate for these patients, coordinating care and ensuring they have the necessary resources and support to achieve better health outcomes. Our ideal RN is caring, compassionate, solution-oriented and enthusiastic about providing an outstanding experience for Devoted Health’s patients. They are committed to integrity, excellence, and empowering our patients to confidently navigate the healthcare system and live healthier lives. They are ready to innovate, adaptable to a continuously evolving startup environment, working with the whole Devoted family to create a revolution in how care is delivered.

Required skills and experience: 3-4 Years of Experience of RN Care Management/telephonic case management experience An unrestricted Compact RN license obtained in the United States with the ability to secure other licensure states Role will work M-F 8:00am - 5:00pm CST or MST Desired skills and experience: Enthusiasm for working in a setting where meaningful time is spent on the phone with patients and/or their caregivers to build trust, educate, and coordinate care Comfort and confidence working in an environment guided by performance and productivity metrics, with a focus on quality outcomes and patient experience Health insurance experience, particularly Medicare Advantage Prior Special Needs Plan, Population Health, or Transitions of Care case/care management experience Clinical analytical thinking that allows you to apply your skills to the individual needs of each patient Telephonic care/case management experience

Working with patients: Engaging with our newly discharged patients telephonically to understand their needs, supported by technology and data tools. Conducting assessments to identify comorbid conditions, ED/hospitalization history, medications, psychosocial factors, and patient values and preferences. Developing care plans in partnership with patients and their caregivers - problems, goals, interventions - while continuously evaluating the patient’s progress. Explaining complicated medical terms in plain language. Educating patients on their chronic conditions including teaching “red flags,” developing plans during an exacerbation, and identifying barriers to important care elements such as medication adherence. Hearing the red flags and providing active care management to close the gaps. Working with other providers and resources: Partnering with the TOC Nurse Practitioners and Physicians to ensure smooth handoffs, comprehensive follow-up, and coordinated care during the post-discharge period. Referring patients to Devoted Medical when applicable and working closely on partnering for patient care. Working closely with Devoted Community Guides (locally-based social workers) to identify community-based organizations to support our patients in meeting their goals. Coordinating post-treatment care and DME needs. Collaborating closely with our PCP partners, to coordinate care and deliver evidence based, effective, and accessible health care.

Devoted Health

Clinical Guide: Diabetes Educator (Certified Diabetes Care and Education Specialist)

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce. At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States. And we've just started. So join us on this mission!

This role is fully remote and must be located within one of the contiguous 50 states A bit about this role: We want to help members navigate the healthcare system in a better and safer way, and we want to empower members to change the trajectory of their chronic diseases for the better. Disease management is critical to achieving this for our members with diabetes, and we think Certified Diabetes Care and Education Specialists (CDCES) are the perfect people to do this work. The CDCES will be responsible for a panel of members, who primarily have out-of-control diabetes. The CDCES will be responsible for guiding members throughout the entirety of their healthcare journey while enrolled in the specialty clinic. The goal is to “graduate” the members once they are clinically stable and become better self managers of their diabetes through education and counseling via virtual communication (phone and video visits).

Required skills and experience: An active unrestricted Compact Registered Nurse license or an unrestricted Registered Dietitian license. You must be able to obtain additional licenses in states where we operate as needed. An active Certified Diabetes Care and Education Specialist (CDCES) At least 2 years of experience clinically managing diabetes Desired skills and experience: Remote experience managing diabetes strongly preferred Experience working with diabetes technology (CGMs and insulin pumps)

Screen members for Diabetes Clinic eligibility and appropriateness Complete detailed assessments and continue following up with members in the Diabetes Clinic to complete ongoing education on all pillars of diabetes management (disease process, medications, glucose monitoring, lifestyle counseling, contingency planning) Schedule follow-up appointments with self and our providers Connect members and providers with the right resources within Devoted to troubleshoot clinical issues Work with the members to create and achieve collaborative SMART goals Utilize motivational interviewing skills with the goal to influence positive sustained behavioral changes Identify gaps in care and provide resources Collaborate with other Diabetes Clinic team members (nurse practitioners, social workers, pharmacists) to develop plans of care and optimize medication regimens to help members achieve goals Maintain documentation related to member and provider interactions Continue to improve skill set with participation in education series within the Diabetes Clinic and outside providers of continuing education

Devoted Health

Bilingual Clinical Guide: Cardiology Nurse

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce. At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States. And we've just started. So join us on this mission!

This role is fully remote and must be located within one of the contiguous 50 states A bit about this role: The Cardiology Nurse, known as the Clinical Guide, is a vital part of Devoted Medical's Congestive Heart Failure (CHF) specialty clinic. This program is dedicated to enhancing the health of our members living with heart failure. The clinic delivers three concurrent interventions: 1) Health Coaching: Educating members to become proactive self-managers of their chronic condition. 2) Volume Optimization and Weight Monitoring: Closely tracking member weight for fluid management. 3) Medication Optimization: Initiating or intensifying Guideline Directed Medical Therapy (GDMT). Clinical Guides manage a panel of enrolled members. They provide virtual guidance, primarily through phone and video visits, supporting members until they successfully "graduate" as competent self-managers. Throughout this journey, they collaborate with a multidisciplinary team, including cardiology-trained nurse practitioners, pharmacists, social workers, and care coordinators. Looking ahead, we are developing a virtual Heart Center of Excellence, which will expand the role and responsibilities of the nurses within the heart failure clinic to support this significant new initiative.

Required skills and experience: An unrestricted, compact RN license A minimum of 4 years of RN experience with at least 2 years in a non-ICU cardiac focused setting, outpatient being ideal A secure & private workspace with a strong & reliable internet connection. Bilingual in English & Spanish. Will be required to conduct patient assessments in Spanish. Strong interpersonal and communication skills, your nursing care will be delivered verbally 100% of the time Highly comfortable with technology (EMRs, messaging platforms, online portals, AI chat) Ability to multi-task: you’ll be listening, talking and typing all at the same time. Team player mentality with a can-do attitude. Comfortable with fast paced and evolving workflows, we will change and improve quickly. Willingness to work 8-5 in Central Time zone or later time zone (MT, PCT) Desired skills and experience: Telehealth/remote experience strongly preferred Bilingual in Spanish Experience working in the Medicare Advantage landscape

Working with our members: Completing remote (telephonic/video) visits to conduct nursing assessments of heart failure, comorbid conditions, ED/hospitalization history, medications, psychosocial factors, and member values and preferences Provide comprehensive clinical education tailored to individual needs (disease process, medications, symptom monitoring, lifestyle counseling, contingency planning). Developing care plans in partnership with members and their caregivers - problems, SMART goals, interventions - while continuously evaluating the member’s progress. Working with and interdisciplinary team Collaborating with an interdisciplinary team of registered nurses, advanced practice nurses, physicians, social workers, and pharmacists on shared members, to ensure we’re working together to meet the needs of the members. Collaborating closely with our PCP partners, as well as other clinical teams within Devoted Medical Group, to coordinate care and deliver evidence based, effective, and accessible health care. Participating in weekly team huddles and patient rounds presentations Improving how we work Adapting to evolving workflows and care delivery models as we continue to grow and develop an emerging Heart Center or excellence Providing feedback and potential solutions to help improve the operational processes, software tools, and clinical care.

Devoted Health

Clinical Guide: Cardiology Nurse

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States. And we've just started. So join us on this mission!

This role is fully remote and must be located within one of the contiguous 50 states A bit about this role: The Cardiology Nurse, known as the Clinical Guide, is a vital part of Devoted Medical's Congestive Heart Failure (CHF) specialty clinic. This program is dedicated to enhancing the health of our members living with heart failure. The clinic delivers three concurrent interventions: 1) Health Coaching: Educating members to become proactive self-managers of their chronic condition. 2) Volume Optimization and Weight Monitoring: Closely tracking member weight for fluid management. 3) Medication Optimization: Initiating or intensifying Guideline Directed Medical Therapy (GDMT). Clinical Guides manage a panel of enrolled members. They provide virtual guidance, primarily through phone and video visits, supporting members until they successfully "graduate" as competent self-managers. Throughout this journey, they collaborate with a multidisciplinary team, including cardiology-trained nurse practitioners, pharmacists, social workers, and care coordinators. Looking ahead, we are developing a virtual Heart Center of Excellence, which will expand the role and responsibilities of the nurses within the heart failure clinic to support this significant new initiative.

Required skills and experience: An unrestricted, compact RN license A minimum of 4 years of RN experience with at least 2 years in a non-ICU cardiac focused setting, outpatient being ideal A secure & private workspace with a strong & reliable internet connection. Strong interpersonal and communication skills, your nursing care will be delivered verbally 100% of the time Highly comfortable with technology (EMRs, messaging platforms, online portals, AI chat) Ability to multi-task: you’ll be listening, talking and typing all at the same time. Team player mentality with a can-do attitude. Comfortable with fast paced and evolving workflows, we will change and improve quickly. Willingness to work 8-5 in Central Time zone or later time zone (MT, PCT) Desired skills and experience: Telehealth/remote experience strongly preferred Experience working in the Medicare Advantage landscape

Working with our members: Completing remote (telephonic/video) visits to conduct nursing assessments of heart failure, comorbid conditions, ED/hospitalization history, medications, psychosocial factors, and member values and preferences Provide comprehensive clinical education tailored to individual needs (disease process, medications, symptom monitoring, lifestyle counseling, contingency planning). Developing care plans in partnership with members and their caregivers - problems, SMART goals, interventions - while continuously evaluating the member’s progress. Working with and interdisciplinary team Collaborating with an interdisciplinary team of registered nurses, advanced practice nurses, physicians, social workers, and pharmacists on shared members, to ensure we’re working together to meet the needs of the members. Collaborating closely with our PCP partners, as well as other clinical teams within Devoted Medical Group, to coordinate care and deliver evidence based, effective, and accessible health care. Participating in weekly team huddles and patient rounds presentations Improving how we work Adapting to evolving workflows and care delivery models as we continue to grow and develop an emerging Heart Center or excellence Providing feedback and potential solutions to help improve the operational processes, software tools, and clinical care.

Avel eCare

RN Behavioral Health, Full Time (Days/Nights) - Remote

Posted on:

December 20, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

South Dakota

Avel eCare is a nationally recognized leader in telemedicine, operating one of the most extensive virtual healthcare networks in the world. Based in Sioux Falls, South Dakota, Avel partners with over 650 healthcare systems, rural hospitals, clinics, and facilities to deliver innovative telehealth solutions. Our services span Behavioral Health, Critical Care, Emergency, Hospitalist, Pharmacy, Specialty Care, Senior Care, and School Health, impacting nearly two million patients annually. For three decades, Avel has been at the forefront of healthcare innovation, developing telehealth solutions that reduce costs, save time, and remove barriers to quality care. Join our mission-driven team and help reshape the future of healthcare.

Avel eCare is seeking a dedicated Registered Nurse (RN) for our Behavioral Health team. This role is designed for individuals who can provide acute mental health crisis evaluation for patients of all ages and ethnic groups. As a key member of the team, the RN-C will apply specialized clinical knowledge and advanced skills in assessment and crisis intervention for individuals facing mental, emotional, and behavioral challenges. The role requires the ability to work in a fast-paced, stressful environment, performing rapid assessments while multitasking effectively. General Hours of Work: Varies, including weekends and rotating holidays (50% nights and 50% days) Exempt/Nonexempt: Nonexempt Department/Unit: Behavioral Health Hours/FTE: 36 hours per week/0.9 FTE Reports To: Avel eCare Supervisor Behavioral Health

DUCATION And/or EXPERIENCE: Graduate from a CCNE or NLN accredited nursing program is strongly preferred; graduation from an approved nursing program is acceptable. At least two years of Behavioral Health nursing experience preferred. Bachelor’s degree preferred. CERTIFICATION, LICENSURE, And/or REGISTRATIONS: Active unrestricted multistate license is required. RN licensure required within the states that eCare Behavioral Health operates within 120 days of hire. Certification in Psychiatric Mental Health Nursing (PMHN) by the American Nurses Credentialing Center (ANCC) preferred. Completion of state-specific certification/education within required time periods.

Inquiry and Assessment: Answer all inquiry calls promptly, provide on-demand assessments, and maintain an updated database with accurate patient information. Ensure excellent customer service as the point of contact for all eCare Behavioral Health services. Psychosocial Assessment: Conduct psychosocial assessments, including suicide/homicide risk evaluations, determine appropriate care levels, and collaborate with providers at the site of care. Patient Placement Support: Assist telemedicine sites with patient placement for psychiatric inpatient beds. Mental Health Support: Provide de-escalation strategies, counseling, and disposition recommendations to individuals in Behavioral Health programs. Develop safety plans to help individuals stay safe in their communities. Community Support: Encourage outpatient care and promote mental health services to keep patients in their communities. Project Support: Participate in additional responsibilities for eCare Behavioral Health projects and community activities as assigned by the Director.

Hatch Pros

Registered nurse End User Support Analyst

Posted on:

December 20, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

RN

State License:

Pennsylvania

At Hatch Pros, we provide a unique blend of IT solutions and staffing services to businesses all across the USA. Our expertise lies in IT and Healthcare IT, while also serving industries like Healthcare, Banking, Software Development, Security, Automobile, Food, Finance, and Manufacturing. We don’t just fill roles — we deliver the right talent combined with technology-driven solutions that help organizations stay ahead in a fast-changing market. ⠀ Whether it’s IT staffing, professional resourcing, or end-to-end managed services, Hatch Pros is a trusted nationwide partner. By connecting skilled professionals with enterprise needs and supporting companies with tailored IT solutions, we empower businesses to build stronger teams, embrace innovation, and achieve lasting growth.

Just an FYI – this role is focused on answering calls and supporting end users. Clinical workflow knowledge is essential, and must be RN. Vaccination / Background Check / Drug Test Background check required

RN (must), must understand clinical workflow in Home Health Extensive experience on front and back end with Homecare Homebase End User Support Tier-2/3 support and troubleshooting

Answer calls and provide end-user support Troubleshoot issues and escalate as needed Collaborate with clinical and operational teams

ECLAT Health Solutions

CDI Auditor

Posted on:

December 19, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Alaska

Founded in 2008, ECLAT Health Solutions has been continuously servicing highquality revenue cycle management healthcare support services for hospitals and health systems nationwide with a focus on delivering the fastest, most accurate, flexible, and affordable solutions available. Recognized as one of Inc.’s 5,000 fastest-growing private companies in America this year, ECLAT Health Solutions is looking to expand services in revenue cycle management by offering effective operational strategies that deliver customized solutions for medical coding accuracy, medical billing processes, ICD-10 Auditing, CDI advances and more. For more information, please visit our website at www.eclathealth.com. “People are our greatest asset” is much more than just an expression to ECLAT. We make every effort to foster an environment where our teams can find an ideal balance between work and fun. Employees at ECLAT believe in being clientcentric, open and ethical, innovative, and outcome-driven. ECLAT is an equal opportunity employer and believes in creating a supportive and diverse workplace

Client Details: Multi Hospital System with Level 2 Trauma as main facility Remote or Onsite: Remote EMR: EPIC ICARE Encoder: 3M 360 CAC Length: Temp to Perm, 6 months Start Date: ASAP Work Schedule: Monday-Friday 8am-5pm EST

3+ years of experience as a CDI Specialist 2+ years of Auditing CDI Looking for a CDI Auditor that has experience with targeted reviews, including PSI's (Patient Safety Indicators) and HAC's (Hospital Acquired Conditions), as well as mortality/deaths. 3M and Epic experience CCDS or CDIP and RN License required States candidate can be from: Alaska, Florida, Idaho, Kansas, Kentucky, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, Pennsylvania (Not Philadelphia or Pittsburgh), South Carolina, South Dakota, Tennessee, Utah, Virginia, West Virginia

ECLAT Health Solutions

Nurse Clinical Documentation Specialist

Posted on:

December 19, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

Based in Virginia with service on a global level, Eclat Health Solutions provides comprehensive healthcare support services that include medical coding and healthcare revenue cycle consulting. We work on the principle that hospitals and physicians’ practices require a partner who can reduce their administrative burden so that they can focus on delivering patient care. Our primary goal is to create a business relationship that is essentially symbiotic in nature – we will act as an extension of your team to help you meet and exceed your operational goals and to collaborate with you to successfully navigate the challenges of today. From large hospital facilities to small independent practice associations across North America, Europe, Australia and India, Eclat works with a variety of healthcare providers. Eclat is committed to delivering medical coding services and revenue cycle solutions that will help your healthcare facilities achieve the correct reimbursement in the quickest possible time while maintaining the most stringent HIPAA compliance with customer and patient data.

We are seeking a certified RN or MD with a CCDS or CDIP Certification for the clinical documentation role. Need to be open to working in either EPIC or Cerner where needed on the inpatient side to include DRG's.

+Minimum reviews: The total number of reviews in the WQs to be completed. This will include initial prebill reviews, follow up reviews with coding, and releasing claims. =For example, if there are 100 charts in the WQ and there are 6 team members: 16 reviews with the focus on opportunities to shift the DRGs, optimize the PDX, etc. +Clarification Rate: 45% based off of initial prebill review +Optimization Rate: 90%, based off of all reviews done

Have to be experienced and can focus on chart reviews, clarification submissions, in both prebill and concurrent spaces Productivity: Aiming for 28-32 per day new/rereviews For productivity, it will be based on the number of reviews each day in the WQs, with an optimization focus. The key will be optimization in a compliant manner which includes PDX review, missing secondary diagnoses that need coded, POA, and submission of clarifications when needed. Productivity will fluctuate but could also be used in a concurrent space with a focus on OB, Newborns and specialty areas such as Ortho, and Cardiology.

BCVS Group

Utilization Review Nurse

Posted on:

December 19, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

California

Position:- Utilization Review Nurse Rate:- $41.45/hr. Location:- Remote in IL & TX

Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation. Awareness of claims processes and claims processing systems. PC proficiency to include Microsoft Word and Excel and health insurance databases. Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings. Organizational skills and prioritization skills. Registered Nurse (RN) with unrestricted license in state. 3 years clinical experience.

RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan. This position is responsible for performing accurate and timely medical review of claims suspended for medical necessity, contract interpretation, pricing; and to Initiate and/or respond to correspondence from providers or members concerning medical determinations.

Forevermore Healthcare

Home Care Agency Nurse Supervisor

Posted on:

December 19, 2025

Job Type:

Role Type:

License:

None Required

State License:

Compact / Multi-State

Join our dynamic home care team as a Home Care Agency Nurse, where you will play a vital role in delivering exceptional nursing care directly to patients in their homes. This position offers an exciting opportunity to utilize your diverse clinical skills, provide personalized patient assessments, and promote health and well-being across a wide range of medical conditions. As a key member of our caregiving team, you will empower clients to maintain independence and improve their quality of life through compassionate, expert care.

Proven experience in home care nursing or related settings such as hospitals, nursing homes, assisted living facilities, or outpatient clinics. Demonstrated expertise in managing acute pain, infectious disease care, trauma medicine (including Level I & II trauma center experience), ICU experience, and emergency medicine protocols. Familiarity with advanced medical procedures including cardiology-related treatments like cardiac catheterization or dialysis management. Proficiency with EMR/EHR systems such as Epic or Cerner for documentation and case management purposes. Strong background working with diverse populations including geriatrics (senior care), behavioral health patients, individuals with developmental disabilities or dementia. Knowledge of Workers' Compensation law as it pertains to injury management in the home setting is a plus. Experience administering injections, venipuncture (phlebotomy), tube feeding management, ventilator support, and other complex nursing skills required for comprehensive patient care. Ability to perform physical assessments using physiology knowledge and anatomy expertise to evaluate patient conditions effectively. Certification in basic life support (BLS) or advanced cardiovascular life support (ACLS) is preferred; ongoing professional development in areas like hospice & palliative medicine or occupational health is advantageous. Join us to make a meaningful difference by providing compassionate home-based nursing care that transforms lives! Familiar with CMS Medicare Medicaid billing

Conduct comprehensive patient assessments, including vital signs, physical examinations, and health history reviews to develop tailored care plans. Administer medications via injections, IV infusions, and other routes while adhering to aseptic techniques and safety protocols. Manage complex medical procedures such as wound suturing, catheterization, ventilator management, and ostomy care in accordance with best practices. Provide specialized care for patients with chronic conditions including Alzheimer’s disease, dementia, long-term care needs, and memory care. Coordinate with physicians and multidisciplinary teams using electronic health record (EHR) systems like Epic or Cerner to document patient progress accurately. Assist with diagnostic evaluations such as laboratory specimen collection, processing, and interpreting results for ongoing patient management. Educate patients and their families on health coaching strategies, medication administration, nutrition, and post-discharge care planning. Ensure compliance with HIPAA regulations and maintain meticulous medical records for legal and quality assurance purposes. Respond promptly to urgent triage calls or emergency situations in the home setting, providing critical interventions when necessary. Support infection control practices and aseptic techniques during all patient interactions to prevent healthcare-associated infections.

Wellmark, Inc.

Health Services Quality Coach (Remote Eligible / RN Required)

Posted on:

December 19, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

RN

State License:

South Dakota

We are a mutual insurance company owned by our policy holders across Iowa and South Dakota, and we’ve built our reputation on over 80 years’ worth of trust. We are not motivated by profits. We are motivated by the well-being of our friends, family, and neighbors–our members. If you’re passionate about joining an organization working hard to put its members first, to provide best-in-class service, and one that is committed to sustainability and innovation, consider applying today!

Full-time Department: Clinical | Health Networks | Provider Support Work Environment: Remote Eligible *see job footer for more info Pay Grade: 20 As an integral partner in upholding Wellmark’s compliance and consistency within utilization management and case management processes, you will be responsible for auditing the work of both clinical and non-clinical team members in support of Wellmark’s business portfolio, including FEP. Your primary focus will be to support internal and external performance metrics by auditing, researching, reporting, and analyzing Health Services activities to ensure alignment with established standards, policies, and procedures. Additionally, you will deliver individualized and group coaching to guide team members in achieving and surpassing company and FEP expectations and metrics. Serving as an expert in Wellmark’s clinical quality assurance review, you will identify and recommend improvements to Health Services procedures and ensure accurate documentation of processes. Building strong relationships and credibility within the organization will be critical to your success in this role. Remote Eligible: You will have the flexibility to work where you are most productive. This position is eligible to work fully remote. Depending on your location, you may still have the option to come into a Wellmark office if you wish to. Your leader may ask you to come into the office occasionally for specific meetings or other ‘moments that matter’ as well.

You are a resourceful analyst with a passion for examining trends, identifying process gaps and opportunities, and leading coaching initiatives to achieve organizational objectives. You excel at auditing documentation and adeptly assist team members in continuous improvement. Detail-oriented and naturally curious, you possess strong active listening skills that facilitate effective, constructive feedback to colleagues. Your transparent and articulate communication—both verbal and written—combined with mentoring capabilities, enables you to motivate and foster growth among team members. Candidates located in Iowa or South Dakota preferred. Top candidates will have quality assurance and coaching experience, and/or health plan experience. Prior remote work experience a plus! Preferred Qualifications - Great to have: Interrater Reliability (IRR) certification. Required Qualifications - Must have: Completion of an accredited registered nursing program. Active and Unrestricted Registered Nurse (RN) license in Iowa or South Dakota (individual must be licensed in the state in which they reside). 4+ years of clinical (e.g., hospital, office, agency) or equivalent industry experience, including exposure to complex operational processes or health services-related quality reviews with demonstrated ability to evaluate/coach/mentor others. Strong communication skills with the ability to articulate and request complex, technical information verbally and in writing. Demonstrated ability to establish and maintain ongoing, positive relations with colleagues, stakeholders, and customers. Ability to influence others and promote collaboration and teamwork. Analytical skills with the ability to effectively evaluate data/trends, solve practical problems, and conduct audits and research as needed. Quality assurance and process improvement mindset. Experience with computer software applications – e.g., Microsoft Office Suite, electronic charting, documentation systems. Technical aptitude to learn new systems.

Assess and evaluate the accuracy of file documentation for complex Health Services processes; including appeal and secondary reviewer processes; phone calls and/or clinical and administrative documentation in accordance with business objectives and goals; identify documentation issues; identify best practices and provide effective solutions. Perform audits, research, and analysis to support department metrics targets, QA score expectations, and ensuring compliance with regulatory, accreditation, FEP and OPM requirements. Research issues identified in quality reviews by performing additional investigation into operational procedures, as well as communicating with the operating areas as needed. Assist in FEP UM and CM audits as needed. Generate reports and create documents that communicate results of analysis, research, and metrics to demonstrate trends, changes, and results of projects and activities. Use clinical knowledge to interpret results and make recommendations for process improvements and/or training needs. Generate and ensure accurate, timely reporting of quality measurements for leadership and business partners. Identify any procedural/documentation concerns, care team needs, and team or individual error trends to Health Services leadership. Report on trainee results and progression towards regular quality reviews. Collaborate with department leaders on individual or team performance or process improvement plans. Support the measurement of outcome and success metrics for Health Services. Collaborate with department trainer(s) in cross-training team members on procedures and guidelines for Health Services functions. Document and update quality review and procedural documents with edits and revisions as changes in guidelines or regulations occur. Proactively submit updates to Health Services processing documents. Serve as a business resource and subject matter expert (SME) for FEP process, reporting and letter requirements. Assist in investigation of quality of care, quality of service and department inquiry and complaints as needed. Participate in FEP pilots and/or projects as needed. Other duties as assigned.

Broadway Ventures

Medical Reviewer (DME)

Posted on:

December 19, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Compact / Multi-State

At Broadway Ventures, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth. Built on integrity, collaboration, and excellence, we’re more than a service provider—we’re your trusted partner in innovation.

Are you a dedicated RN looking for a rewarding career in medical claims review? Broadway Ventures is seeking an experienced Registered Nurse (RN) to conduct pre- and post-payment medical reviews. This is an exciting opportunity to apply your clinical expertise in a non-traditional setting while making a meaningful impact on healthcare compliance and claim accuracy. About the Role: As a Medical Claims Reviewer, you will conduct medical reviews for Durable Medical Equipment (DME) claims. Using clinical expertise and established guidelines, you will assess claims, determine medical necessity, and document decisions. This role involves collaboration with providers and internal teams to ensure compliance and accuracy in claims processing. Position Details: Work Location: Remote: Work from home with high-speed (non-satellite) internet and a private home office. On-Site: Candidates living within driving distance of Nashville, TN will work in our Nashville office. Schedule: Monday – Friday, 8:00 AM to 5:00 PM CT Employment Type: Full-time (40 hours/week)

Licensure: Active, unrestricted RN license in the U.S. (or active compact multistate RN license under the Nurse Licensure Compact - NLC). Education: Associate’s degree in a related field OR graduate of an Accredited School of Nursing. Experience: Minimum two years of clinical nursing experience. Skills: Ability to work independently, prioritize tasks, and make sound decisions. Strong analytical, critical thinking, and organizational skills. Proficiency in Microsoft Office and ability to work with multiple software programs. Confidentiality: Ability to handle sensitive information with discretion. Preferred: Medicare Part B experience Medicare DME claims experience (strongly preferred) Intermediate computer proficiency with multitasking capabilities

Conduct medical claim reviews for complex services, pre-authorizations, appeals, fraud investigations, and coding accuracy. Use established clinical guidelines and protocol sets to make coverage and reimbursement determinations. Ensure claims meet contractor standards and comply with Medicare guidelines. Document medical rationale for claim approvals or denials. Provide education and support to internal/external teams regarding medical reviews, coverage determinations, and coding procedures. Participate in quality control activities and support LPN team members. Assist with special projects and additional responsibilities as assigned.

Broadway Ventures

Clinical Program Manager – CMS Medical Review (RVC)

Posted on:

December 19, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Louisiana

At Broadway Ventures, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth. Built on integrity, collaboration, and excellence, we’re more than a service provider—we’re your trusted partner in innovation.

Location: Remote (U.S.) Schedule: Monday–Friday, 8:00 AM–4:30 PM ET Employment Type: Full-Time We are seeking an experienced Program Manager to oversee daily operations for the CMS Review and Validation Contractor (RVC) Program. This role serves as the primary point of contact to the CMS RVC COR and is responsible for ensuring all contract, operational, and medical review requirements are executed in accordance with CMS guidelines. The ideal candidate brings a strong clinical background (RN), extensive Medicare program knowledge, and proven leadership experience managing large, complex healthcare projects.

Required Qualifications: 5+ years of Program Management experience overseeing large or complex healthcare projects. Experience in medical review, healthcare auditing, or clinical review operations. Extensive knowledge of the Medicare program, including CMS regulatory and operational requirements. Working knowledge of the CMS FFS RAC Program. Strong leadership abilities with experience managing multidisciplinary teams. Education & Licensure: Master’s degree in Business, Healthcare Administration, Nursing, Management, or a related healthcare field from an accredited institution. Current, active U.S. Nursing License (RN); must be maintained throughout employment. Preferred Skills: Excellent written and verbal communication skills. Strong analytical, organizational, and problem-solving abilities. Experience working with government contracts or federal healthcare programs. Ability to manage multiple projects and deadlines in a fast-paced environment.

Serve as the contractor’s authorized representative on all daily operational matters. Maintain ongoing communication with the CMS RVC COR regarding contract performance, staffing, and deliverables. Oversee medical review activities and ensure compliance with CMS guidelines and FFS RAC Program requirements. Lead cross-functional teams and manage staff required to support RVC operations. Ensure accurate interpretation of Medicare coverage, documentation, and regulatory standards. Monitor project progress, performance measures, and quality assurance outputs. Prepare operational updates, reports, and data summaries for CMS and internal leadership. Ensure effective workflows, staffing coverage, and adherence to deadlines and contract terms. Provide clinical oversight and guidance across medical review tasks and methodologies.

Broadway Ventures

Medical Review Manager – CMS Medicare (RVC)

Posted on:

December 19, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Louisiana

At Broadway Ventures, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth. Built on integrity, collaboration, and excellence, we’re more than a service provider—we’re your trusted partner in innovation.

The Medical Review (MR) Manager is responsible for overseeing all medical review activities and quality assurance functions for the CMS Review and Validation Contractor (RVC) program. This role ensures accurate application of Medicare policy, directs daily workflow for medical review staff, and supports the validation of Recovery Audit Contractor (RAC) determinations. The MR Manager must be available Monday–Friday, 8:00 AM to 4:30 PM ET. Work Schedule Monday through Friday 8:00 AM to 4:30 PM ET Availability required during these hours for CMS and operational needs

Required Qualifications: Minimum of 5 years of medical review experience. Minimum of 3 years of experience as a Medical Review Manager, including QA oversight. Extensive knowledge of the Medicare program, including coverage, payment, billing, and policy requirements. Working knowledge of the CMS Fee-for-Service (FFS) Recovery Audit Program. Strong analytical and decision-making skills with demonstrated clinical judgment. Education and Licensure: Registered Nurse (RN), currently licensed in the United States or U.S. Territory (license verified annually). Bachelor’s degree in Nursing (BSN) required. Core Competencies Medical review expertise Clinical judgment and decision-making Medicare coverage and policy knowledge Quality assurance and audit experience Leadership and staff management Policy interpretation and training Strong written and verbal communication Attention to detail and accuracy

Manage and oversee medical review operations, including accuracy reviews, disputes, RAC topic evaluations, and special studies. Lead and supervise medical review staff to ensure proper application of Medicare policies and procedures. Provide clinical expertise and guidance for complex or questionable claim review situations. Conduct quality assurance (QA) audits to verify compliance with contract and regulatory requirements. Brief, train, and educate review personnel on policy interpretation and validation processes. Stay current on medical practice, technology changes, billing trends, and potential areas of improper payments. Ensure medical review activities align with CMS FFS Recovery Audit Program requirements. Serve as the clinical resource for Medicare coverage, documentation, coding, and regulatory requirements. Maintain timely communication with CMS and internal leadership as required. Ensure that all duties requiring clinical expertise are performed directly by the MR Manager; non-medical staff may not substitute.

Travel Nurse Across America, LLC

Clinical Director

Posted on:

December 17, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Akansas

Travel Nurse Across America (TNAA) has been a leader in the healthcare staffing industry for 20+ years. We understand the company you choose to work with can make all the difference in your career as a travel nurse, travel tech, travel therapist, or travel radiologist. At TNAA, we focus on exceeding expectations and providing next-level, highly personalized services with a full-team approach to accommodate each healthcare traveler’s unique needs and career plans. We place great value on individual attention, respect, and a genuine commitment to every nurse, tech, radiologist, or therapist we travel.

Clinical Director (Temporary Role) Remote | SimpliFi SimpliFi is looking for an experienced, service-oriented Clinical Director to join us in a temporary role. In this position, you’ll support our MSP programs by resolving escalated clinician issues, serving as a clinical subject matter expert, and partnering closely with both internal teams and hospital leadership. If you're a confident communicator, a strong clinical leader, and someone who thrives in a fast-paced environment—you’ll feel right at home here. This temporary role works closely with our Client Relationship team, Clinical Directors, Compliance, Operations, CAP Managers, and the Sr. VP of Clinical. Role Details: This is a temporary role with SimpliFi. Duration, hours, and additional details will be reviewed during the interview process. Compensation Pay Rate: $48.00-$52.00 per hour (based on experience) Hours: Temporary, full-time schedule Duration: Final details will be shared during the interview process

What You Bring (Required) Bachelor of Science in Nursing (BSN) 3+ years of nursing experience across multiple specialty areas Active RN license in at least one state Demonstrated ability to lead and develop others Excellent interpersonal skills for navigating sensitive and escalated situations Strong attention to detail and discretion with confidential matters Ability to write clearly and present effectively to employees, leadership, and customers Ability to work in a fast-paced, complex environment with a sense of urgency Proven ability to build productive cross-functional relationships Proficiency with Outlook, Word, and Excel Ability to travel up to 15% Will accept any suitable combination of education, training, or experience Preferred Qualifications: Master’s degree in Nursing, Administration, or Education Prior leadership experience

Lead and support the Clinical Interview Specialist team, ensuring high-quality candidate interviews, feedback, and collaboration with the Client Relationship team. Act as the key clinical point of contact during implementation and launch of MSP services. Serve as a clinical SME during meetings with prospective clients, CNOs, and senior RN executives to communicate SimpliFi’s clinical processes. Provide clinical resources and guidance to SimpliFi staff and internal partners. Review vendor applicants, conduct interviews as needed, and contribute to process improvements. Ensure terms/cancels are processed appropriately; review trends and make recommendations on clinical guidelines. Monitor clinician performance evaluations and follow up on coaching or recognition opportunities as needed. Partner with Risk Management on high-risk situations involving travelers or clients. Uphold and model our Core Values: Own Your Relationships – Be someone others can count on. Strengthen connections through reliability, trust and communication. Own the Outcome – We hold ourselves accountable for outcomes — not just effort. Through focus, follow-through, and a commitment to improvement, we achieve results that advance our mission.​ Obsess Over the Experience - Create experiences that make people feel valued — every conversation, every interaction, every time.​ Perform other duties as assigned.

Travel Nurse Across America, LLC

Allied or Nursing Recruiting Specialists (Sales-Driven)

Posted on:

December 17, 2025

Job Type:

Full-Time

Role Type:

License:

None Required

State License:

Akansas

TNAA & TotalMed are now one of the fastest-growing healthcare staffing firms in the country. Our culture is built on honesty, transparency, and unmatched customer service. Here, you’ll find: A rewarding and competitive atmosphere (we work hard and celebrate big wins). A place where results are rewarded and your effort truly matters. A team that lives by our Core Values: Own Your Relationships – Be someone others can count on. Strengthen connections through reliability, trust and communication. Own the Outcome – We hold ourselves accountable for outcomes — not just effort. Through focus, follow-through, and a commitment to improvement, we achieve results that advance our mission.​ Obsess Over the Experience - Create experiences that make people feel valued — every conversation, every interaction, every time.​ Act with Integrity and Respect – We do what’s right—for our clients, clinicians, and each other. We treat everyone with honesty, empathy, and respect, no matter the circumstance.​

Now Hiring Allied & Nursing Recruiting Specialists (Sales-Driven) Start Date: February 9th, 2026 (subject to change) Location: Nationwide (remote options available) Are you a natural closer who thrives in a fast-paced sales environment? If you love building relationships, hitting metrics, and making an impact, this role could be the perfect fit. At TNAA & TotalMed, we connect nurses, surgical techs, and allied professionals with healthcare facilities nationwide. We’re looking for driven professionals with a strong sales background who want to grow into a career in healthcare recruiting.

6+ months experience in a fast-paced sales role. Proven track record of achieving sales metrics and goals. Negotiation and problem-solving skills. Ability to build strong, long-term relationships. Proven ability to persuade, influence, and close. Proficiency in Microsoft Word, Outlook, and general business applications.

Prospect healthcare professionals (calls, texts, emails, social media). Interview and qualify Travelers to match them with assignments. Partner with internal teams to ensure successful placements. Provide ongoing support and expertise throughout each assignment. Advise Travelers by aligning pay and assignments with their goals. Live our Core Values every day.

TIMESSQUARETECH NYC INC

Clinical Quality Management Analyst

Posted on:

December 17, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

This is a medical review position. Will be mining medical records Must be a Registered Nurse in PA Must have 3-5 years of medical review experience Must have HEDIS experience Must have medical review experience Must have Customer service experience Must have attention to detail Must be proficient in Excel Must be tech savvy Quality improvement experience preferred Must complete the Clinical Quality Management Analyst Assessment.

This job works with appropriate departments in the areas of compliance, process improvement, medical record review and coding, and member and provider satisfaction for all product lines. Recommends and implements process improvements related to the potential of quality medical care and service to members and to improve documentation of these services for appropriate ICD 10-CM coding.

TIMESSQUARETECH NYC INC

Care Manager RN

Posted on:

December 17, 2025

Job Type:

Contract

Role Type:

Care Management

License:

RN

State License:

Pennsylvania

5+ years of relevant experience Must be a current licensed RN in the state of PA Disease Management knowledge or experience. Prior experience working in case management and managed care Knowledge of assessments and care plans Experience with community resources Some knowledge of preventive health services Experience working with the Medicaid population Must have great work ethic Able to work independently Telephonic outreach to members Excellent verbal and written communication skills

ATD Technology

Care Manager

Posted on:

December 17, 2025

Job Type:

Contract

Role Type:

Care Management

License:

RN

State License:

Pennsylvania

ATD Technology, LLC is a certified minority woman owned business that creates opportunities to match qualified job seekers with our client programs while meeting all parties’ financial needs and technical goals. ATD is a full service provider with offerings in Contract, Permanent and Temp-to-Perm staffing solutions. We serve Fortune 1000, mid cap and small cap companies in the Commercial, Private, Public and Government sectors across North America.

5+ years of relevant experience Must be a current licensed RN in the state of PA Disease Management knowledge or experience. Prior experience working in case management and managed care Knowledge of assessments and care plans Experience with community resources Some knowledge of preventive health services Experience working with the Medicaid population Must have great work ethic Able to work independently Telephonic outreach to members Excellent verbal and written communication skills Certified Case Manager preferred 1-800-line experience preferred Candidates must complete the Care Manager Assessment in Glider.

Function as a primary clinician for members with complex health needs with the depth of engagement ranging from basic coaching to intensive case management. Across the continuum of services the goal is always to help develop and support the member’s ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision making. Conduct telephonic clinical assessments that address the health and wellness needs of the Organization's members using a broad set of clinical and motivational interviewing skills with the goal of effecting members’ self-management and positive behavior changes. Develop case or condition-specific plans of care using the clinical information system to establish short and long-term goals. Establish a plan for regular telephonic contact with each member to review progress and assess the potential for additional needs. Communicate with the member’s treating provider or providers in more complex clinical situations requiring case management intervention. Also serves as a subject matter expert to clinicians from other HMS teams to provide education, consultation, and training when indicated. Identify on-line, telephonic and community-based resources that can assist the member to achieve and maintain their personal health goals and assists the member to access those services. Proactively incorporate lifestyle improvement and prevention opportunities into member interactions and coaching. Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards. Other duties as assigned or requested, such as coordination of Blue Distinction Centers for Transplant Excellence for their services to ensure that members access these facilities whenever applicable. Senior Specialized Case Managers also work closely with Benefits Analysts to coordinate interpretation of benefit language and to ensure that all related services such as appeals/denials, provider inquiries, and claims processing are completed thoroughly and accurately.

Qualified Recruiter

Utilization Review Nurse

Posted on:

December 17, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Texas

This contract role as a Remote Utilization Review Nurse must be a Registered Nurse working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan.

Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation. Awareness of claims processes and claims processing systems. PC proficiency to include Microsoft Word and Excel and health insurance databases. Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings. Organizational skills and prioritization skills. Registered Nurse (RN) with unrestricted license in state. 3 years clinical experience.

Responsible for performing accurate and timely medical review of claims suspended for medical necessity, contract interpretation and pricing. Initiate and/or respond to correspondence from providers or members concerning medical determinations.

Central Florida Inpatient Medicine

Remote Nocturnist ARNP-Block

Posted on:

December 17, 2025

Job Type:

Full-Time

Role Type:

License:

NP/APP

State License:

Florida

Since 2001, Central Florida Inpatient Medicine is a Hospitalist Group shifting the paradigm to meet patient needs throughout their healthcare journey. At CFIM, our leadership team with over 50 years' experience in Value Based care has been actively observing the landscape in healthcare as it continues to evolve. We understand the importance of population health management strategies by bridging the gap throughout the continuum of care. We discharge over 70,000 patients from the 10+ Hospitals where we round. While also seeing the patients in over 70 post-acute centers and serve over 5,000 wound care/podiatry clients with a focus of providing quality care to all of our clients.

MUST LIVE IN FLORIDA MUST HAVE ONE YEAR HOSITALIST EXPERIENCE, AS MED STAFF REQUIRES IN PATIENT CASE LOGS-THIS IS NECESSARY TO GET CREDENTIALED AND ACCESS TO REMOTE EMR A dedicated and experienced Nurse Practitioner (NP) or Physician Assistant (PA) to provide high-quality remote care during night shifts for acute and post-acute care facilities. The ideal candidate will triage, evaluate, and manage patient care, ensuring continuity of care and reducing unnecessary emergency department visits. This is a fully remote role that requires clinical expertise, strong communication skills, and the ability to work independently during nighttime hours.

Minimum of 2 years of clinical experience as an NP/PA in acute, post-acute, or telehealth settings. Qualifications and Education Requirements Active Florida NP/PA license Must pass Level 2 AHCA background screen

Remote Patient Care: Respond promptly to after-hours calls from acute and post-acute care facilities. Provide comprehensive assessments via telecommunication to determine the appropriate level of care. Manage acute conditions, chronic disease exacerbations, and other patient needs, adhering to evidence-based practices. Collaboration & Communication: Collaborate with facility staff, including nurses and on-site providers, to ensure optimal patient care. Document encounters accurately and efficiently to ensure smooth handoff with dayshift team. Clinical Decision-Making: Prescribe medications and treatments within the scope of practice and in compliance with state regulations. Facilitate referrals or escalate care to on-site providers or emergency services when necessary. Compliance & Quality Assurance: Ensure all clinical decisions comply with facility protocols and regulatory requirements. Participate in quality improvement initiatives as needed.

Insight Physicians Care, LLC

Telemedicine Nurse Practitioner (Primary Care)

Posted on:

December 17, 2025

Job Type:

Part-Time

Role Type:

Primary Care

License:

NP/APP

State License:

Illinois

Primary Care Telemedicine Nurse Practitioner (NP) Full-Time – Chicago, IL (Remote/Telehealth) Our Primary Care and Wound Care House Call practice is expanding our telemedicine services, and we are looking for a reliable, clinically strong Nurse Practitioner to join our team. This role is ideal for someone who is comfortable working independently, communicates clearly, documents accurately, and can manage a wide range of primary care concerns through virtual visits. Schedule: Monday to Friday 9:00 AM – 6:00 PM CST One weekend on-call per month This role is not flexible on hours

Active NP license in the state of IL Experience in Primary Care required; wound care experience a plus Comfortable with telehealth platforms and EMR systems Strong clinical judgment and communication skills Ability to work in a fast-moving, growth-focused practice Reliable internet and quiet professional workspace Full practice preferred

Provide virtual primary care visits for established and new patients Review medical histories, labs, imaging, and care plans Manage chronic conditions and acute concerns within telehealth guidelines Coordinate care with in-field providers, support staff, and collaborating physicians Complete accurate and Medicare-compliant documentation in a timely manner Participate in one weekend on-call rotation per month (phone triage only) Support wound care teams when needed by reviewing orders or giving clinical guidance

Centene

Senior Risk Adjustment Coding Compliance Analyst (Clinical)

Posted on:

December 17, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Missouri

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 job have the flexibility to work remote from home anywhere in the Continental United States.

Executes Line 2 oversight of Risk Adjustment activities, including monitoring, auditing, and supports Line 1 oversight. Reviews medical records to assess proper extraction of medical diagnoses and ensure accurate and complete diagnosis coding in alignment with HCCs and other risk adjustment models. Identifies and evaluates clinical documentation gaps, assesses risk levels, and communicates findings to business stakeholders to support the integrity and quality of risk adjustment data. Collaborates with coding teams to improve documentation practices and ensure compliance with regulatory and coding guidelines.

Education/Experience: High School Diploma or GED required Bachelor's Degree Nursing, Healthcare Management, Business Management or related field preferred 5+ years professional coding experience in a hospital or physician setting required Experience in Managed care preferred Licenses/Certifications: LVN, LPN or RN required and Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) required NP or PAN preferred Certified Risk Adjustment (CRC) preferred

Ensure coding accuracy by reviewing inpatient and outpatient medical records using clinical expertise to interpret documentation in accordance with ICD-10, Coding Clinic, AHIMA, and company coding guidelines. Validate clinical documentation to support appropriate risk adjustment coding, including Hierarchical Condition Categories (HCCs), with emphasis on clinical relevance and site of coding clinical appropriateness. Apply ICD-10, AHIMA standards, Coding Clinic guidance, and company policies to ensure accurate and compliant coding practices, incorporating clinical judgment to assess documentation sufficiency. Implement CMS risk adjustment guideline oversight and evaluate clinical documentation to ensure alignment with regulatory standards and coding compliance. Review and appropriately challenge coding decisions based on clinical interpretation of documentation, current industry guidelines, audit findings, and regulatory requirements. Conduct Line 1 gap analyses and provide clinical best practice recommendations; design and execute Line 2 oversight to evaluate the effectiveness and compliance of risk adjustment quality programs. Provide expert guidance on CMS coding requirements, clinical documentation improvement (CDI), and industry best practices to coding teams and providers. Assess risk levels in coding data using clinical insight and recommend mitigation strategies to address potential compliance or reimbursement risks. Support remediation efforts for identified non-compliance issues by applying clinical knowledge to root cause analysis and corrective action planning. Evaluate policies and procedures to ensure completeness, clinical accuracy, and adherence to current regulatory requirements and best practices. Perform clinical chart reviews and advise on clinical best practices related to risk adjustment coding, HCC capture, and documentation improvement. Performs other duties as assigned. Complies with all policies and standards.

New Age Software Services, Inc

Risk Adjustment Chart Reviewer/ Medical Coder

Posted on:

December 16, 2025

Job Type:

Contract

Role Type:

License:

RN

State License:

Massachusetts

Retrospective Risk Adjustment Chart Reviewer DURATION: 6 Month+ with strong potential to convert to hire LOCATION: Remote. Qualified candidates must be located within 2 hours of Boston MA. US citizens and Green Card Holders and those authorized to work in the US are encouraged to apply. We are unable to sponsor (or transfer) H1B candidates at this time. If you need sponsorship now or in the future (OPT, STEM,) our client is not able to provide sponsorship. SUMMARY: A growing risk adjustment company looking for motivated candidates with a clinical and coding background to join our team of senior coders/nurses. As a Retrospective Risk Adjustment Reviewer, you would be responsible for reviewing medical records, evaluating and assessing provider documentation, and submitting supported ICD-10 diagnosis codes according to specified guidelines. Chart review performed remotely via Electronic Health Record (EHR).

REQUIRED KNOWLEDGE AND SKILLS: In-depth knowledge of medical terminology, ICD-10 coding, and Risk adjustment. Medical chart review experience. Preferably Epic. Basic concepts of human anatomy, physiology, and pathology. Ability to work with accuracy and attention to detail. Excellent understanding of clinical documentation requirements and coding guidelines. PREFERRED QUALIFICATIONS: At least three of the following criteria: Minimum 5 years of experience in risk adjustment or medical chart review Clinical Background, i.e.. RN, NP, PA, MD. •Certified Professional Coder (CPC). Certified Risk Coder (CRC). ICD-10 coding background. EDUCATION: Associate degree (or equivalent combination of formal education and experience) required. Bachelor’s Degree preferred.

ICD-10 Coding of Outpatient and Inpatient diagnoses. Evaluating and assessing provider documentation. Applying client-specific guidelines in the coding of diagnoses.

IntellaTriage

Remote Hospice Triage RN PT 3:30p-8:30p + rotating Sat & Sun 9:30a-4p CST

Posted on:

December 16, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We are seeking a compassionate registered nurse (RN) to join our growing team! In this role, you will provide critical after-hours support, triaging hospice patients and family needs over the phone wit professionalism and empathy. You will help ensure timely interventions and coordination of care for patients receiving hospice services.

Active multistate Registered Nurse (RN) license Hospice, palliative, or end-of-life care is strongly preferred Must be comfortable with technology and electronic medical records (EMR) utilized for documentation of calls Ability and comfort with typing documentation and notes in a fast-paced environment Must be able to handle stress and multitask when receiving calls (minimum of 5 calls per hour on weekdays, and up to 8 per hour on weekends) Strong communication and critical thinking skills Ability to work independently in a remote environment This is a remote position that requires consistent attendance, active communication, and reliable internet connectivity during all scheduled shifts to support timely patient care coordination

Provide telephone triage for hospice patients and families Assess patient conditions and determine appropriate next steps Collaborate with on-call teams to coordinate care and resources Accurately document all communications and interventions Maintain a calm and professional demeanor while handling urgent calls.

IntellaTriage

Remote Hospice Triage RN PT 3:30p-11p + rotating Sat & Sun 3:30p-11p CST

Posted on:

December 16, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

We are seeking a compassionate registered nurse (RN) to join our growing team! In this role, you will provide critical after-hours support, triaging hospice patients and family needs over the phone wit professionalism and empathy. You will help ensure timely interventions and coordination of care for patients receiving hospice services.

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

Active multistate Registered Nurse (RN) license Hospice, palliative, or end-of-life care is strongly preferred Must be comfortable with technology and electronic medical records (EMR) utilized for documentation of calls Ability and comfort with typing documentation and notes in a fast-paced environment Must be able to handle stress and multitask when receiving calls (minimum of 5 calls per hour on weekdays, and up to 8 per hour on weekends) Strong communication and critical thinking skills Ability to work independently in a remote environment This is a remote position that requires consistent attendance, active communication, and reliable internet connectivity during all scheduled shifts to support timely patient care coordination

Provide telephone triage for hospice patients and families Assess patient conditions and determine appropriate next steps Collaborate with on-call teams to coordinate care and resources Accurately document all communications and interventions Maintain a calm and professional demeanor while handling urgent calls.

Circle of Life Community Hospice

Registered Nurse

Posted on:

December 16, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Nevada

Established in 1999 and locally owned, Circle of Life Hospice is a trusted and highly respected provider of hospice care in Reno. We are known for our compassionate approach, strong interdisciplinary teamwork, and commitment to both patient-centered care and employee well-being. Supportive and collaborative work environment Meaningful, mission-driven work Opportunities to support patients in homes and our Hospice Guest House Emphasis on balance, flexibility, and sustainability for our clinical team

Circle of Life Hospice is currently seeking two (2) Part-Time Registered Nurses (RNs) with a Hospice Heart to join our compassionate and dedicated team. These roles support our mission of providing comfort, dignity, and exceptional end-of-life care to patients and families throughout Northern Nevada. Position Type Part-Time Registered Nurse (2 openings) Schedule & Availability Part-time hours Schedule may include weekends Ability to work days and/or nights as needed Flexible scheduling based on patient and operational needs

Active Registered Nurse (RN) license in the State of Nevada Valid driver’s license with acceptable driving record Minimum one year of nursing experience (hospice, oncology, med-surg, or home health preferred) Comfortable using electronic medical records and technology Ability to travel within Washoe, Lyon, Carson, Storey, and Douglas Counties Flexibility to work days, nights, and weekends as required

As a Part-Time Registered Nurse, you will provide hospice nursing care and compassionate support to hospice patients and their families, including: Delivering individualized nursing care and symptom management Collaborating with the interdisciplinary care team Educating patients, families, and caregivers Supporting hospice admissions and visits as needed Providing on-call or after-hours support based on scheduling needs Upholding Circle of Life Hospice standards, policies, and values

Enjoin

Director of Clinical Documentation Integrity

Posted on:

December 16, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Tennessee

For more than 35 years, Enjoin has provided health systems with clinical documentation integrity (CDI) education, infrastructure and process development. A pioneer of CDI programs, Enjoin continues to be an industry leader and innovator. Led by nationally renowned physicians with a strong academic background in scientific-based medicine and years of clinical practice coupled with certified coding and clinical documentation credentials, our unique approach addresses today’s quality-driven initiatives uniting documentation and coding across the healthcare continuum.

We are seeking a dynamic and strategic Executive Director to lead our enterprise-wide programs in Clinical Documentation Excellence, Denials Management, Patient Education, and Utilization Review. This executive leader is responsible for program planning, daily oversight, and performance evaluation across these critical functions, ensuring compliance with regulatory requirements and alignment with health system goals. This role partners closely with physician advisors, care management, coding, patient financial services, and other operational leaders to advance systemwide strategies, improve performance, and support high-quality clinical documentation and patient care.

Bachelor’s Degree in Nursing required. Master’s Degree in a healthcare-related clinical discipline or business management highly preferred. Current RN license AND CCDS or CDIP required. Minimum 5 years of CDI leadership experience required. Coding experience highly preferred. Experience developing and executing strategies in a large, matrixed or academic health system required. Strong knowledge of regulatory requirements for documentation, coding, billing, and utilization management. Expertise in performance measurement, financial statistics, data reporting, and quality improvement. Demonstrated leadership ability to develop staff and oversee multiple departments. Excellent written, verbal, and presentation skills. Proficiency in Microsoft Office, electronic databases, and EMR systems (Epic preferred). Exceptional customer service and ability to interact effectively with leaders, staff, and providers. Work Environment: This is a full-time remote position. General hours of work are Monday through Friday during regular business hours. Work is generally sedentary, requiring long periods at workstation. Must have a reliable internet connection, phone, and a dedicated, secure workspace to ensure adherence to HIPAA Privacy and Security policies and procedures when viewing Protected Health Information (PHI).

Program Leadership & Operations: Direct and oversee enterprise Clinical Documentation, Denials Management, Patient Education, and Utilization Review programs to meet health system goals. Guide and develop staff responsible for clinical case management, ensuring adherence to regulatory, coding, and billing standards. Drive collaboration with enterprise coding and acute care utilization review teams. Assure accuracy and compliance with patient admission documentation and after-visit summaries. Develop, update, and enforce departmental policies, procedures, workflows, and best-practice standards. Plan, justify, and monitor operational and capital budgets. Performance & Compliance: Monitor performance metrics and trends related to documentation accuracy, clinical acuity, quality indicators, and case review volumes. Produce regular department performance reports using industry benchmarks and annual assessment data. Ensure compliance with CMS, Joint Commission (JCAHO), DHHS, and other regulatory entities. Participate in task forces to design or improve documentation, denials management, and utilization review processes. Technology, Tools & Resources: Ensure effective use of Epic tools and other technology platforms to support efficient workflows. Manage departmental resources, staffing, and education to maintain high-performing operations. Support development and enhancement of staff training and orientation programs. Collaboration & Physician Engagement: Coordinate work priorities and strategy alignment with Physician Advisors. Partner with service-line leadership and medical staff to drive cross-functional problem solving and documentation improvement initiatives. Promote a unified, enterprise-wide approach to documentation, utilization review, and denials management.

USTech GCC Private Limited

Nurse Case Manager II

Posted on:

December 16, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com. US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Duration: 3+ months contract possible contract extension or conversion to perm Job Description: The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

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

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

eTeam Inc

Case Manager

Posted on:

December 16, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Pennsylvania

The Client is looking for candidates with experience with Disease Management. The candidates must be nurses with strong assessment skills for care coordination and education of members for their Disease Management program. Past Case Management, telephonic experience and Medicaid knowledge are pluses. Please work to identify new candidates who meet this experience. Experience with Disease Management required, CCM a plus Remote work - prefer local to Pittsburgh Contract only – expected duration is 6 months Candidates must complete the Care Manager Assessment in Glider.

5+ years of relevant experience Must be a current licensed RN in the state of PA Disease Management knowledge or experience. Certified Case Manager preferred Prior experience working in case management and managed care Knowledge of assessments and care plans Experience with community resources Some knowledge of preventive health services 1-800-line experience preferred Experience working with the Medicaid population Must have great work ethic Able to work independently Telephonic outreach to members Excellent verbal and written communication skills ET_RV01 Job Type: Contract Pay: $45.00 - $48.81 per hour Expected hours: 40 per week Experience Case management: 1 year (Required) managed care: 1 year (Required) Working with community resources: 1 year (Required) working with the Medicaid population: 1 year (Required) Location: Pittsburgh, PA (Preferred) Work Location: Remote

Function as a primary clinician for members with complex health needs with the depth of engagement ranging from basic coaching to intensive case management. Across the continuum of services the goal is always to help develop and support the member’s ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision making. Conduct telephonic clinical assessments that address the health and wellness needs of the Organization's members using a broad set of clinical and motivational interviewing skills with the goal of effecting members’ self-management and positive behavior changes. Develop case or condition-specific plans of care using the clinical information system to establish short and long-term goals. Establish a plan for regular telephonic contact with each member to review progress and assess the potential for additional needs. Communicate with the member’s treating provider or providers in more complex clinical situations requiring case management intervention. Also serves as a subject matter expert to clinicians from other HMS teams to provide education, consultation, and training when indicated. Identify on-line, telephonic and community-based resources that can assist the member to achieve and maintain their personal health goals and assists the member to access those services. Proactively incorporate lifestyle improvement and prevention opportunities into member interactions and coaching. Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards. Other duties as assigned or requested, such as coordination of Blue Distinction Centers for Transplant Excellence for their services to ensure that members access these facilities whenever applicable. Senior Specialized Case Managers also work closely with Benefits Analysts to coordinate interpretation of benefit language and to ensure that all related services such as appeals/denials, provider inquiries, and claims processing are completed thoroughly and accurately.

IntellaTriage

Remote Hospice Triage RN PT 3:30p-11a + rotating Sat & Sun 9:30a-4p CST

Posted on:

December 16, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We are seeking a compassionate registered nurse (RN) to join our growing team! In this role, you will provide critical after-hours support, triaging hospice patients and family needs over the phone wit professionalism and empathy. You will help ensure timely interventions and coordination of care for patients receiving hospice services.

Provide telephone triage for hospice patients and families Assess patient conditions and determine appropriate next steps Collaborate with on-call teams to coordinate care and resources Accurately document all communications and interventions Maintain a calm and professional demeanor while handling urgent calls.

Active multistate Registered Nurse (RN) license Hospice, palliative, or end-of-life care is strongly preferred Must be comfortable with technology and electronic medical records (EMR) utilized for documentation of calls Ability and comfort with typing documentation and notes in a fast-paced environment Must be able to handle stress and multitask when receiving calls (minimum of 5 calls per hour on weekdays, and up to 8 per hour on weekends) Strong communication and critical thinking skills Ability to work independently in a remote environment This is a remote position that requires consistent attendance, active communication, and reliable internet connectivity during all scheduled shifts to support timely patient care coordination

OncoveryCare

Oncology Survivorship Nurse Practitioner

Posted on:

December 16, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Massachusetts

OncoveryCare is an early-stage virtual healthcare company committed to fundamentally rethinking and transforming the landscape of physical and mental healthcare for cancer survivors. Our team is composed of cancer survivors, clinicians, and experts in cutting-edge healthcare delivery. We believe that world class care after a cancer diagnosis shouldn’t end when treatment is over, and we provide an innovative, evidence-based approach to deliver patient-centered, whole-person support for survivors throughout the cancer journey. Our vision is a world where living beyond cancer isn’t just “surviving”—it’s thriving. A few tidbits about cancer survivorship: There are over 18 million cancer survivors in the United States today—and that number is expected to grow to 26 million by 2040 Cancer survivors experience a range of physical and mental health side effects from treatment Survivorship starts at the moment of diagnosis and continues post-treatment—we are starting in the “transitions of care” phase post-treatment, when there is often not a specialized team to take over caring for the survivor moving forward Our Guiding Principles: By survivors, for survivors: We build the survivor voice and experience into all that we do Clinical integrity and rigor: We prioritize evidence-based approaches and an integrated team to deliver the highest-quality care Trauma-informed care: We “meet survivors where they are” and respect their lived experience Changing the status quo: We are committed to radically reinventing how cancer survivorship care is designed, delivered, and experienced Transparency & inclusivity: Building a new frontier of cancer care is both hard and rewarding—everyone has a role to play, and fostering a positive and open team culture is our priority

At OncoveryCare, we deeply understand the impact of cancer on a patient’s physical and mental health, and we are dedicated to supporting our patients with trauma-informed and evidence-based care. As an Oncology Survivorship Nurse Practitioner, you will play a pivotal role in the lives of our patients as they navigate the many challenges of cancer survivorship. You will serve as the quarterback of the care team, working closely with our multidisciplinary team, which includes survivorship MDs, NPs, behavioral health clinicians, care navigators, and peer guides. We prioritize equipping our clinicians with the necessary tools and resources to deliver exceptional patient care. To support this, our care team is supported by a robust clinical operations team that assists with admin and billing, custom tools to streamline care delivery and documentation, and consultation from clinical leadership. Additionally, you will have access to vetted referral partners and community resources to facilitate seamless transitions of care for your patients. You will also have an opportunity to help shape the future landscape of survivorship care through working closely with executive leadership on program delivery and patient experience.

What You Will Need: 3-5+ years of advanced practice experience in an oncology healthcare setting Preferably experienced in providing cancer survivorship care or strong symptom / supportive care management experience Master’s degree in nursing Current certification as a Nurse Practitioner in appropriate specialty to care for adult patients Willingness to obtain licensure as a registered NP in specified states as required Commitment to self-directed learning to stay updated with clinical knowledge and evolving evidence-based practices within the healthcare field Ability to educate patients on complex medical information in an understandable manner, adapting to individual patient needs Excellent communication, empathy, and active listening skills Proficiency in using and documenting effectively and timely within electronic medical records Ability to independently drive work forward and collaborate effectively with diverse stakeholders Full-time availability for a 40-hour workweek, Monday to Friday, 9 am to 5 pm Who You Are: Strong clinical focus. You’re committed to delivering excellent evidence based and trauma-informed clinical care to cancer survivors Survivor-centered. Patients are your “why” for the work - you value building and maintaining meaningful relationships with cancer survivors and thinking creatively about how to improve their care High emotional intelligence. You pride yourself on being a strong listener, communicator and are able to empathize with people with diverse life experiences Go-getter: You’re psyched to roll-up your sleeves, get things done, and don’t mind playing a versatile role on a fast-paced team Growth Mindset. You embody a spirit of continuous improvement, actively seek to enhance care programs, and are comfortable sharing insights with clinical leadership Forward thinking. You are interested in fast paced, early stage health innovation and are excited by big ideas and creating impact

Comprehensive Patient Assessment: Conduct thorough assessments of cancer survivors via telemedicine to identify physical, emotional, and psychosocial needs Personalized Treatment Planning: Provide evidence-based guidance and education,collaborating closely with the survivorship care team to identify and address patients’ needs, considering their individual history and unique experiences Care Planning: Develop and update survivorship care plans in collaboration with patients, incorporating input from behavioral health professionals to support overall well-being Coordinate Multidisciplinary Care: Collaborate and communicate effectively with all members of patient internal and external care team, including oncologists, PCPs, and other specialists Patient Education: Provide education and support to patients regarding cancer survivorship, ongoing care needs, and available resources, using OncoveryCare’s evidence-based materials Program Development: Work with clinical leadership to build and enhance survivorship care programs, incorporating patient feedback and best practices to improve patient experiences and outcomes

OncoveryCare

Oncology Survivorship Advanced Practice Provider

Posted on:

December 16, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

New York

OncoveryCare is an early-stage virtual healthcare company committed to fundamentally rethinking and transforming the landscape of physical and mental healthcare for cancer survivors. Our team is composed of cancer survivors, clinicians, and experts in cutting-edge healthcare delivery. We believe that world class care after a cancer diagnosis shouldn’t end when treatment is over, and we provide an innovative, evidence-based approach to deliver patient-centered, whole-person support for survivors throughout the cancer journey. Our vision is a world where living beyond cancer isn’t just “surviving”—it’s thriving. A few tidbits about cancer survivorship: There are over 18 million cancer survivors in the United States today—and that number is expected to grow to 26 million by 2040 Cancer survivors experience a range of physical and mental health side effects from treatment Survivorship starts at the moment of diagnosis and continues post-treatment—we are starting in the “transitions of care” phase post-treatment, when there is often not a specialized team to take over caring for the survivor moving forward Our Guiding Principles: By survivors, for survivors: We build the survivor voice and experience into all that we do Clinical integrity and rigor: We prioritize evidence-based approaches and an integrated team to deliver the highest-quality care Trauma-informed care: We “meet survivors where they are” and respect their lived experience Changing the status quo: We are committed to radically reinventing how cancer survivorship care is designed, delivered, and experienced Transparency & inclusivity: Building a new frontier of cancer care is both hard and rewarding—everyone has a role to play, and fostering a positive and open team culture is our priority

At OncoveryCare, we deeply understand the impact of cancer on a patient’s physical and mental health, and we are dedicated to supporting our patients with trauma-informed and evidence-based care. As an Oncology Survivorship Advanced Practice Provider, you will play a pivotal role in the lives of our patients as they navigate the many challenges of cancer survivorship. You will serve as the quarterback of the care team, working closely with our multidisciplinary team, which includes survivorship MDs, APPs, behavioral health clinicians, care navigators, and peer guides. We prioritize equipping our clinicians with the necessary tools and resources to deliver exceptional patient care. To support this, our care team is supported by a robust clinical operations team that assists with admin and billing, custom tools to streamline care delivery and documentation, and consultation from clinical leadership. Additionally, you will have access to vetted referral partners and community resources to facilitate seamless transitions of care for your patients. You will also have an opportunity to help shape the future landscape of survivorship care through working closely with executive leadership on program delivery and patient experience. Candidates must hold an active license in New York.

How You’ll Thrive: Within the first 90 days, you will onboard with our clinical care team, engaging with executive leadership and healthcare providers focused on the physical and mental health of cancer survivors. You will become familiar with the OncoveryCare philosophy, technology platform and our integrated approach to survivorship, and begin conducting virtual visits with patients. Within the first year, you will establish strong relationships with OncoveryCare patients and providers. You will develop proficiency in assessing and meeting the unmet needs of survivors, gaining a thorough understanding of the referral partner landscape in patients' local communities. You will also provide critical insights to OncoveryCare’s leadership and clinical team, contributing to ongoing enhancement of our program delivery and protocols. Long-term growth opportunity: You will have the chance to rapidly progress within a dynamic startup and play a pivotal role in the design and delivery of survivorship care programs for cancer survivors. What You Will Need: 3-5+ years of advanced practice experience in an oncology healthcare setting, preferably with outpatient solid tumor experience Preferably experienced in providing cancer survivorship care or strong symptom / supportive care management experience Master’s degree in nursing Hold a current, active Nurse Practitioner or Physician Assistant license in New York Current certification as a Nurse Practitioner or Physician Assistant in appropriate specialty to care for adult patients Commitment to self-directed learning to stay updated with clinical knowledge and evolving evidence-based practices within the healthcare field Ability to educate patients on complex medical information in an understandable manner, adapting to individual patient needs Excellent communication, empathy, and active listening skills Proficiency in using and documenting effectively and timely within electronic medical records Ability to independently drive work forward and collaborate effectively with diverse stakeholders Full-time availability for a 40-hour workweek, Monday to Friday, 9 am to 5 pm (flexible) Who You Are: Strong clinical focus. You’re committed to delivering excellent evidence based and trauma-informed clinical care to cancer survivors Survivor-centered. Patients are your “why” for the work - you value building and maintaining meaningful relationships with cancer survivors and thinking creatively about how to improve their care High EQ. You pride yourself on being a strong listener, communicator and are able to empathize with people with diverse life experiences Go-getter: You’re psyched to roll-up your sleeves, get things done, and don’t mind playing a versatile role on a fast-paced team Growth Mindset. You embody a spirit of continuous improvement, actively seek to enhance care programs, and are comfortable sharing insights with clinical leadership Forward thinking. You are interested in fast paced, early stage health innovation and are excited by big ideas and creating impact

Comprehensive Patient Assessment: Conduct thorough assessments of cancer survivors via telemedicine to identify physical, emotional, and psychosocial needs Personalized Treatment Planning: Provide evidence-based guidance and education, collaborating closely with the survivorship care team to identify and address patients’ needs, considering their individual history and unique experiences Care Planning: Develop and update survivorship care plans in collaboration with patients, incorporating input from behavioral health professionals to support overall well-being Coordinate Multidisciplinary Care: Collaborate and communicate effectively with all members of patient internal and external care team, including oncologists, PCPs, and other specialists Patient Education: Provide education and support to patients regarding cancer survivorship, ongoing care needs, and available resources, using OncoveryCare’s evidence-based materials Program Development: Work with clinical leadership to build and enhance survivorship care programs, incorporating patient feedback and best practices to improve patient experiences and outcomes

TN for Greenstaff Medical US

Remote RN - Tele Health| Diabetic Care

Posted on:

December 16, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Remote Registered Nurse (RN) – Telehealth | Diabetic Care Contract Length: 21 Weeks Location:Remote Schedule: 8:00 AM – 4:00 PM Pay:$25/hr | OT: $37.50/hr Overview: We are hiring an experienced Remote Registered Nurse (RN) to support Telehealth Diabetic Care services for patients across New York State. This 21-week remote assignment offers a consistent day schedule and the opportunity to deliver high-quality, patient-centered care from the comfort of your home. The ideal candidate will have strong clinical knowledge in diabetes management and excellent communication skills to provide education, monitoring, and support through virtual platforms.

3+ years of Diabetic Care experience (Required) AHA BLS Certification Active NY State RN License and Compact/Multistate License Required Please apply only if you hold a valid NY State license and also a Multistate/Compact license.

Emory Healthcare

Perioperative Registered Nurse

Posted on:

December 16, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Georgia

Be inspired. Be rewarded. Belong. At Emory Healthcare. At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide: Comprehensive health benefits that start day one! Student Loan Repayment Assistance & Reimbursement Programs Family-focused benefits Wellness incentives Ongoing mentorship, development, leadership programs…. and more!

Our Anesthesia Preop Clinic at Emory University Hospital is seeking a Preoperative Registered Nurse (RN) with at least 1 year experience. The Specialty Services Registered Nurse Clinician is an experienced healthcare professional with a strong understanding of patient care for a specific population. Using clinical knowledge, research, and experience, they adapt to changing situations and personalize care based on the AACN Synergy Model for Patient Care. They serve as a resource for colleagues and advocate for patients and families. Join our team today! The Emory Healthcare Network, established in 2011, is the largest clinically integrated network in Georgia, with more than 3,450 physicians concentrating in 70 different subspecialties. We are made up of 11 hospitals-4 Magnet® designated, the Emory Clinic, and more than 425 provider locations. Emory Anesthesia Pre Op Clinic – EUH Number of Rooms: 9 Nursing scope of practice: Thorough assessments on all patients needing general anesthesia done either in the clinic or remotely using telehealth, providing pre-procedural education. Nurses also assist with drawing blood, COVID testing, and executing EKGs, as needed. Daily patient population: Approximately 40 Staffing Hours: 7a-5:30p, Monday through Friday; closed weekends and Holidays. Other Info: There is a 6-week orientation

Graduate of an accredited prelicensure Bachelor of Science in Nursing (BSN), AND A. 12 months of recent nursing experience within the past five years OR B. Recent completion of a re-entry nursing program OR Graduate of an accredited prelicensure Associate Degree in Nursing (ADN) with a minimum of 2 years of recent nursing experience within the past five years. *Exceptions: Current LPNs employed within the Emory Healthcare (EHC) system who have completed an accredited RN program and obtain RN licensure are eligible to transition into this role while completing the RN Resident Program. Emory LPNs enrolled in an Emory ADN program as of 3/30/2025 must sign an obligation agreement to complete an ADN-to-BSN program within two years of entering the RN Clinician role. A valid, unencumbered Registered Nursing License approved by the Georgia Board of Nursing. BLS certification ACLS may be required for certain departments, post hire Additional certifications may be required based on department and specialty

Delivers safe, effective, and independent nursing care using the nursing process. Performs thorough patient assessments and recognizes the impact of nursing care on outcomes. Develops and implements patient care plans, incorporating patient/family input and adjusting as needed. Documents care accurately and efficiently in electronic and physical records. Identifies patient and family learning needs, recommending appropriate resources. Recognizes cultural differences and individualizes care accordingly. Delegates appropriately using the Synergy Model of Care. Works effectively with the interdisciplinary team, patient, and family care partners. Functions in a developing leadership role, including Charge Nurse responsibilities when assigned. Assists in orienting staff and students in the absence of a designated preceptor. Demonstrates strong communication and conflict resolution skills. Identifies the need for policy revisions based on evidence-based research. Engages in professional growth and actively applies the Synergy Model for Care in practice. Collects, reports, and analyzes data to improve patient care and meet organizational standards. Participates in surveys, interviews, and other methods to identify and resolve areas for improvement. Maintains required points and contact hours per the clinical lattice PLAN system.

Indiana Health Centers, Inc.

Clinical Care Manager

Posted on:

December 16, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Indiana

Indiana Health Centers, Inc. (IHC) is a mission-driven organization providing high-quality, affordable healthcare to underserved and uninsured populations since 1977. At IHC, a Federally Qualified Health Center, we specialize in integrated care which means having access to essential services to meet the needs of patients we serve in the community. With ten healthcare centers, eight Women, Infants, and Children (WIC) nutrition program locations, a Mobile Health Unit, and in-house Pharmacy services, we offer primary medical, dental, and behavioral healthcare services to community-based patient populations throughout Indiana that are diverse in age, educational background, and income level.

IHC seeks an experienced LPN or RN for the Clinical Care Manager position. The ideal candidate will have excellent communication and interpersonal skills, experience working with patients with complex chronic disease states and multiple comorbidities, and ability and patience to navigate complex systems of care. They should also be organized, detail-oriented, and able to work independently. If you meet these qualifications, we encourage you to apply for this exciting opportunity! Clinical Care Manager Job Overview: The Clinical Care Manager facilitates communication between patients, their families, caregivers, providers, and other members of the healthcare team. Their focus is to offer individualized assistance to patients with complex disease states and multiple comorbidities, as well as their families and caregivers, to overcome healthcare system and community barriers and facilitate consistent and timely medical care across the continuum of care. The Clinical Care Manager is an integral part of the Patient-Centered Medical Home and Patient Care Team.

Valid LPN or RN license in the state of Indiana preferred. 2 years general experience providing patient care in community or hospital setting. 1 year case management experience or experience providing health education and outreach activities. Care coordinator certification preferred.

Perform social determinant of health (SDoH) assessments. Link patient with resources based on SDoH assessment. Provide general clinical care coordination orientation to patients and communicate the goals and objectives of the program. Provide assistance for patients referred to/from providers, case managers, and from other points of entry. Evaluate patients deemed high risk by risk algorithm for care management and enroll patients who elect to participate. Guide patients through transitions of care from inpatient settings to home. Contact patients to facilitate continuity of care and escalate issues to appropriate team members. Assist patients with adherence to existing self-management goals or development of new goals (in collaboration with practice clinical staff). Assist in identifying individual and/or community needs which encourage healthy lifestyles and environments (i.e., community resources, transportation assistance, exercise programs, etc.). Interact with the multidisciplinary team on behalf of the patient to resolve barriers. Communicate outcomes to patient/family/caregivers. Maintain timely and appropriate documentation on patient interactions in the care management system. Provide disease-specific and preventive care patient education per patient need. Execute effective interventions to reduce inappropriate ER visits or length of hospital to improve care and reduce costs. Quality functions: Assist in the collection and assembly of quality improvement information for the purpose of tracking and trending. Participate in cross-functional team meetings aimed at improving patient outcomes or operational processes. Regularly participate in care team huddles with care managers to identify priorities, tasks, and interventions. Perform population management activities as assigned. Administrative functions: Compile and distribute educational material based on patient need. Perform follow-up activities with patients as needed after emergency department visits or inpatient discharges. Assist with scheduling medical and specialty appointments. Provide reminder phone calls for appointments and/or follow-up calls post appointment. Retrieve discharge summaries and copies of medical records. Other: Develop and maintain excellent working knowledge of common chronic conditions and seek information as part of continuous learning.

CSTS Customer Service and Technology Solutions LLC

Case and Disease Manager LPN

Posted on:

December 16, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

LPN/LVN

State License:

Florida

CSTS is a third-party administrator that conducts the administrative and operational work for an insurance plan. The administrative work often includes processing claims, enrolling customers, collecting premiums, and complying with federal regulations. At CSTS we aim high. Our mission is to transform the healthcare experience — the way healthcare is accessed and delivered — by bringing outstanding products and services to our partners.

We’re looking for a compassionate LPN to support our Care Management and Disease Management programs. You’ll help members stay healthy and independent through advocacy, education, and coordination of services—working closely with RN case managers, physicians, and health plan partners. You’ll engage with a diverse population—from adults to seniors—and support members across various lines of business (Medicare, Medicaid, Duals, MA, etc.). This is a collaborative role where you’ll make a real impact on outcomes, costs, and quality of care.

Active Florida LPN license, in good standing. 1–3 years of experience in ambulatory care, care coordination, case management support, hospital, SNF, or health plan preferred. Familiarity with Medicare, Medicaid, Dual Eligible, and Medicare Advantage programs is a plus. Bilingual preferred (English + Spanish). Tech skills: 40 WPM typing; proficient in Outlook, Excel, Word; experience with case management software (CERME/InterQual® preferred). Strong communicator with excellent phone etiquette, empathy, and member education skills. Comfortable working in a metrics-driven environment and following clinical protocols under RN supervision. Work & Travel: Attends ICT, IPA/MSO, POD, client meetings, educational events/seminars, and PCP office visits across Florida.

Engage members by phone and in person to complete health risk screenings (e.g., HRA, fall risk) and gather info needed for care plans—following RN/clinical protocols. Support individualized care plans: identify barriers, set goals, track progress, and document outcomes—escalating complex needs to RN/Medical Director. Provide disease education and coaching (med adherence, chronic condition stability, patient safety) and share written materials per health plan service level agreements. Coordinate care: schedule appointments, facilitate preventive services, arrange referrals, and help prevent avoidable ER visits/readmissions. Document all contacts (successful/unsuccessful, mode of contact) accurately and timely in case management systems. Track program metrics (members identified/enrolled, goals met, duration, impact) and contribute to quality projects. Collaborate daily with PCP offices, specialists, care teams, and health plans; participate in Interdisciplinary Care Team (ICT) meetings. Assist with medication reviews (adherence, cost-effective alternatives, generics) and arrange Patient Assistance Programs (PAPs) when needed. Support delegated CM/DM requirements and payer initiatives (e.g., CMS Stars, HEDIS, patient safety). Use case management tools (InterQual® Care Enhance Review Manager Enterprise—CERME preferred) and maintain HIPAA compliance. Refer complex cases to RN case managers and corporate Medical Directors.

Molina Healthcare

Eligibility Screener (IRIS) (Dane County, WI)

Posted on:

December 16, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Wisconsin

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

TMG is on the lookout for our next great Eligibility Screener! If you love doing meaningful work that helps others live their best lives, we want to hear from you! We’re currently in search for someone with a background in human services, social work, healthcare or case management to join our team. This is a remote position, where you will partner with people in your community who use the TMG IRIS Consultant Agency. While this role is home-based, you will spend most days visiting IRIS participants in their homes. While you’ll have a routine for the work that you do, no two days are alike! As an Eligibility Screener, you would be responsible for completing the Adult Long-Term Care Functional Screens (LTC-FS) for participants of the Wisconsin IRIS program – a Medicaid long-term care option for older adults and people with disabilities. The job includes completing annual rescreens and any change-in-condition screens using the Adult LTC-FS tool to ensure program eligibility. Successful candidates will be approachable, compassionate and respectful of people of all different backgrounds and abilities, and be able to see and articulate the strengths that people inherently have. TMG is committed to maintaining a diverse and inclusive workforce, and prioritizes helping staff have a good work/life balance. Even though the position is remote, you’ll have lots of support from your TMG team and coworkers across the organization. If this sounds like the job for you, apply today!

At least 2 years experience in health care, preferably in care coordination, and least 1 year of experience serving target groups of the IRIS program (adults with physical/intellectual disabilities or older adults), or equivalent combination of relevant education and experience. Must be currently certified to conduct/administer the adult long-term care functional screens or pass the Wisconsin adult long-term care functional screen certification modules (80% or higher on each module) within first week of hire and maintain certification as a screener. Bachelor of arts or science degree or more advanced degree in a health or human services related field (e.g. social work, psychology) or graduate from an accredited school of nursing. If a graduate from an accredited school of nursing, must have an active and unrestricted Wisconsin Registered Nurse (RN) license in good standing. Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements. Attention to detail and ability to ensure accuracy of data. Strong organizational and time-management skills. Strong customer service skills and the ability to work cooperatively as part of a team and independently. Ability to remain flexible in the work environment and willing and able to adapt to changing organizational needs. Excellent verbal and written communication skills. Demonstrated computer and software skills required including Microsoft Office suite/applicable software program(s) proficiency. Travel Requirements 5%. Preferred Qualifications Current or former certification to conduct/administer adult Long-Term Care Functional Screening (LTCFS) in the state of Wisconsin.

Meets with IRIS participants face to face to complete the screening process. Completes the Adult Long Term Care Functional Screen (LTC-FS) for people in IRIS according to the Wisconsin Adult LTC-FS Instructions. Completes contacts to verify screen results with IRIS Consultants, Medicaid Personal Care agencies, and verifies diagnosis information with physicians and the Social Security Administration, when needed.  Meets the highest standards of documentation and program regulations, while ensuring timely completion of screens. Maintains screening skills by participating in weekly team meetings, monthly All Screener Meetings, trainings and testing. Other duties as assigned by management.

Anchor Staffing, Inc.

Remote Nurse Case Management Senior Analyst- Tennessee

Posted on:

December 15, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Tennessee

THIS ROLE IS A REMOTE ROLE HOWEVER MUST RESIDE IN ONE OF THE FOLLOWING STATES FOR CONSIDERATION: ILLINOIS, TEXAS, NEW MEXICO, OKLAHOMA, MONTANA, AND TENNESSEE Monday through Friday 8:00 am - 5:00 pm CST Pay Range between $40.00-$45.00 per hour

An active and unrestricted RN license in the state of Illinois, Texas, New Mexico, Oklahoma, Montana, and Tennessee 2 years of case management experience 3 years of clinical experience Proficiency in Microsoft Office (Word, Outlook, Excel and Teams)

Nurse Case Management -Senior Analyst plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan. The Senior Analyst will utilize clinical skills to assess, plan, implement, coordinate, monitor and evaluate options and services in order to facilitate appropriate healthcare outcomes for members.

MedStar Health

RN Utilization Review (PRN)

Posted on:

December 15, 2025

Job Type:

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

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.

Conducts admission concurrent and retrospective case reviews to ensure appropriate admit status and level of care by utilizing the nationally approved guidelines. Collaborates with medical staff and ancillary hospital disciplines to ensure high-quality patient care in the most efficient way.

Education: Associate's degree in Nursing required Bachelor's degree in Nursing preferred Experience: 3-4 years Experience in acute care setting required 2 years experience in case management insurance utilization review required Licenses and Certifications: RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia or the State of Maryland depending on work location required CCM - Certified Case Manager preferred Knowledge Skills and Abilities: Excellent problem-solving skills and ability to exercise independent judgment. Business acumen and leadership skills. Strong verbal and written communication skills with ability to effectively interact with all levels of management internal departments and external agencies. Working knowledge of various computer software applications.

Conducts admission concurrent and retrospective case reviews to meet hospital objectives of high-quality patient care in the most efficient way Strives to meet the department goals adheres to organizational policies procedures and quality standards. Complies with rules and regulations set forth by the governmental and accrediting agencies. Collaborates with medical staff physician advisor social workers and other ancillary hospital disciplines to meet patients' health care needs in the most cost-effective way. Performs patients' medical record reviews document pertinent information and communicate with third party payors in a timely fashion to ensure proper hospital reimbursement and eliminate unnecessary denials. Implements strategies to avoid potential denials by communicating with all the key stakeholders including attending physician. If necessary non-coverage ABN MOON letters and other appropriate documents as per organizational governmental and accrediting organizations policies and regulations. Actively participates in IDRs Length of Stay and other meetings as per hospital policies. Identifies potential risks pertaining to patients' care and communicates with appropriate hospital discipline including risk management quality safety and infection control. Serves as a resource to the health care team by educating the health care team through in-services staff meetings and formal educational settings in areas of utilization management. Demonstrate current knowledge of State and Federal regulatory requirements as it pertains to the utilization review process. Identifies dynamics of neglect/abuse and reports to the appropriate in-house departments and governmental agencies.

Drägerwerk AG & Co. KGaA

Clinical Applications Spec

Posted on:

December 15, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

As an international leader in medical and safety technology, Since 1889, Dräger has been developing advanced technical devices and solutions trusted by users all over the world. No matter where Dräger products are used: it’s always about life. Whether for use in clinical, industrial or mining applications, in firefighting or rescue services, Dräger products protect, support and save lives.

Location: Los Angeles Function: Sales Work Location: Remote Employment Type: Permanent We're hiring! If you want your contributions to make a real difference, check out this new career opportunity with us at Draeger where we are led by the guiding principle "Technology for Life". The Clinical Applications Specialist is a remote position which covers the Southern California Territory. This position is is responsible for providing clinical user training and clinical support to customers for pre-sale clinical evaluations and post-sale clinical implementations. This position is an integral part of our sales process and customer satisfaction focus. Clinical Applications Specialists are expected to develop strong customer relationships in their assigned regional coverage areas and work cooperatively with their assigned sales and sales management personnel in the development and execution of sales and account strategies.

Education: AS/BS/BSN degree in Respiratory Care or the equivalent combination of experience and training Related Experience: 5+ years of acute care experience (i.e. Critical Care ventilation) Licensed as an RRT Previous experience as clinical educator and/or related experience in mentoring, content delivery or presentation skills strongly preferred Valid Drivers License Special Competencies or Certifications: Ability to read and interpret documents such as safety rules, operation and clinical instructions and procedure manuals Ability to write routine reports and correspondence Ability to speak effectively before groups of customers or organizational employees Proficiency in Microsoft Office Suite Knowledge of adult learning methods and/or educational program development strongly preferred Familiarity with the hospital/clinical environment, equipment treatment methods, personnel roles and organizational issues Able to travel up to 80% of work related time including overnights and occasional weekends

Provide product and clinical education to customers for assigned modality (Ventilators) Develop and provide customer appropriate clinical in-servicing for purchased devices to meet clinical needs Conducts advanced clinical education including accredited classes for CEU/CRCE credits and Train-the-Trainer courses Coordinates with customer, project manager, service and sales concerning product training and clinical implementation Provide clinical support, educational resources, troubleshoots, observes and communicates with customers and colleagues to ensure proper use of equipment and applications Provide documentation of the clinical support process Provide product and clinical education to potential clinical users during demonstrations and clinical evaluations Consult with Sales Team to understand the goals of demonstration/clinical evaluation Provide clinical/product support and training during the defined timeframe of demonstration/clinical evaluation. Addresses clinical features, benefits and inquiries for all levels of hospital personnel Provide documentation of the clinical evaluation Provide timely, effective follow-up and response to customer generated clinical questions Promote Draeger Medical Education / Training to customers and sales team members Present, promotes and assists in the sale of Draeger Medical Complementary Products during pre-sale / post-sale customer visits Participate in state / national trade / symposiums as required and as schedule permits

Club Xcite

Remote Credentialed School Nurse Consultant (1099 Contract)

Posted on:

December 15, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

None Required

State License:

California

Club Xcite was founded in 2004 to help children, teens, & young adults of all skill levels to thrive by offering the personalized attention, positive reinforcement, academic skillset, & emotional intelligence that have been scientifically proven to lead to academic success & overall well-being. Getting homework done, mastering concepts from school, participating in physical activity, & sharing the company of friends are all important to a student’s self-mage & happiness. Some students struggle in one or more of these areas, leading to increased stress in their daily lives, poor self-image, & diminishing opportunities as they get older. Club Xcite coaches and tutors understand these struggles & how to overcome them. Our services provide the structured & balanced approach to foster a growth-mindset & make after-school hours both productive & fun.

We are seeking an experienced Credentialed School Nurse Consultant to provide remote clinical guidance to school nurses contracted through our agency. This is a 1099 consulting role with flexible, remote availability during standard school hours. **Consultation needs are light until contracted nurses fully onboard.** Compensation: $60–$75/hour (DOE, 1099 contractor) $250 bonus paid upon completion of required upfront trainings

Current CTC School Nurse Services Credential (required) Clean Livescan background check Strong school-health experience and confidence in providing clinical advisement. Reliable communication and timely responsiveness during school hours

Support school-site nurses by phone or virtual communication. Serve as a reliable, professional resource to ensure high-quality care for students. Collaborate with agency leadership to support nurse success and compliance.

TotalMed Medfi

Utilization Review Registered Nurse

Posted on:

December 15, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Minnesota

In the rapidly-changing, highly regulated industry that is healthcare, you need a medical staffing partner who works for you. Enter TotalMed. We’re an award-winning medical staffing agency delivering flexible healthcare staffing solutions no matter how complex your needs. But even more than that, we’re a team who really cares. Our end goal is to achieve quality patient care while enhancing your employee morale. If you’re a healthcare professional in either clinical or non-clinical healthcare, our recruiters can help you navigate the sea of healthcare jobs, uncovering your ideal career path. Or, if you’re faced with open positions and short-staffed projects in either business care or patient care, TotalMed can provide customized medical staffing solutions to fulfill your hiring requirements.

Pay: $40.00-$42.00 per hour Hours: Monday-Friday 8 am-5 pm Location: Remote *Must live in Minnesota OR Wisconsin*

3-5+ years of clinical experience 3 years of Utilization Management experience Active unrestricted RN license

Utilization Management Nurse-Post Acute, are responsible for reviewing and documenting prior authorization and concurrent stay requests along with member case history in compliance with policies and procedures, clinical criteria (MCG) and member coverage. Utilization review activities require interfacing with members, providers, facilities, medical directors, intake staff, case managers and other departments internally. This role requires attention to detail and the use of clinical judgment to determine the medical necessity of post-acute stays, including skilled nursing facility, acute inpatient rehabilitation, and long-term acute care hospitals

Centurion Health

CQI Specialist

Posted on:

December 15, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Illinois

Centurion Health is a national leader in the correctional healthcare industry, with more than 9,000+ employees caring for patients in 325+ facilities across the United States. We partner with state and local government agencies in 15 states to provide medical, behavioral health, and dental care to individuals in correctional facilities, hospitals, courts, clinics, and more. As we continue to grow, we’re always looking for new team members whose values align with our belief that correctional healthcare is core to public health and plays a vital role in our communities. Centurion Health seeks talented healthcare professionals who are fulfilled by a career driven by purpose and community impact. Our employees are among the most dedicated in the business — working with diverse patient populations in a variety of roles and responsibilities, from clinical to administrative. If you’re looking to make a direct impact on the health and welfare of your community from day one, we’d love to talk to you. Browse our jobs below to see if there’s an opening that’s right for you, and visit centurionjobs.com to learn more about how we can help you take the next big step in your career.

Centurion is proud to be the provider of comprehensive services to the Illinois Department of Corrections. We are currently seeking a Full-time CQI Specialist to join our Regional Office team in Springfield, Illinois. This is a remote position. Candidates must reside in Illinois and live a commutable distance to our regional office for meetings and site visits as needed. Based out of the regional office, the Statewide CQI Specialist develops and implements the Continuous Quality Improvement (CQI) program in accordance with the mission and strategic goals of the company, federal and state laws and regulations, accreditation standards and specific contractual requirements.

Licensure as a RN or Bachelor’s Degree (Master’s Degree preferred) in a clinical or allied health field from an accredited institution required Certification as a Professional in Healthcare Quality (CPHQ) preferred Minimum of two years of experience in health information, quality, utilization or risk management Minimum of two years of experience in Quality Assurance/ Continuous Quality Improvement preferred Knowledge of statistics, data collection, analysis and data presentation Skilled in use of computer software for maintaining statistics and developing reports Excellent problem solving and writing skills Experience in a correctional setting preferred Must be appropriately and actively certified in Cardio-Pulmonary Resuscitation (CPR) Ability to obtain a security clearance, to include drug screen and criminal background check

TTF Search and Staffing

Remote Inpatient DRG Auditing Nurse

Posted on:

December 15, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Florida

TTF is a healthcare search and staffing company that partners with hospitals, physician groups, TPA's, medical management companies, pharmaceutical and pharmacy benefit plan organizations, surgery centers, DME/home health, consulting companies, and all other healthcare fields.

TTF is recruiting for DRG Auditors who have worked in Inpatient Revenue Integrity to work remotely for a company based out of the Southwest. We are seeking individuals with experience in CDI with either CCDS, CCS, or RHIT certifications. This is a full-time, direct-hire role, where you can work anywhere in the United States. The starting salary is $46-$52/hour and comes with full benefits. The TTF Coding and HIM Division partners with healthcare organizations nationwide to match top talent in the Coding and HIM industry with organizations that want to hire the best talent. We place Remote Coders, Coding Managers, Coding Directors, and ICD10 Certified Trainers on a contract and direct-hire basis. Our goal is to offer outstanding opportunities to talented coders and coding professionals with RHIT, RHIA, CCS, CPC, and other coding certifications.

Qualified candidates must have: CCDS, CCS, RHIT certifications Five years acute care coding experience Prior experience as CDI/Coding Auditor is preferred but not required

University Hospitals

Clinical Documentation Integrity Analyst (Remote) ($5K Sign on)

Posted on:

December 15, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Caring for patients and their families. Advancing medical knowledge, technologies and practices. Developing and educating the next generation of exceptional health care professionals. You can help us with all this and more, when you add your talents to those who have already made the commitment to Be the Difference at University Hospitals. From our flagship facility, University Hospitals Cleveland Medical Center, to our network of 21 community hospitals, outpatient health & surgery centers, outpatient surgery centers, and specialty care centers, we provide leading-edge medicine and thoughtful, patient-centered care to the people of Northeast Ohio and beyond. We also provide rewarding career opportunities for today best and brightest health care professionals.

Applies clinical expertise and knowledge of health care workflows in order to educate and train CDI Specialists in the essential duties of their role to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes Educates CDI Specialists on the rules/regulations associated with coding and clinical documentation integrity. Trains newly hired CDI Specialists and provides ongoing coaching and education specific to daily CDI Specialist job functions. Ensures the work output of the Clinical Documentation Integrity staff is accurate and compliant. Collaborates with CDI leadership and Coding team to identify training opportunities and assist with education of CDI and Coding staff with regard to clinical documentation integrity and/or clinical and coding scenarios as needed.

Education: Other Accredited Program: Diploma in Nursing or in Health Information Management (Required) or Associate’s Degree preferably in Health Information Management or Nursing (Required) or Bachelor’s Degree preferably in Health Information Management or Nursing (Required) or Doctorate Degree in Medicine (Required) Work Experience: 3+ years CDI experience as a concurrent reviewer (Required) Knowledge, Skills, & Abilities: Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting (Required proficiency) Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues (Required proficiency) Demonstrates comprehension of Case Mix Index (CMI) and can interpret, analyze, evaluate data, provide rationale for trends/impacting factors and develop strategy for correcting/optimizing CMI (Required proficiency) Knowledge of age-specific patient needs and the elements of disease processes and related procedures (Required proficiency) Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers (Required proficiency) Assertive personality traits to facilitate ongoing physician communication (Required proficiency) Working knowledge of inpatient admission criteria. (Required proficiency) Ability to work independently in a time-oriented environment as well as working as part of a team, primarily in a virtual setting. (Required proficiency) Applies knowledge and expertise to daily job responsibilities. Maintains professional knowledge by reading and/or attending webinars that pertain to Clinical Documentation Improvement. (Required proficiency) Earns and maintains Certification for Clinical Documentation Improvement. (Required proficiency) Incorporates current literature, research and best practice ( ACDIS and AHIMA ) into daily practice. (Required proficiency) Up to-date clinical and coding experience, and current working knowledge of pathology, pharmacology, surgical procedures, etc. (Required proficiency) Detail-oriented and organized, have excellent time-management skills, and have good analytical and problem-solving ability. (Required proficiency) Notable client service, communication, presentation and relationship building skills. (Required proficiency) Licenses and Certifications: Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) or Registered Health Information Administration (RHIA) (Required Upon Hire) or Registered Health Information Technologist (RHIT) (Required Upon Hire) and Certified Clinical Documentation Specialist (CCDS) (Required Upon Hire) or Clinical Documentation Improvement Practitioner (CDIP) (Required Upon Hire) International medical doctor education and experience can meet qualifications in lieu of RN, RHIA or RHIT

Performs post-discharge, final coded, pre-bill reviews of targeted records identified for second-level review for opportunity to accurately capture patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations Documents SLR findings within CDI application. If a documentation opportunity is identified, place physician query and follow up for response to ensure completeness and accuracy of the medical record. If coding opportunity is identified, coordinate with coder and/or Coding Leadership to review and address opportunity as applicable Subject matter expert that exhibits excellent skills in essential components of the CDI Specialist role Responds to CDS requests for concurrent chart reviews on challenging cases with recommendations and supporting rationale Performs concurrent second level reviews based on defined criteria and shares feedback with CDI Specialist assigned to the encounter for action on opportunities identified. Maintains a summary of opportunities identified through second level review for feedback and education with the CDI team Coordinates with other Second Level Reviewers, CDI Leads, and CDI Educator to compile trends and areas of opportunity and conduct education both 1:1 and group education with the CDI team based on the findings Periodically review the criteria established for cases triggering a second level review and recommend updates or modifications to the criteria to assist in identifying areas of opportunity Is actively engaged in quality and process improvement efforts Performs targeted audits as assigned in support of department initiatives Participates in quality initiatives such as HAC/PSI and US News/Mortality Collaborates with CDI Leadership, Leads and Educators to optimize query templates Identifies and shares feedback regarding workflow improvement opportunities identified when completing the SLR process Facilitates change and supports the CDI team through change management processes Actively engages in advancing the CDI practice throughout the UH enterprise Actively engages in department and/or enterprise-wide committee Additional Responsibilities: Performs other duties as assigned. Complies with all policies and standards. For specific duties and responsibilities, refer to documentation provided by the department during orientation. Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

Premier Women's Care of Southwest Florida

OB Telephone Triage Nurse

Posted on:

December 15, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Florida

We are seeking a dedicated OB Telephone Triage Nurse to provide expert nursing support via phone for obstetric and gynecological patients. This role involves assessing patient needs, providing guidance, and coordinating care in a fast-paced healthcare environment. The ideal candidate will have extensive experience with EMR/EHR systems such as Athenahealth, and possess strong clinical judgment in obstetrics, gynecology, and acute care settings. Experience with triage protocols, medical documentation, and patient assessment is essential to ensure high-quality patient care and safety.

Valid RN or LPN license with current state licensure required. Extensive experience in obstetrics/gynecology nursing; familiarity with labor & delivery units or postpartum care preferred. Proficiency in EMR/EHR systems such Athenahealth. Knowledge of medical terminology including ICD-10/ICD-9 coding and CPT coding for documentation purposes. Experience with triage protocols in acute care settings or urgent care environment Excellent communication skills with the ability to work effectively with diverse populations including, geriatrics, patients with disabilities or developmental delays. Certification in Basic Life Support (BLS) required. This position offers an opportunity to work within a dynamic healthcare team dedicated to providing exceptional patient care. The ideal candidate will demonstrate compassion, clinical expertise in obstetrics and gynecology nursing practices, and proficiency in managing cases across various healthcare settings.

Conduct comprehensive patient assessments via telephone, including vital signs, symptom evaluation, and medical history review. Utilize clinical judgment to determine urgency and appropriate level of care for OB/GYN patients. Provide evidence-based guidance on symptoms related to pregnancy, postpartum issues, or gynecological concerns. Coordinate referrals and follow-up appointments with obstetricians, gynecologists, or other specialists as needed. Document all interactions accurately within EMR/EHR systems such as Athena, adhering to HIPAA regulations. Educate patients on medication administration, self-care techniques, and health coaching strategies. Collaborate with multidisciplinary teams including physicians, to optimize patient outcomes. Stay current with medical terminology related to obstetrics and gynecology.

Sixteenth Street Community Health Centers

RN - WIN Remote Monitoring

Posted on:

December 15, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

RN

State License:

Wisconsin

Join our team committed to the highest quality healthcare!

Fluent Spanish-speaker. Active RN licensure in Wisconsin Current BLS. 2 years of clinical experience. Exhibits excellent interpersonal communication skills with compassion, empathy and sensitivity to participant needs. Desire and willingness to collaborate as a member of a high-functioning transdisciplinary team. Can work remotely as approved by SSCHC HIPAA team with in-person requirements as needed.

Monitor patient vital signs and health data using remote devices. Analyze data trends to identify potential health risks. Provide patient coaching, education and support about health data. Collaborate with Providers to tailor care plans. Document patient interactions accurately in electronic health records. Facilitate the ongoing adherence of team-based, asynchronous, digital care model (TAG) protocols and therapies to assure that all individuals with intermediate to high ASCVD risk receive comprehensive and timely treatment and interventions that are consistent with best practice recommendations. Coordinate with SSCHC departments and community resources to ensure wrap-around support to enrollees. Inform program leads of challenges and opportunities to develop a successful TAG model. Work with SSCHC analyst to provide program performance metrics. Work with the multi-disciplinary team to build a strong team atmosphere, to foster continuous improvement in current and future TAG processes. Work directly with patients as needed for remote monitoring purposes and outreach with instructions when appropriate. May act as an RN team leader, rendering and supervising patient care in an ambulatory care setting, as directed. Work directly with DON to grow an existing remote monitoring program into a sustainably higher level of performance and volume.

Healthcare Management Solutions LLC

MEDICAL FACILITY SURVEYOR

Posted on:

December 15, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

West Virginia

OUR VISION: We devote our knowledge, skill, and experience to transform and improve the quality of care for those we serve. OUR MISSION: We protect vulnerable populations and veterans by providing clinical and technology solutions to our customers and partners. CORE VALUES: Act with integrity and honesty. Listen without interrupting. Lead by example. Make reasonable decisions. Accept responsibility for outcomes. Treat others with respect. Recognize the contributions of others. Exceed customer expectations. Face change with an open mind. Deal with challenge in a positive manner.

For 20 years, we have been privileged to partner with the Centers for Medicare and Medicaid Services (CMS), supporting their vital mission to improve healthcare across the U.S. healthcare system. Since 2014, we have collaborated with more than half of the U.S. states through direct contracts with state health agencies, advancing healthcare quality and safety initiatives. We are also proud to have supported a leading non-profit cardiothoracic surgery organization. Our success is strengthened by our valued collaborations with exceptional prime and subcontractors, whose expertise enhances and complements our own. The Medical Facility Surveyor will conduct surveys of long-term care (LTC) and/or non-LTC (NLTC or ACC) programs throughout the United States and the Territories. Non-LTC (NLTC or ACC) programs include Ambulatory Surgical Centers, Critical Access Hospital, Acute Care Hospital, End Stage Renal Disease, Home Health, Hospice, EMTALA, Organ Procurement Organization and organ transplant. Candidates interested in Long Term Care Surveying must possess the Surveyor Minimum Qualifications Test (SMQT) qualification. The Surveyor will conduct surveys in accordance with the State Operations Manual (SOM) and will prepare a deficiency report in accordance with the Principles of Documentation (PoD) and the HMS Master Writing Guide. The Medical Facility Surveyor will communicate their survey findings through the approved Quality Assurance process. The Surveyor will identify opportunities for improvement in the survey process and will effectively communicate said opportunities to the appropriate leadership staff. The Surveyor should be willing to accept survey assignments as needed and as directed by CMS and HMS. Travel will be extensive. All travel arrangements are made by the company travel department so there are minimal out of pocket expenses. Full-time, part time and Casual (as needed, as available with flexible schedule) employment opportunities are available. Opportunities for advancement and/or cross training. Eligible employees may participate in a comprehensive employee benefits package including PTO accrual, 401(k) retirement plan, and Employee Stock Ownership Program

Experience completing CMS surveys is required Required CMS training for provider type/s which you have interest in surveying Ability to critically think and be competent in decision making skills Ability to perform all facility required tasks Bachelor’s degree and 3 years relevant experience or an equivalent combination of education and experience. Preference given to registered nurse, LPN's, licensed social workers, dietitians Surveyor Minimum Qualifications Test (SMQT) qualification for LTC surveyors Licensed RN is preferred Must be able to pass a federal background check

Medical Facility Surveyors will conduct on-site surveys consisting of Initial, Recertification, Revisit (and/or Desk Audit), Complaint, Focus, and Pilot surveys in accordance with the State Operations Manual Complete deficiency reports in accordance with the Principles of Documentation and the HMS Master Writing Guide while maintaining deadlines and timeframes established by the client. Surveyor deficiencies should clearly link identified deficient practice with associated regulation. Documentation is to be completed with accuracy and special attention to detail using laptop or tablet computer technology Report survey findings involving Immediate Jeopardy (IJ) Condition level findings or Substandard Quality of Care (SQC) to appropriate Quality Assurance staff while maintaining deadlines and timeframes Coordinate with Quality Assurance staff to ensure survey findings are adequately documented and defensible prior to submission to CMS or SSA Submit documentation according to established time deadlines Perform Medical Facility Surveyor duties in accordance with the HMS Core Values and the applicable contract Maintain current knowledge of CMS and HMS policies and procedures, Medicare regulations for applicable healthcare facilities and CMS QSO memos that include program, policy, and process changes/revisions Remote

ColigoMed

Care Coordinator – Gastroenterology (RN) - CGRN preferred

Posted on:

December 15, 2025

Job Type:

Contract

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

ColigoMed is a US-based digital health company. At ColigoMed, our AI-enabled continuum platform connects patients, medical providers, and payers and provides the scale for at-home and virtual care programs to improve healthcare quality and patient outcomes. Our application is driven by our proprietary AI engine, ColigoAssist, which serves as a digital care assistant for both patients and providers, enabling better management of chronic medical conditions. Our provider portal delivers real-time clinical visibility across hospitals, clinics, and connected monitoring devices. ColigoMed is focused on helping patients live healthier, more independent lives. To achieve this, we recruit high-caliber professionals who combine deep clinical excellence with compassion and accountability. Our global team culture is built on trust, innovation, performance, and mission-driven care delivery.

We are seeking an experienced Registered Nurse (RN) with strong Gastroenterology expertise to support the expansion of our Gastroenterology-focused Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs. This role is designed for nurses with hands-on experience managing Inflammatory Bowel Disease (IBD), chronic liver disease, GERD, Barrett’s Esophagus, gastroparesis, and complex GI medication regimens including biologics and immunosuppressants. The Nurse plays a critical role in advanced clinical triage, specialty care coordination, medication monitoring, patient education, and escalation management, working alongside a remote interdisciplinary care team that includes Providers, Nursing staff and MA’s. Core Conditions Managed Under the GI CCM Program This role directly supports patients living with high-risk chronic GI and liver conditions including but not limited to: Inflammatory Bowel Disease (IBD): Crohn’s Disease, Ulcerative Colitis Chronic Liver Disease: NAFLD, Hepatitis, Cirrhosis, Metabolic Liver Disease Chronic Esophageal Disorders: GERD, Barrett’s Esophagus, Gastroparesis Other GI Disorders: IBS, Pancreatic Exocrine Insufficiency (PEI) Compensation: Engagement Type: Independent Contractor (1099) Standard Hourly Rate Range: $33.00 – $40.00 per hour, based on: Depth of gastroenterology clinical experience Chronic Care Management (CCM) & Remote Patient Monitoring (RPM) expertise Experience managing biologics, infusion therapy & complex GI medication regimens Overall clinical leadership, documentation quality, and ability to manage GI escalations independently Premium Specialist Rate (Exception Basis): Candidates holding a CGRN (Certified Gastroenterology Registered Nurse) credential and/or possessing advanced biologics, infusion and complex GI case-management experience may be considered for a higher ratewith leadership approval. Benefits: This is a 1099 contractor role with no benefits during the initial engagement period.

Education, Licenses & Experience: Active Registered Nurse (RN) license in state of residence with multistate compact license CGRN (Certified Gastroenterology Registered Nurse) strongly preferred 3–5+ years clinical Gastroenterology nursing experience (inpatient, outpatient, infusion, or specialty GI clinics) Experience managing: IBD patients Biologic medication programs GI infusion therapies Experience working in remote care, CCM, RPM, or chronic disease programs preferred Proficiency with: EMRs, Digital health platforms and Remote monitoring tools Key Skills: High-level GI clinical assessment and triage skills Strong patient education and behavioral coaching ability Excellent multidisciplinary care coordination capability Highly organized with strong time-management discipline Clear, compassionate, and confident communicator Ability to work remotely with minimal supervision Strong understanding of HIPAA, Medicare CCM documentation & compliance regulations Experience in biologic therapy management & escalation protocols is a major plus Bilingual (Spanish) is a plus Working Model: Fully remote (work-from-home) position Professional and confidential home workspace required Strong internet and telehealth-capable environment required Working Hours: 40 hours per week with approved hours that align with clinic requirements from Monday to Friday, normally from 8.00am to 5.00pm daily ET with one hour lunch break. Weekend support will be needed at times as part of the job role, particularly during the mid-to end-of-month period. Candidates should be prepared to accommodate these operational needs as part of the job role. Flexibility required as patient programs and coverage expand

Support the expansion of the Gastroenterology-focused CCM and RPM programs Conduct advanced clinical assessment and specialist GI triage Provide oversight to ensure compliance with GI CCM/RPM clinical protocols Sign-off on GI care plans and medication adjustments per Provider instruction Provide specialist patient education on: Dietary triggers and nutrition Biologic injections and infusion therapies Symptom management (pain, diarrhea, flare symptoms) Monitor complex GI medication regimens (biologics, immunosuppressants, antivirals) Coordinate care across: Gastroenterologists Primary Care Providers Infusion centers Dietitians Labs & imaging providers Lead escalation prevention through early symptom detection Support remote RPM data monitoring for flare detection and intervention Oversee patient communications and ongoing monthly CCM engagement Participate in hospital-to-home transition of care (TOC) for GI patients Maintain full Medicare CCM documentation compliance Conduct clinical training and mentorship for LPNs and GI care team members Maintain deep knowledge of: Gastroenterology disease management Remote GI care models ColigoMed platform functionality Support surveillance procedure coordination (e.g., Colonoscopy, EGD) for Barrett’s Esophagus, IBD, and chronic liver patients where clinically indicated Manage allocated patient case load to meet required timelines, quality care standards and meet billing metrics of average fifteen (15) CCM units per day Perform additional duties as assigned

CVS Health

Registered Nurse Case Manager

Posted on:

December 15, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes. Requires an RN with unrestricted active license (compact license required) Woking Hours Monday - Friday 8:00 a.m. to 5:00 p.m. CST Job Types: Full-time, Contract Pay: Up to $32.61 per hour People with a criminal record are encouraged to apply

RN with current unrestricted compact state licensure. Case Management Certification CCM preferred Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures Experience: 3 years Clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required. Healthcare and/or managed care industry experience. Case Management experience preferred-- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Typical office working environment with productivity and quality expectations? Application Question(s): Must have a compact license. they must reside in the CST time zone. But will consider EST if candidate is exceptional. Experience: Case management: 1 year (Required) License/Certification: Nurse Licensure Compact (NLC) (Required)

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

tango

Supervisor, Utilization Management (Remote) (RN)

Posted on:

December 14, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Arizona

tango is a leader in the home health management industry and is preparing for significant growth! Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care.

We are currently looking for a Supervisor, Utilization Management to join our growing team!  Position Description: The Supervisor of Utilization Management (UM) oversees team leads and ensures the overall management of referrals to support smooth transitions of care into the home health setting. This role is responsible for team productivity, performance metrics, and effective collaboration with internal departments. The Supervisor also serves as a clinical resource and ensures that all utilization processes align with company policies, payer requirements, and quality standards. Office Location: Remote

Licensed clinician: RN with no restrictions. Ability to obtain additional state licensure as required. Prior home health experience preferred. Minimum of 10 years of clinical experience. Previous supervisory experience required. Strong ability to teach, coach, and apply adult learning techniques. Self-directed, motivated, and able to work independently under the Sr. Supervisors guidance. Strong verbal, written, and interpersonal communication skills. Effective problem-solving skills with ability to resolve complex issues. Skilled in adapting to procedural and organizational changes. Ability to read, analyze, and interpret technical procedures, regulatory documents, and payer contracts. Experience presenting to and collaborating with physicians, managers, payers, and external stakeholders. Knowledge and Experience: Extensive knowledge of the post-acute continuum of care. Expertise in CMS Chapter 7 guidelines and Milliman criteria. Strong proficiency with Microsoft Office (Outlook, Word, Excel, SharePoint), Adobe, and medical management systems. Ability to work in a fast-paced environment and manage competing priorities.

Mentor and coach team members to further develop competencies. Lead by example and model behaviors aligned with company values. Maintain an open-door policy to encourage communication and improve staff engagement. Partner with the Clinical Educator to train new staff, ensuring adherence to payer and company procedures and performance standards. Collaborate with team leads to monitor, coach, and measure team performance, including productivity, quality, and attendance. Serve as a clinical resource to non-clinical team members. Educate direct reports on all aspects of the pre-authorization and concurrent review process. Schedule and lead monthly team meetings to communicate updates, audit results, and process improvements. Ensure timely and accurate processing of delegated and non-delegated home health contracts. Support plan requirements related to turnaround times and compliance. Manage work queues, monitor key metrics, and ensure workload distribution. Collaborate with the Sr. Supervisor to plan staffing levels, monitor labor utilization, and manage overtime. Participate in hiring, performance reviews, improvement plans, and disciplinary actions as directed. Complete cases weekly to maintain “super-user” knowledge of processes and software. Demonstrate knowledge of home health care and specialty programs in all communications with referral sources and healthcare partners. Oversee workflow coordination to ensure efficient and timely operations. Partner with intake, compliance, claims, network, quality, and other departments to ensure services meet regulatory and contractual requirements. Ensure smooth onboarding of new payer contracts. Provide excellent customer service in all communications with internal and external stakeholders. Escalate administrative oversight issues related to clinical staff (RNs, PTs, OTs, SLPs, etc.) to the Sr. Supervisor as appropriate. Perform other duties as assigned.

tango

Lead, Utilization Review Team (RN)

Posted on:

December 14, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Arizona

tango is a leader in the home health management industry and is preparing for significant growth! Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care.

We are currently looking for a Lead, Utilization Review Team  to join our growing team! Position Description: To provide services for dedicated health plan accounts and members; to ensure the efficient, cost effective, and high quality delivery of utilization management/review service by supporting a team of nurses; to oversee the management of home health cases worked by review nurses; to oversee individual and overall results/outcomes of cases within their scope of responsibilities; and to ensure customer satisfaction through the provision of cost effective and high quality utilization review service that meets their needs. Office Location: Remote

Qualifications: Working knowledge of home care and utilization management Ability to exercise initiative and sound clinical judgement Active unrestricted RN license required in states tango conducts business Knowledge and Experience: Five (5) years of clinical practice experience or equivalent combination of healthcare and supervisory experience. Strong knowledge of utilization review practices PC literate, including Microsoft Office products, Outlook, Excel, Word, Adobe, and the ability to work within multiple medical management software systems Leadership/ motivational skills Good organizational skills Excellent interpersonal skills Ability to work in a team environment Ability to meet or exceed Performance Competencies and Productivity Standards

Assists in mentoring, reinforcement of training, and development of utilization management/review staff. Oversees a team ensuring utilization management services are delivered promptly, cost effectively, courteously, and according to legal and contract requirements, operational, and quality assurance standards. Monitors PTO and coordinates with other department leads, supervisor and management team for coverage. Responds to QIO appeals in a timely manner and write a DENC to send to member. Provides support, guidance, leadership, and motivation to promote maximum performance of team members Collaborates with supervisor in establishing performance development plans and conducting performance reviews Collaborates with educator/trainer to establish and ensure achievement of office/unit customer service, utilization patterns, productivity, quality, and financial goals Ensures that staff adheres to quality assurance and productivity standards: assists supervisor in evaluating customer service utilization patterns, productivity, quality, and financial results ensuring that service delivery is within parameters defined by the company Reinforces pertinent changes in policy/process, regulatory mandates, or business functions; acts as a resource. Other clinical and team lead duties as required. Responds to call center agency/provider/member questions/concerns promptly Completes case reviews at a minimum of 50% of UM reviewer established goals Communicates/defers to director on administrative oversight of RNs, PTs, OTs, and other disciplines as needed

tango

Utilization Management (UM) Clinical Support Specialist (Remote)

Posted on:

December 14, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

None Required

State License:

Arizona

The UM Clinical Support Specialist plays a vital role in supporting the leadership of the Utilization Management team by collecting, analyzing, and reporting data. This position is responsible for maintaining utilization and productivity logs, developing, and monitoring reports, and ensuring accurate and timely documentation. The role also provides administrative support to the clinical team by managing inbound and outbound calls that do not require clinical intervention, review referrals for completeness, assisting reviewers with obtaining clinical information when needed, and supporting compliance, training, and appeal processes Office Location: Office located at 7600 North 16th Street, Suite 140 Phoenix, AZ 85020 Remote

Qualifications: Associate degree in healthcare administration, business administration, or a related field required; Bachelor’s degree preferred. Proven experience in a healthcare support role, particularly in data collection and reporting. Prior experience supporting clinical teams and handling administrative tasks related to healthcare services. Knowledge and Experience: Proficiency in relevant software applications (e.g., Excel, Power BI, database management systems). General medical knowledge. Understanding of healthcare utilization management processes and terminology. Awareness of privacy regulations and data security practices in healthcare. Excellent organizational skills with strong attention to detail. Critical thinking and troubleshooting skills. Ability to manage multiple tasks and prioritize effectively in a fast-paced environment. Well-developed interpersonal and communication skills. Professional appearance and manner. Ability to work both independently and collaboratively in a team environment.

Works independently with minimal supervision and demonstrates accountability for work quality. Support the UM Director and Supervisor in data collection and analysis. Creates and manage comprehensive reports on utilization and productivity and performance trends. Reviews the human resource credentialing reports with the Supervisor to ensure clinician licenses remain current in all applicable states. Monitors Relias for completion of mandatory training and ensure staff compliance within required timelines. Records and tracks QIO appeal requests and provides assistance as needed. Assists the clinical team by managing non-clinical calls, inquires and administrative tasks. Assists the clinical team by reviewing referrals for missing clinical documentation and obtaining clinical information from providers or facilities when necessary and providing decision notifications back to the providers. Assist UM reviewers with administrative tasks in relation to the PA/RA/Appeals process. Assist UM department with non-clinical RA decisions. Answers and resolves portal tickets in a timely manner. Maintains accurate logs, tracks data trends and identifies opportunities for process improvements. Exhibits a professional, pleasant and welcoming demeanor both in person and on the phone. Schedules 1:1 meetings for leadership and staff as directed. Other duties as assigned.

tango

Healthcare Manager (Referral Management)

Posted on:

December 14, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

None Required

State License:

Arizona

tango is a leader in the home health management industry and is preparing for significant growth! Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care.

We are currently looking for a Manager, Referral Management to join our growing team! As a key member of the Referral Management team, you will implement KPIs, mentor your supervisors, provide leadership development, and ensure SLAs and compliance metrics are met. Working closely with the Director of Referral Management and your supervisors, the Manager is responsible for onboarding new employees, coordinating with HR, liaising between HR and supervisors for HR issues, schedules and coverage, team building and employee recognition, monitoring of KPI’s, disciplinary actions, hiring and employment termination, and completion of root cause analysis.

Must be at least 18 years of age Home care / healthcare background is required Bachelor’s Degree or equivalent work experience in management or  Must be able to travel to Phoenix office for onsite meetings throughout the year Must be available for holiday and weekend coverage

Office Location: * Remote * Responsibilities and Duties: Responsibilities of the Manager include, but are not limited to the following: Employee Management: Address employee concerns and conflicts. Collaborate with HR as needed. Manage professional development for employees. Maintain department organization charts and employee directory. Conduct performance and salary reviews in conjunction with Director, Referral Management.  Lead and manage assigned teams, providing guidance, mentorship, and support. Collect, analyze, and measure employee quality and productivity data; review data for trends and gaps that may require additional employee support. Perform monthly one-on-ones with each employee to deliver coaching and performance reviews. Ensure appropriate scheduling of team members for day-to-day production coverage. Working with QA and Training teams, support employee productivity and quality improvement; identify and support employee gaps. Review daily productivity to ensure appropriate distribution of referrals, productivity concerns, and re-dissemination of referrals for timely completion. Collaboration and Communication: Collaborate with cross-functional teams to ensure quality-related requirements are understood and met. Communicate quality-related metrics, trends, and issues to senior management. Foster a positive and collaborative work environment to ensure effective teamwork and high morale within the teams. Process Improvement and Risk Management: Utilizes knowledge of healthcare regulations, such as HIPAA, CMS, FDA, or other applicable standards to process referrals within the seven day turnaround time frame. Support identification of trends, participate in root cause analysis, and create corrective/preventive action plans to address identified issues. Promote a culture of continuous improvement by driving quality initiatives and best practices across the organization. Disseminate process changes live and redirect team as needed to achieve company goals.

HealthArc

Manager of clinical operations

Posted on:

December 14, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Florida

We are seeking a compassionate, organized, and experienced Registered Nurse (RN) to join our care team as a Clinical Care Manager. This role combines patient-centered care with remote monitoring and chronic care management (RPM/CCM) and includes supervisory responsibility over a team of CMAs (Certified Medical Assistants / Medication Aides) and LPNs and RNs. The ideal candidate will ensure high-quality patient care, streamline care coordination, and lead a clinical support team to deliver efficient and safe patient services. Location: Remote (FL, GA, NJ, NY, OH, TX)

Active, unrestricted Registered Nurse (RN) license. Knowoledge or remote care space and virtual care Preferred: BSN degree from an accredited institution Minimum of 2–5 years of clinical nursing experience; prior exposure to case management, chronic care, telehealth, home-health.

Lead a team of clinical personnel to provide the highest quality patient care Monitor and review biometric and physiologic data (e.g. blood pressure, glucose, weight, heart rate, oxygen saturation, etc.) transmitted via RPM devices from patients’ homes. Perform clinical assessments (telephonic or virtual) based on RPM data, identify alarming signals or concerning trends, and escalate care or intervene as appropriate and coach others on how to do this. Provide patient education and coaching — explain device usage, help patients understand their health data, reinforce treatment plans, and encourage adherence. Document all data, assessments, interventions, and communications accurately in electronic health records (EHR) or care-management software; ensure compliance with clinical and billing documentation requirements. Team Supervision & Leadership (CMAs & LPNs) Supervise and oversee the daily work of CMAs and LPNs assigned under your direction — assign shifts and duties to ensure adequate coverage and balanced workload. Provide orientation, training, and ongoing education for CMAs/LPNs regarding care protocols, safety standards, documentation procedures, and scope-of-practice guidelines Mentor and coach the team — offer clinical guidance, support decision-making, answer questions, and promote professional development of support staff. Evaluate performance of team members, provide feedback, conduct performance reviews, and implement corrective actions or improvement plans when necessary. Ensure that tasks assigned to CMAs/LPNs are within their legal scope of practice and follow appropriate delegation rules under RN supervision. Monitor quality and consistency of care delivered — perform periodic audits, review documentation, and conduct rounds (in-person or virtual) to ensure safety and adherence to standards. Manage staffing and scheduling — maintain adequate staffing levels per shift, adjust assignments based on patient acuity, leave or peak times, and ensure coverage for all necessary care services. Serve as a liaison between the nursing/support staff and other healthcare professionals (physicians, specialists, therapists, social workers), ensuring proper communication, smooth handoffs, and coordination of care across disciplines. Care Coordination, Quality Assurance & Program Management: Oversee the overall care delivery process for patients under RPM/CCM and the clinical support team — ensuring care quality, patient safety, and regulatory compliance. Participate in developing, implementing, and maintaining protocols, policies, and standard operating procedures (SOPs) for care delivery, remote monitoring, documentation, and care coordination. Track clinical outcomes, readmissions, hospitalizations, patient satisfaction, and other relevant metrics; analyze trends and recommend quality improvement initiatives. Facilitate patient and family education — teach about chronic disease management, self-care, medication adherence, use of RPM devices, lifestyle modifications, and health literacy. All other assigned duties.

Purple Cow Recruiting

Travel Nurse & Allied Health Recruiter - REMOTE

Posted on:

December 14, 2025

Job Type:

Contract

Role Type:

License:

RN

State License:

Colorado

Travel RN Recruiter (Independent Contractor – 1099) We’re seeking an experienced Travel Nurse Recruiter to join our team. This role requires current (within the last 4 months) hands-on experience recruiting Travel RNs through both VMS platforms and direct client relationships. If you do not have recent, active experience recruiting Travel Nurses, please DO NOT APPLY. Compensation & Structure: 1099 Independent Contractor (Commission Only). You control your methods, schedule, and approach — we focus solely on results. Recruiters are responsible for their own business expenses (job boards, sourcing tools, networking, etc.). Commissions are paid upon successful candidate placements. Contract Continuation: Ongoing partnership depends on meeting or exceeding outlined performance expectations. Failure to maintain consistent results may result in termination of the agreement at the company’s discretion.

Available to work full-time or near full-time hours on a commission-only basis as an independent contractor. Must respond to all new job postings within 4 hours. Note: we work across PST to EST so you need to be flexible and able to work across all time zones. Must respond to all candidate / applicants within 4 hours through text, email, call. Note: we work across PST to EST so you need to be flexible and able to work across all time zones. 1+ years of proven success recruiting Travel Registered Nurses (RNs) across the U.S. Current (within last 4 months) experience with VMS/MSP platforms and direct client placements — required. Ability to demonstrate personal performance metrics (submissions, interviews, hires, margins, etc.) during the interview. Self-motivated, organized, and able to manage a high volume of requisitions independently. Available to work full-time or near full-time hours on a commission-only basis as an independent contractor.

Within your first two weeks, you should consistently submit a minimum of three (3) qualified Travel RN candidates per week Success is based on quality, speed, and consistency of candidate submissions and placements.

IntellaTriage

Remote Hospice Triage RN PT 3:30p-8:30p + rotating Sat & Sun 3:30p-11p CST

Posted on:

December 14, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We are seeking a compassionate registered nurse (RN) to join our growing team! In this role, you will provide critical after-hours support, triaging hospice patients and family needs over the phone wit professionalism and empathy. You will help ensure timely interventions and coordination of care for patients receiving hospice services.

Active multistate Registered Nurse (RN) license Hospice, palliative, or end-of-life care is strongly preferred Must be comfortable with technology and electronic medical records (EMR) utilized for documentation of calls Ability and comfort with typing documentation and notes in a fast-paced environment Must be able to handle stress and multitask when receiving calls (minimum of 5 calls per hour on weekdays, and up to 8 per hour on weekends) Strong communication and critical thinking skills Ability to work independently in a remote environment This is a remote position that requires consistent attendance, active communication, and reliable internet connectivity during all scheduled shifts to support timely patient care coordination

Provide telephone triage for hospice patients and families Assess patient conditions and determine appropriate next steps Collaborate with on-call teams to coordinate care and resources Accurately document all communications and interventions Maintain a calm and professional demeanor while handling urgent calls.

Great Lakes Mgmt Co

Triage RN-REMOTE MN, WI or CO

Posted on:

December 14, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Minnesota

At Great Lakes Management, we don’t have a job - we have a Mission – to make a positive difference in the lives of others. We are driven by our core values of Accountability, Compassion and Teamwork. We come to work ready to win the day, every day, which creates a dynamic work environment where employees feel empowered to succeed through support, encouragement and opportunity. We currently operate a portfolio which consists of nearly $1 Billion in assets across 40 communities totaling approximately 4,000 rental units, of which 1,800 are senior housing. Through our wholly-owned subsidiary, Gentle Touch Health (GTH), GLM delivers health care services in independent, assisted living and memory care communities under management. GTH is committed to hiring and training the best nurses, resident assistants and medication administrators in the industry. We have a dedicated Staff Development Coordinator who creates dynamic healthcare training curriculum that goes above and beyond what is accepted and expected from a regulatory perspective. At GLM we fully recognize that investing in and training employees empower them to succeed by providing the best possible services to seniors to are entrusted to our care.

We are hiring for a part-time Triage RN! This is a remote position working 26 hours per week. If you are interested in joining our team, we encourage you to apply today! Must reside in the state of MN, WI or CO. and be licensed in these states or willing to obtain. Triage RN Job Details: Hours - 24 hours per week (12 hour shifts) Schedule - Day Shirft 7 am-7pm, every other weekend Pay - $36 - $40 / hour REMOTE

Maintains a current state license as a Registered Nurse per state regulations. A minimum of 5 years’ experience in home health, assisted living or long-term care is preferred. Good organizational skills with the ability to self-start and follow through with initiatives with a minimal amount of supervision. Exhibits a caring heart with a passion to care for the elderly. Possesses good judgment, problem-solving, and decision-making skills. Exceptional verbal and written communication skills. Experience using an HER specifically Eldermark and Point Click Care Must have excellent communication skills, patience and empathy for onsite staff and residents. Must be confident in clinical knowledge and decisive. Have a good understanding of pharmacology, basic first aid and Blood Glucose monitoring. Past supervisory experience a plus.

Take triage calls from the various AL and MC sites during nonbusiness hours and on weekends. Document appropriately in the EHR any direction and necessary information for the site clinical team to follow up and through with Prepare activity and incident reporting for the site Clinical Team(s) to use in order to analyze call volume and potential training necessary for site staff to work safely and efficiently. Must be willing to participate in any investigations and or surveys where after-hours calls are involved. Documents appropriately in the EHR. Promotes a positive, team approach and a healthy work environment for those who rely on their expertise.

Medcor Inc

Remote Triage Nurse

Posted on:

December 14, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Illinois

At Medcor, we’re passionate about caring for our advocates as much as you are passionate about caring for your patients! Join our team and receive the support you need to be successful in your practice and to focus on your patients. In addition to a collaborative work environment, we offer great pay and benefits and emphasize your wellness. Here’s why people love working for Medcor: Stability! We’ve been around since 1984. Potential for retention and performance incentives Opportunities galore! Medcor has a lot more to offer than just this job. There are opportunities to move vertically, horizontally, and geographically. Annually, 20% of our openings are filled by internal employees. The fact is, opportunity exists here! Training! We believe in it and we’ll train and support you to be the best you can be. We feel we offer more training than most other companies. We have an open-door policy. Do you have something to say? Speak your mind! We encourage it and we look forward to how you can help our organization.

Medcor is looking to hire a full-time Registered Nurse for our remote 24/7 Occupational Health triage call center! The hours for this position include 8-hour or 10-hour shifts between the hours of 12pm and 2am CST. Job Type: Full-time - 40 hours per week Salary: $28 per hour with additional shift differential pay available for evenings, nights & weekends. By joining our nursing team, you will be helping thousands of employers better manage their workplace injuries and improve the quality of healthcare for their employees. Nurses who are successful in this position must be able to talk on the phone for long periods while typing and navigating through various software applications simultaneously. Our nurses must be able to visualize an injury while on the phone and clarify details about the injury while following our propriety algorithms to guide the triage of the injured worker. Training: Training for this role will last 5-6 weeks, with 2.5 weeks of classroom instruction and 2.5 weeks of precepting. These first 5-6 weeks of training are held Monday through Friday, from 8a-4p CST. The training schedule is non-negotiable, and all training must be successfully completed within the 6-week time frame. Following training, you will transition to your permanent schedule between the hours of 12p and 2a CST with an every-other-weekend requirement and holiday rotation. Changes to the permanent schedule are not allowed within the first 12 months of employment.

Be bilingual, fluent in both the English and Spanish language Have a valid RN license and current BLS (CPR) certification Be able to handle a high volume of consecutive calls Have strong technological skills as well as a typing speed of at least 30 WPM Work a major U.S. holiday rotation Work every other weekend Have effective written, verbal, and interpersonal communication skills. Ability to read, analyze, and interpret triage tools and information along with care instructions to injured employees and their managers. Be able to talk and/or hear. You are required to sit and use your hands. Specific vision abilities required by this job include close vision for computers and written work with the ability to adjust focus Be able to work on a computer for long periods Have a private space in your home with 4 walls and a door for patient privacy Have access to high-speed internet (no satellite) within your primary residence Be able to receive and apply feedback It's a Plus If: You have call center experience You have occupational health experience

Manage a rapid flow of incoming telephone calls from Medcor customers in a call center environment Document each call efficiently and accurately Monitor and track individual as well as call center goals, productivity metrics, and statistics Reflect all shift activities using the phone system and be responsible for personal schedule adherence Provide superior customer service to Medcor’s clients and employees Complete accurate assessment of symptoms and/or concerns utilizing Medcor’s Triage Algorithms Follow HIPAA Compliance Policies

Calyxo

Richmond, VA based Clinical Specialist - Remote, USA

Posted on:

December 13, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

Calyxo, Inc. is a medical device company headquartered in Pleasanton, California, USA. The company was founded in 2016 to address the profound need for improved kidney stone treatment. Kidney stone disease is a common, painful condition that consumes vast amounts of healthcare resources each year. Our team is led by executives and investors with a proven track record of commercializing paradigm-shifting devices to meet unmet needs within urology. Are you ready to change the future of kidney stone treatment? We are seeking high achievers who want to be part of a dynamic team working in a fun, diverse atmosphere.

The Clinical Specialist is a focused individual who has a passion for patient care and physician and staff education. This person will proctor cases to excellence and independently cover CVAC procedures, training the surgical team on the safe and effective uses of the device. The Clinical Specialist works closely with the surgical team members to provide clinical product assistance to the surgeon by being familiar with the surgical procedure, instruments, supplies, and equipment. The Clinical Specialist will train the surgical team on instrument preparation prior to cases and during the surgical procedure. This role will manage inventory needs in the account and any accompanying administrative requirements. This role is not considered for pathway to a Territory Sales Manager at Calyxo Inc, due to the tenure and experience required to execute the Territory Sales Manager role. Ideal candidates will live in the targeted geographical area. This position can cover any CVAC case in the territory, region, or at times, the nation, as assigned. The Clinical Specialist will also provide clinical support for physician training and sales training programs.

Who You Will Report To: Regional Clinical Manager (RCM) Clinical Specialist I Requirements: Clinical experience such as: Scrub Tech X-Ray Tech RN or BSN Laser Tech Clinical Specialist II Requirements: In addition to all of the above: Industry experience (1-3 years) Prior Employment as a Clinical Specialist with a medical device company or experience working with Mobile Litho Provider Companies Comfortable with the pace required to be successful in a start-up Ability to provide intraoperative procedural guidance Willingness to travel outside of the designated territory Sr. Clinical Specialist Requirements: In addition to all of the above Industry experience: 3+ years of full-time employment by a medical device company as a clinical specialist (or comparable position) focused on case coverage and patient outcomes (not equipment/service provider). Clinical experience: Intraoperative Coaching Experience OR experience: Fluent in Staff and Support Training Track record of success. Urology experience preferred. Understands the medical device industry Comfortable with the pace required to be successful in a start-up Ability to provide intraoperative procedural guidance Understands sales processes and training Willingness to travel outside of the designated territory General Requirements:  Experience in surgical technique and sterile procedures in the operating room Experience utilizing fluoroscopy is a plus Customer relationship and procedural skill development are highly desired Highly desirable candidates will have a degree or certification in a medical-related field (ex: LPN, RN, Surg Tech, Rad Tech, etc). Able to travel by car up to 90% Compliance with relevant county, state, and federal rules regarding vaccinations.

Provide clinical case coverage as assigned Train the surgical team to assist in good patient outcomes and verbally support cases during training period Acquire and maintain current knowledge of perioperative surgical technology practice and hospital policies and procedures Develop technical acumen to a level to serve as an educational resource Demonstrate appropriate interactions with all hospital service providers Maintain and prepare equipment and kits for surgery, including Quality Control audits of equipment and kits Troubleshoot equipment according to standard procedure Provide intra-operative clinical product support Ensure that 100% of received inventory and returned inventory matches shipping documents Reconcile inventory/usage as well as missing inventory Assist in the delivery of procedural training to physicians and medical staff Be an effective member of the commercial team and play a key role in ensuring positive clinical outcomes In partnership with TSM, perform account management: such as Account Set Up, Clinical Engagement, Case Support and Clinical Outcomes In Partnership with TSM, support education of APPs, Office and Hospital Staff In partnership with TSM, help facilitate and support Residency Education Ensure compliance with all company policies, including the quality policy, on label promotion and interactions with health care professionals In this role, you will collaborate with Clinical Specialist teams to review and discuss case presentations and peer to peer knowledge sharing Other duties as assigned

CareFirst BlueCross BlueShield

Care Manager (Remote)

Posted on:

December 13, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Over 3.2 million people trust us with their health insurance. We take this responsibility seriously. For generations, CareFirst BlueCross BlueShield has provided security and stability to the members and communities we serve. We believe all people should have access to quality, affordable healthcare and that by working together with our partners, providers and the local community, we will make a meaningful difference in the lives of the people we serve. Today we are faced with an ever-changing landscape, but rather than avoiding change we are committed to leading it forward.

Under minimal supervision, the Care Manager researches and analyzes a member's medical and behavioral health needs and healthcare cost drivers. The Care Manager works closely with members and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes. This position will support the Federal Employee Program line of business. We are looking for an experienced professional to work remotely from within the greater Baltimore/Washington DC metropolitan areas. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business related activities.

Education Level: High School Diploma or GED Licenses/Certifications: RN - Registered Nurse - State Licensure And/or Compact State Licensure RN- Registered Nurse in MD, VA or Washington, DC Upon Hire Required Accredited Case Manager (ACM): Must have CCM/ACM or other RN Board Certified certification in case management. Incumbents not certified at the time of hire must have two years of case management experience and meet requirements to take CCM or ACM exam and successfully achieve the certification within the first year of employment upon hire preferred or CCM - Certified Case Manager: Must have CCM/ACM or other RN Board Certified certification in case management. Incumbents not certified at the time of hire must have two years of case management experience and meet requirements to take CCM or ACM exam and successfully achieve the certification within the first year of employment upon hire preferred. Experience: 5 years clinically related experience working in Care Management, Discharge Coordination, Home Health, Utilization Review, Disease Management or other direct patient care experience. Preferred Qualifications: Bachelor's degree in nursing CCM/ACM or other RN Board Certified certification in case management. Must have CCM/ACM or other RN Board Certified certification in case management. Incumbents not certified at the time of hire must have two years of case management experience and meet requirements to take CCM or ACM exam and successfully achieve the certification within the first year of employment. Previous experience working with a Healthcare payor organization. Knowledge, Skills and Abilities (KSAs): Knowledge of clinical standards of care and disease processes. Ability to produce accurate and comprehensive work products with minimal direction. Ability to triage immediate member health and safety risks. Basic understanding of the strategic and financial goals of a health care system or payor organization, as well as health plan or health insurance operations (e.g. networks, eligibility, benefits). Excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for members. Knowledgeable of available community resources and programs. Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint. Ability to provide excellent internal and external customer service. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Identifies members with acute/complex medical and/or behavioral health conditions. Engages onsite and/or telephonically with member, family and providers to develop a comprehensive plan of care to address the members needs at various stages along the care continuum. Identifies relevant CareFirst and community resources and facilitates program, network, and community referrals. Collaborates with member and the interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member?s medical, behavioral and/or social determinant of health needs. Engage members and providers to review and clarify treatment plans ensuring alignment with medical benefits and policies to facilitate care between settings. Monitors, evaluates, and updates plan of care over time focused on member's stabilization and ability to self-manage. Ensures member data is documented according to CareFirst application protocol and regulatory standards.

CareFirst BlueCross BlueShield

Medical Policy Analyst (Remote)

Posted on:

December 13, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Over 3.2 million people trust us with their health insurance. We take this responsibility seriously. For generations, CareFirst BlueCross BlueShield has provided security and stability to the members and communities we serve. We believe all people should have access to quality, affordable healthcare and that by working together with our partners, providers and the local community, we will make a meaningful difference in the lives of the people we serve. Today we are faced with an ever-changing landscape, but rather than avoiding change we are committed to leading it forward.

In collaboration with the Medical Director, the Medical Policy Analyst will research, analyze, evaluate, and revise medical policies and operating procedures to support the corporate philosophy, provider and member contracts, and accepted standard of medical practice. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities

Education Level: Bachelor's Degree in Nursing, Public Health, English or related field directly related to the position OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience. Experience: 3 years Clinical experience within the field of Medical Surgical, Mental Health, Durable Medical Equipment, and/or Utilization Management, including some experience in research methodology and systematic evaluation of medical literature and translation of evidence into policy in a healthcare setting. Preferred Qualifications: Certified Professional Coder (CPC). Knowledge, Skills and Abilities (KSAs) Ability to analyze essential facts, make timely and sound decisions, resolve performance and job-related issues. Demonstrated desire to share knowledge and work as a team. Excellent written and verbal communication skills, and the ability to present to internal clients of all levels. Working knowledge of medical insurance and managed care principles and knowledgeable of CPT and ICD-10 coding systems. Knowledge of all types of medical necessity decisions including various places of service and provider types. Knowledge of principles, practices, evidence-based guidelines and standardized processes and procedures for evaluating medical support operations business practices. Licenses/Certifications: RN - Registered Nurse - State Licensure And/or Compact State Licensure Registered Nurse (RN) Required. Certified Coder (CCS or CPC)-AHIMA or AAPC AAPC Certified Professional Coder (CPC) within 1 Year Required.

Performs in-depth research on medical topics identified in existing medical policies and operating procedures scheduled for revision or updates based upon changes in the standard of care. Evaluates current peer-reviewed articles and other literature to determine its appropriateness of clinical guidance and mandated legislation in support of and inclusion in policies. In collaboration with the Medical Director, revise evidenced-based medical policies and operating procedures in compliance with legislative mandates, contractual provisions, corporate philosophy, and accepted standards of medical practice in order for them to be applied uniformly and consistently across all lines of business. Maintains the Medical Policy Reference Manual (MPRM) including resource files and publications. Ensures dissemination of medical policies and operating procedures to internal and external customers according to CareFirst application protocol and regulatory standards.

Hoag Health System

Triage Nurse I (RN) - Clinic : MSO Hoag Clinic Nurse Triage - Full Time - 08HR - Remote CA

Posted on:

December 13, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

California

Hoag Memorial Hospital Presbyterian is a nonprofit regional health care delivery network in Orange County, California, consisting of three acute-care hospitals with sixteen urgent care centers, eleven health centers and a network of more than1,800 physicians, 100 allied health members, 8,000 employees, and 2,000 volunteers. More than 30,000 inpatients and 550,000 outpatients choose Hoag each year. For over 70 years, Hoag has delivered a level of personalized care that is unsurpassed among Orange County’s health care providers. Since 1952, Hoag has served the local communities and continues its mission to provide the highest quality health care services through the core strategies of quality and service, people, physician partnerships, strategic growth, financial stewardship, community benefit and philanthropy. Hoag offers a comprehensive blend of health care services including six institutes providing specialized care in the areas of cancer, heart and vascular, neurosciences, women's health, orthopedics, and digestive health through our institutes. Hoag was the highest ranked hospital in Orange County in the 2024-2025 U.S. News &World Report, the only Orange County hospital ranked in the top 10 for California. The organization was ranked the #5 hospital in the Los Angeles Metro Area and the #10 hospital in California.

Required: Two (2) years clinical nursing experience Basic keyboarding skills and basic knowledge of Microsoft Office Suite, including Outlook, Word and Excel Strong clinical documentation knowledge and skills Preferred: One (1) year experience in an ambulatory care setting and/or in telephone triage Bachelor of Science in Nursing (BSN) Knowledge of electronic medical record systems Knowledge of patient registration, scheduling, and insurance verification processes License Required: Current licensure as a Registered Nurse in good standing in the State of California License Preferred: N/A Certifications Required Current BLS certification Certifications Preferred N/A

The Triage Nurse I provides professional telephone triage nursing services to Hoag Clinic patients. This role performs detailed evaluation of patient symptoms and determines urgency of patient condition, facilitates next steps in patient care, makes recommendations for escalation of care, and provides appropriate medical advice on treating symptoms. Provides patient education and incorporates available education material. Communicates changes in patient condition to health care provider. Responses to emergency situations. Collaborates with other members of the health care team to ensure quality patient care and confer when facing ethical and legal issues. Documents all nursing services provided in the patient record. Utilizes the nursing process based on research and evidence-based outcomes to meet patient care needs. Facilitates appropriate utilization of healthcare resources. Enhances the patient experience. Provides services in compliance with all applicable regulatory and professional standards, including the California Nurse Practice Act. Performs other duties as assigned.

CSTS Customer Service and Technology Solutions LLC

Registered Nurse

Posted on:

December 13, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Florida

This is a full-time remote role for a Registered Nurse at CSTS Customer Service and Technology Solutions LLC. The Registered Nurse will be responsible for assessing member needs, creating and implementing care plans, and collaborating with healthcare professionals to ensure quality member outcomes.

Case management skills Strong communication and interpersonal skills Ability to work collaboratively in a remote team environment Time management and organizational skills Knowledge of electronic health records and healthcare technology Current FL RN license and BLS certification FL Resident Experience in a customer service-focused healthcare setting

June Skin

Aesthetic Nurse Injector - No Experience Required

Posted on:

December 13, 2025

Job Type:

Contract

Role Type:

License:

RN

State License:

New York

We are redefining aesthetic medicine by making high-quality treatments more accessible — both for clients and providers. Our mission is to support medical professionals in achieving lucrative and enjoyable careers while offering clients convenient, expert care in the comfort of their homes. We welcome nurses at all stages of their careers — whether you're looking to break into aesthetics, expand your skill set, or take your established practice to the next level. For those new to the field, there are options to help you gain the expertise needed to succeed.

We are seeking licensed medical professionals (RN, NP, PA, or MD) to provide medical aesthetics services including Botox, fillers, and chemical peels, directly to clients in their preferred setting. Applicants are welcome all across the country. We are currently looking for nurses in 45 states. As a leader in providing advanced aesthetic treatments, we are dedicated to delivering exceptional patient care and outcome-focused results. In this role, you will have the opportunity to work in a concierge capacity from client's homes, choose your own hours, and utilize the latest technologies and techniques in aesthetic medicine. You will be responsible for assessing patients' needs, developing personalized treatment plans, and administering safe and effective injectable products to enhance their natural beauty. Everything you need to succeed is provided to you: medical supervision, marketing tools, a supportive network, and cutting-edge technology. No prior aesthetic experience is needed. Compensation & Benefits: Competitive Pay: Earn $100 to $200 per treatment Flexible Schedule: Work as much or as little as you choose Full Coverage: We provide malpractice and liability insurance Custom Tech Platform: Our nurse-designed app simplifies scheduling, payments, and charting Love Your Work: Help clients feel confident while building a career you love

Licensed Professionals: Active RN, NP or PA license CPR/BLS Certified: Must have current certification Choose Your Own Hours: Meet with clients when it’s best for you Self-Motivated: Entrepreneurial mindset with a passion for aesthetics Social Media Savvy: A plus if you enjoy marketing your services online New Grads Welcome: Experience in aesthetics is not required Please note: You will be delivering treatments in your local community. We do not operate from a physical clinic.

Conduct thorough patient consultations to understand individual aesthetic goals and medical history. Administer injectable treatments with precision and care. Monitor patients for any adverse reactions or complications following treatments and provide appropriate follow-up care. Educate patients about available aesthetic treatments, expected outcomes, and aftercare procedures. Maintain an organized, safe, and sanitized treatment environment in accordance with health and safety regulations. Stay current with industry trends, techniques, and new products to provide the best possible care to patients.

CVS Health

Case Manager Registered Nurse – Integrated Care Management – Must reside in IL

Posted on:

December 13, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Illinois

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

Program Overview: Join Aetna’s mission-driven team supporting dual-eligible members through the Dual Special Needs Plan (D-SNP FIDE). Our integrated care model addresses both medical and social determinants of health, serving members with complex needs through compassionate, coordinated care. As we expand into new markets, this role offers the opportunity to make a meaningful impact in the lives of vulnerable populations. Position Summary / Mission: The Care Manager Registered Nurse serves as a frontline advocate for members who may not be able to advocate for themselves. This role is responsible for assessing, planning, implementing, and coordinating case management activities to support members’ overall health and wellness. The Care Manager collaborates with members, providers, and interdisciplinary teams to overcome barriers and promote optimal outcomes.

Travel Expectations: Travel up to 25% within the residing area and nearby regions as needed to support in-person member engagement and care coordination. Reliable transportation and a valid driver’s license are required. Mileage reimbursement is provided in accordance with company policy. Required Qualifications: Candidate must reside in Illinois Candidate must have active and unrestricted Registered Nurse license in the state of Illinois 3–5 years of clinical experience Comfortable working independently and virtually Proficient in Microsoft Office Suite and virtual collaboration tools (Teams, Outlook, etc.) Strong communication, organizational, and problem-solving skills Preferred Qualifications: Certified Case Manager (CCM) credential Experience working with dual-eligible populations or in managed care settings 2+ years of experience in case management, discharge planning, or home health coordination Education: Associate's Degree in Nursing (REQUIRED) Bachelor's Degree in Nursing (PREFERRED) License: Active and unrestricted Registered Nurse license in the state of Illinois

Develop proactive care plans to address identified health and social issues, enhancing short- and long-term outcomes. Conduct comprehensive assessments using clinical tools and data sources to evaluate member needs and benefit eligibility. Apply clinical judgment to reduce risk factors and address complex health and social indicators. Use a holistic approach to determine referrals to clinical and interdisciplinary resources. Collaborate with supervisors and care teams to overcome barriers and present cases at interdisciplinary case conferences. Utilize motivational interviewing techniques to engage members and assess health status. Document case management activities in compliance with regulatory and company policies.

Maximus

Long-Term Care Nurse

Posted on:

December 13, 2025

Job Type:

Contract

Role Type:

Primary Care

License:

RN

State License:

Virginia

We’re moving people forward by providing transformative technology services, digitally enabled customer experiences, and clinical health services that change lives. Our employees share an authentic desire to make vital services available to the public and support the missions of our customers.

Maximus Federal is seeking a Long-Term Care Registered Nurse to join the Medical Consultant panel to be an Expert Medical Reviewer to conduct medical judgment appeals. Why Join Us? Remote Work: Enjoy the convenience of working from home and in person while making a significant impact. Competitive Compensation: Earn $50 - $200 per case with an additional $150 bonus after onboarding. Exclusive Opportunity: You will play a vital role in conducting medical judgment appeals, ensuring the best possible outcomes for patients. Impactful Work: Contribute to improving healthcare services for government stakeholders and the general population.

Licensed: Registered Nurse for more than 3 years. Direct Patient Care: Must be actively engaged in providing direct patient care for more than 20 hours a month. Experience: Long-Term Care for more than 3 years. Work Arrangement: This is a 1099 (at-will) role for both parties.

Peer Review for Quality Management may only be used to improve the quality of healthcare or utilization of healthcare resources in VA medical facilities. Its primary focus is whether the clinical decisions and actions of a clinician during a specific clinical encounter met the standard of care.

Maximus

Clinical Review Coordinator (Remote)

Posted on:

December 13, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Oregon

We’re moving people forward by providing transformative technology services, digitally enabled customer experiences, and clinical health services that change lives. Our employees share an authentic desire to make vital services available to the public and support the missions of our customers.

Date: Monday, December 8, 2025 City: Remote Country: United States Working time: Part-time Description & Requirements: Maximus is hiring a Clinical Review Coordinator (Remote) to support the OR MED program. The Clinical Review Coordinator will review assessments for quality and review medical records and other documentation as needed. **This is a Part-Time fully remote position that requires Oregon licensure. About the program: We partner with Oregon DHS to manage in-person eligibility reviews for people that may be experiencing mental illness along with possible physical needs for the Aging and People with Disabilities (APD) Program. Through the mental or emotional disorders (MED) Review process, we give DHS accurate review recommendations of an individual's primary need for services. Our assessment enables DHS to make informed program eligibility decisions based on a clear and accurate understanding of which programs may best address an individual's unique needs. Why Join Maximus? Work/Life Balance Support – Flexibility tailored to your needs! Competitive Compensation – Bonuses based on performance included! Comprehensive Insurance Coverage – Choose from various plans, including Medical, Dental, Vision, Prescription, and partially funded HSA. Additionally, enjoy Life insurance benefits and discounts on Auto, Home, Renter's, and Pet insurance. Future Planning – Prepare for retirement with our 401K Retirement Savings plan and Company Matching. Unlimited Time Off Package – Enjoy UTO, Holidays, and extended sick leave, along with Short and Long Term Disability coverage. Holistic Wellness Support – Access resources for physical, emotional, and financial wellness through our Employee Assistance Program (EAP). Recognition Platform – Acknowledge and appreciate outstanding employee contributions. Tuition Reimbursement – Invest in your ongoing education and development. Employee Perks and Discounts – Additional benefits and discounts exclusively for employees. Maximus Wellness Program and Resources – Access a range of wellness programs and resources tailored to your needs. Professional Development Opportunities-Participate in training programs, workshops, and conferences. Licensures and Certifications-Maximus assumes the expenses associated with renewing licenses and certifications.

Minimum Requirements: Current Registered Nurse (RN) license valid in the state of practice is required High School Degree or equivalent required Minimum 2 years of clinical experience required Active and unrestricted RN or LCSW license Preferred Skills and Qualifications: Minimum of 1 (one) year of psychiatric experience Home Office Requirements: Maximus provides company-issued computer equipment Reliable high-speed internet service Minimum 20 Mpbs download speeds/50 Mpbs for shared internet connectivity Minimum 5 Mpbs upload speeds Private and secure workspace

Review requests for services including admission, discharges and continued stays for adherence to clinical criteria, state and federal policy, and related requirements. Issue approvals, denials or recommendations based on contract requirements. Identify need for additional clinical documentation or consultation. Complete documentation of activities within contract systems. Communicate with providers, individuals and their designees, or state workers as required. Performs other related duties as assigned.

CVS Health

Transition of Care Management - Registered Nurse

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

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

Help us elevate our member care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Fully Integrated Dual Eligible Plan (FIDE) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand to change lives in new markets across the country. The Transition of Care CM plays a critical role in ensuring that our high-risk, medically complex, and vulnerable members—those enrolled in HIDE/FIDE SNP and other Medicaid waiver programs—experience safe, effective, and seamless transitions across care settings. The TOC CM ensures the member experiences a seamless transition to their next care setting. This includes members undergoing significant changes in health status that result in emergency department visits, inpatient admissions, or stays in skilled nursing or rehabilitative facilities. This position provides comprehensive care coordination, assists with the development and implementation of care plans, facilitates communication with interdisciplinary teams, and supports members and families to reduce readmissions, promote health equity and improve health outcomes. Through person-centered planning and timely interventions, the TOC CM ensures that all necessary care, supports, and services are in place at discharge to maintain continuity of care and support optimal recovery.

Required Qualifications: Candidate must have an active and unrestricted Registered Nurse (RN) License in Virginia OR Compact Registered Nurse (RN) License in state of residence 3+ years of clinical practice experience 1+ year(s) of experience in care coordination or working with high-risk populations Proficient in Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams, with the ability to effectively utilize these tools Confidence working at home / independent thinker, using tools to collaborate and connect with teams virtually Access to a private, dedicated space to conduct work effectively to meet the requirements of the position Preferred Qualifications: Certified Case Manager 3+ years Care Management, Discharge Planning and/or Home Health Care Coordination experience preferred Working knowledge of LTSS and HCBS options, Chronic disease management, Medication side effects, Health equity and cultural competency and Community-based services and public benefits Excellent analytical and problem-solving skills Effective communications, organizational, and interpersonal skills. Ability to work independently multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care Bilingual Education: Associate’s Degree in Nursing (REQUIRED) Bachelor’s Degree in Nursing (PREFERRED) License: Active and unrestricted Registered Nurse (RN) License in Virginia OR Compact Registered Nurse (RN) License in state of residence

Complete a market specific post discharge assessment to identify member’s needs, including Health Related Social Needs and Social Determinants of Health (SDoH). Providing comprehensive discharge planning, including facilitating transitions of care between institutional and community settings, ensuring continuity and quality of care. Ensuring the member has filled/received their medication(s) and has an understanding on how to take their ordered medications. Providing clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports) Identifying and engaging barriers to achieving optimal member health Utilizing discretion to apply strategies to reduce member risk Lead and coordinate the Interdisciplinary Care Team (ICT) to develop and implement Individualized Care Plans (ICPs). Facilitating overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage Coordinating post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up Provide education to members and caregivers on care plans, medications, and available community resources, as needed. Understanding Payer/Plan benefits, policies, procedures, and articulating them effectively to providers, members, and other key personnel Updating the Care Plan for any change in condition or behavioral health status Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality. Responsibilities: Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines. Schedule follow-up appointments and ensure medication reconciliation is completed. Identify and address barriers to care such as transportation, housing, or access to medications. Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions. Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community. Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions. Ensure compliance with state and federal regulations, including NCQA standards.

Geisinger

RN - Registered Nurse - Senior Clinical Documentation Improvement Specialist - CCDS Certification

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Geisinger is among the nation’s leading providers of value-based care, serving 1.2 million people in urban and rural communities across Pennsylvania. Founded in 1915 by philanthropist Abigail Geisinger, the nonprofit system generates $10 billion in annual revenues across 126 care sites — including 10 hospital campuses — and Geisinger Health Plan, with more than half a million members in commercial and government plans. Geisinger College of Health Sciences educates more than 5,000 medical professionals annually and conducts more than 1,400 clinical research studies. With 26,000 employees, including 1,700 employed physicians, Geisinger is among Pennsylvania’s largest employers with an estimated economic impact of $15 billion to the state’s economy. On March 31, 2024, Geisinger became the first member of Risant Health, a new nonprofit charitable organization created to expand and accelerate value-based care across the country. For more information, visit geisinger.org/careers or connect with us on Facebook, Instagram, LinkedIn and Twitter.

Job Summary: The Clinical Documentation Improvement Program (CDI) is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. The role of the Clinical Documentation Improvement Specialist (CDIS) is to assist the providers with accurately identifying and documenting the healthcare services provided to the patient. This is accomplished with the recognition of complete and accurate diagnoses, procedures performed, and the treatment provided. The core of the program uses highly trained staff members to perform a concurrent inpatient review of the record. This allows the record to be coded post discharge in a timely and accurate manner. A highly successful CDI program is based on a highly interactive process between physicians, CDIS staff and other support services. The program does not challenge the provider’s medical judgement, but rather provides a methodology in which to clarify existing documentation. Acts as a liaison between the clinical and coding functions. Provides education to the medical staff and other clinical professional on documentation relevant to the Revenue Management processes and Discharge Not Final Billed reduction. Provides daily interactions with physicians and clinical professionals regarding documentation clarification and optimization. It is expected that the CDIS have previous clinical skills, including an understanding of Anatomy and Physiology in order to appropriately discuss with the physician such issues as the underlying etiology, principal diagnosis, diagnostic studies, treatment modalities, to name a few. The essential focus of this position is to analyze the clinical information, using the documentation as the primary driver for overall System Case Mix Index. Applicants must currently hold the required CDI certification in order to be considered for this position. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP). This is a work from home position. The position is full-time, 40 hours weekly; Dayshift; Monday through Friday. Candidates must hold a Registered Nurse license in Pennsylvania or a Multistate License. A minimum of 3 years RN work experience is required; BSN is strongly preferred. The Senior CDI Specialist improves the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Assists the providers with accurately identifying and documenting the healthcare services provided to the patient. The position will, through ongoing education, support the improvement and continue to sustain clinical documentation related to relative patient acuity, risk reduction, ad overall improvement and accuracy of Case Mix Index. Acts as documentation liaison to physician staff as a means of finalizing information in the medical record.

Education: Bachelor's Degree-Healthcare Related Degree (Required) Experience: Minimum of 3 years-Nursing (Required) Certification(s) and License(s)

Reviews inpatient medical records within 24-48 hours of admission for a specified patient population to: evaluate the documentation in order to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation. Attends physician rounds on assigned units, as well as interdisciplinary team meetings as appropriate to daily patient assignment. Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient’s record. Collaborates with the nursing staff, clinical nutrition, pharmacist, along with the physicians on documentation in an attempt to resolve queries prior to the patient’s discharge. Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation. Maintains the confidentiality of all information acquired, pertaining to the patient, physician, associates, and visitors to Geisinger. Promotes a partnership with the Inpatient Coding staff, to provide clinical education, to assure documentation of discharge diagnosis and any secondary diagnoses’ to reflect the accuracy of the patient’s clinical status and care. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient. Complies with established hospital and Department Policies, Procedures Assists the Director with daily organization of CDI work flow at all Geisinger facilities. Communicates and partners with the CDI Director regarding issues in need of a coordinated resolution. Position Details: Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.

NPHire

Telehealth NP (New Grads Welcome)

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

NPHire connects top NP talent with leading healthcare employers and staffing agencies. We're the only job-matching platform built exclusively for Nurse Practitioners, simplifying both the job search and the hiring process so the best match rises to the top every time.

A nationwide virtual care program is bringing on Nurse Practitioners who are passionate about whole-person, wellness-focused primary care. This role blends traditional primary care with lifestyle counseling, prevention, and long-term health coaching. Patients are adults seeking consistent support, stress/sleep guidance, chronic condition management, and a provider who takes time to listen. You’ll have strong autonomy with a highly supportive clinical team available when needed.

FNP, ANP, AGNP, AGACNP, PMHNP, or similar At least one active NP license (multi-state welcome) Comfortable with general primary care Warm, relationship-focused communication style New graduates welcome

Provide virtual primary care visits Support patients with lifestyle changes, wellness habits, and long-term goals Review labs & adjust care plans Guide patients on chronic condition management & prevention Document using streamlined EMR templates

Healthmap Solutions

RN Care Navigator - PA (Remote)

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Pennsylvania

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 Registered Nurse, 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 RN license required 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 Travel No Travel Location: We are hiring candidates located in Pennsylvania. This position is 100% remote for Pennsylvania residents. #LI-Remote

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

Healthmap Solutions

RN Clinical Services Educator

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Florida

Healthmap Solutions (Healthmap) is an NCQA-accredited kidney population health management company. Healthmap uses advanced technology, clinical expertise, and complex care management to improve the lives of people living with kidney disease. Healthmap also helps healthcare providers and payers achieve the value-based results they need. Our company is a diverse and growing organization committed to our clients, the patients we support, and our employees. We are champions for better health, for those who need us most.

The Registered Nurse, Clinical Services Educator plays a pivotal role in fostering the professional growth and competency of Clinical Services staff, including nurses, social workers, dietitians, wellness coaches, and non-clinical support teams. This role is responsible for assessing training needs, designing and implementing educational programs, and ensuring the delivery of high-quality learning experiences. By promoting continuous education and competency across the organization, the associate ensures excellence in clinical services and provides strategic guidance to leadership teams.

Bachelor’s degree required; active RN licensure Minimum 5 years of clinical experience as an RN 2 years in nephrology, cardiac clinical practice (e.g., dialysis centers, nephrology offices, or cardiac care) or managed care 2 years of preceptorship, staff development, clinical educator, or similar experience Skills: Strong communication, interpersonal, and educational skills Proficient in organization, research, and mentoring Comfortable working across time zones and managing multiple priorities Advanced proficiency in Microsoft Office (Outlook, Word, Excel, PowerPoint) Demonstrated ability to handle confidential information with discretion Adaptable, detail-oriented, and capable of thriving in dynamic environments Collaborative team player with a proactive and solution-oriented mindset Strong project management and problem-solving abilities Commitment to lifelong learning and promoting a culture of education and development within the organization Travel: Limited Travel, Scheduled per needs of the business #LI-Remote

Design, deliver, and evaluate comprehensive training programs, including new hire orientation and ongoing education for Clinical Services staff Facilitate continuing education programs, track knowledge retention, and monitor progress through core competency assessments Lead the development of innovative training solutions, including self-directed learning modules, in response to emerging needs and interests Maintain accurate documentation of employee participation, skills reviews, and competency verification processes Develop and manage onboarding programs to ensure seamless integration for new clinical team members Identify opportunities for enhanced learning and orientation experiences for Clinical Services associates Collaborate with leadership on special projects and organizational initiatives Drive quality improvement efforts in educational settings and advocate for best practices in clinical training Partner with interdepartmental teams and stakeholders to align training objectives with organizational goals Participate in relevant committees and contribute to strategic discussions Perform other duties as assigned to support organizational and team objectives

CVS Health

Case Manager, Registered Nurse (Remote, Ohio)

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Ohio

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

The Care Manager—Registered Nurse is a key member of our Special Needs Plan (SNP) care team, responsible for coordinating care for members who often face multiple chronic medical and behavioral health conditions, as well as various social determinants of health (SDoH) needs. This role involves conducting comprehensive assessments to evaluate members’ needs and addressing SDoH challenges by connecting them with appropriate resources and support services. The Care Manager provides education and guidance to members and their families on managing chronic conditions and navigating the healthcare system. Additionally, the Care Manager develops and implements individualized care plans, monitors member progress, advocates for necessary services, and collaborates with the interdisciplinary care team to ensure optimal health outcomes. Accurate and timely documentation of assessments and interventions is essential, as is participation in team meetings to discuss member status and care strategies.

Required Qualifications: Must have active and unrestricted Registered Nurse (RN) licensure in the state of Ohio OR compact licensure in state of residence Proficient in Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams, with the ability to effectively utilize these tools within the context of the CM RN role Access to a private, dedicated space to conduct work effectively to meet the requirements of the position Confidence working at home / independent thinker, using tools to collaborate and connect with teams virtually 3+ years of nursing experience 2+ years of case management, discharge planning and/or home healthcare coordination experience Preferred Qualifications: Experience providing care management for Medicare and/or Medicaid members Experience working with individuals with SDoH needs, chronic medical conditions, and/or behavioral health Experience conducting health-related assessments and facilitating the care planning process Bilingual skills, especially English-Spanish Education: Associate’s of Science in Nursing (ASN) degree and relevant experience in a health care-related field (REQUIRED) Bachelor’s of Science in Nursing (BSN) (PREFERRED) License: Must have active and unrestricted Registered Nurse (RN) licensure in the state of Ohio State-specific license required prior to start date (internal candidates)

50-75% of the day is dedicated to telephonic engagement with members and the coordination of their care. Compiles all available clinical information and partners with the member to develop an individualized care plan that encompasses goals and interventions to meet the member’s identified needs. Provides evidence-based disease management education and support to help the member achieve health goals. Ensure the appropriate members of the interdisciplinary care team are involved in the member’s care. Provides care coordination to support a seamless health care experience for the member. Meticulous documentation of care management activity in the member’s electronic health record. Collaborate with other participants of the Interdisciplinary Care Team to address barriers to care and develop strategies for maintaining the member’s stable health condition. Identifies and connects members with health plan benefits and community resources. Meets regulatory requirements within specified timelines. The Care Manager RN supports other members of the Care Team through clinical decision making and guidance as needed. Additional responsibilities as assigned by leadership to support team objectives, enhance operational efficiency, and ensure the delivery of high-quality care to members. This may include participating in special projects, contributing to process improvement initiatives, or assisting with mentoring new team members. Essential Competencies and Functions: Ability to meet performance and productivity metrics, including call volume, successful member engagement, and state/federal regulatory requirements of this role. Conduct oneself with integrity, professionalism, and self-direction. Experience or a willingness to thoroughly learn the role of care management within Medicare and Medicaid managed care. Familiarity with community resources and services. Ability to navigate and utilize various healthcare technology tools to enhance member care, streamline workflows, and maintain accurate records. Maintain strong collaborative and professional relationships with members and colleagues. Communicate effectively, both verbally and in writing. Excellent customer service and engagement skills.

Vālenz Health®

Utilization Management Nurse

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Pennsylvania

Vālenz® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible.

As a Utilization Management Nurse, you will have a meaningful impact each day by delivering comprehensive, patient centered care. You’ll assess individual needs, shape personalized care plans, and bring together the right healthcare partners to keep patients moving forward. With your clinical insight, you’ll help members navigate the healthcare system with confidence, reinforce treatment plans, and champion high quality outcomes through clear communication, education, and steady support. You’ll also play an important role in promoting wellness, using resources wisely, and ensuring we meet both regulatory and organizational standards. You’ll also have the chance to work on a wide variety of cases, which is a great way to build new skills, expand your clinical thinking, and grow your expertise over time. Schedule: This role follows a full time, Monday through Friday schedule during standard business hours. Below you'll find the schedule according to your time zone. EST: 9:30am to 6pm CST: 8:30am to 5pm MST: 7:30am to 4pm PST: 6:30am to 3pm Why You'll Love Working Here Valenz is proud to be recognized by Inc. 5000 as one of America’s fastest-growing private companies. Our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare. With this commitment, you’ll find an engaged culture – one that stands strong, vigorous, and healthy in all we do. Benefits: Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card. Spending account options: HSA, FSA, and DCFSA 401K with company match and immediate vesting Flexible working environment Generous Paid Time Off to include vacation, sick leave, and paid holidays Employee Assistance Program that includes professional counseling, referrals, and additional services Paid maternity and paternity leave Pet insurance Employee discounts on phone plans, car rentals and computers Community giveback opportunities, including paid time off for philanthropic endeavors

3+ years of clinical nursing experience. 1+ years of UM experience Active, Unrestricted RN License in your state of residence. Ability to work in a fast-paced, detailed, deadline-driven environment. Ability to maintain strict confidentiality and handle sensitive information with discretion. Experience working independently with strong problem solving and organization skills. Strong aptitude for relationship building with a highly effective communication style. A plus if you have: Utilization Management or Case Management Certification. Where You’ll Work: This is a fully remote position, and we’ll provide all the necessary equipment! Work Environment: You’ll need a quiet workspace that is free from distractions. Technology: Reliable internet connection—if you can use streaming services, you’re good to go! Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software. Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA.

Review prospective, concurrent, and retrospective UM cases and apply the appropriate criteria and plan documents. Work with providers and internal partners to make sure the right guidelines are used within the required timelines. Support quality care and cost-effective outcomes that help members stay healthy and engaged. Follow CMS, URAC, and other regulatory requirements tied to UM activities. Flag any potential overuse, underuse, or misuse of services. Identify high risk, catastrophic, or disease management cases and route them to the right teams. Communicate UM decisions clearly with providers and members so everyone stays aligned. Document UM activities accurately and maintain confidentiality at all times. Participate in ongoing education to keep your UM knowledge fresh and current. Help support smooth transitions of care for inpatient members, including early discharge planning. Bring forward any potential quality or patient safety concerns. Take on additional responsibilities as needed to support the team. Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

Vālenz Health®

Oncology Utilization Management Nurse

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Pennsylvania

Vālenz® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible.

As a Utilization Management Nurse, you will make a real impact each day by delivering comprehensive, patient centered care across a full range of cases, with a strong focus on oncology. You’ll assess individual needs, shape personalized care plans, and partner with the right providers and care teams to keep patients moving in the right direction. Your clinical insight will help members navigate the healthcare system with confidence, stay engaged in their treatment plans, and achieve strong outcomes through clear communication, education, and steady support. You’ll also play a key role in promoting wellness, using resources responsibly, and ensuring we meet all regulatory and organizational standards. Schedule: This role follows a full time, Monday through Friday schedule during standard business hours. Below you'll find the schedule according to your time zone. EST: 9:30am to 6pm CST: 8:30am to 5pm MST: 7:30am to 4pm PST: 6:30am to 3pm Why You'll Love Working Here Valenz is proud to be recognized by Inc. 5000 as one of America’s fastest-growing private companies. Our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare. With this commitment, you’ll find an engaged culture – one that stands strong, vigorous, and healthy in all we do. Benefits: Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card. Spending account options: HSA, FSA, and DCFSA 401K with company match and immediate vesting Flexible working environment Generous Paid Time Off to include vacation, sick leave, and paid holidays Employee Assistance Program that includes professional counseling, referrals, and additional services Paid maternity and paternity leave Pet insurance Employee discounts on phone plans, car rentals and computers Community giveback opportunities, including paid time off for philanthropic endeavors

What You’ll Bring to the Team: 3+ years of clinical nursing experience, preferably with exposure to oncology care 1+ years of UM experience Active, Unrestricted RN License in your state of residence. Ability to work in a fast-paced, detailed, deadline-driven environment. Ability to maintain strict confidentiality and handle sensitive information with discretion. Experience working independently with strong problem solving and organization skills. Strong aptitude for relationship building with a highly effective communication style. A plus if you have: Utilization Management or Case Management Certification. Where You’ll Work: This is a fully remote position, and we’ll provide all the necessary equipment! Work Environment: You’ll need a quiet workspace that is free from distractions. Technology: Reliable internet connection—if you can use streaming services, you’re good to go! Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software. Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA.

Review prospective, concurrent, and retrospective UM cases, with a focus on oncology, and apply the appropriate criteria and plan documents. Work with providers and internal partners to make sure the right guidelines are used within the required timelines. Support quality care and cost-effective outcomes that help members stay healthy and engaged. Follow CMS, URAC, and other regulatory requirements tied to UM activities. Flag any potential overuse, underuse, or misuse of services. Identify high risk, catastrophic, or disease management cases and route them to the right teams. Communicate UM decisions clearly with providers and members so everyone stays aligned. Document UM activities accurately and maintain confidentiality at all times. Participate in ongoing education to keep your UM knowledge fresh and current. Help support smooth transitions of care for inpatient members, including early discharge planning. Bring forward any potential quality or patient safety concerns. Take on additional responsibilities as needed to support the team. Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

Vālenz Health®

Oncology Case Management Nurse

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Vālenz® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible.

As an Oncology Nurse Case Manager, you’ll be a key support for patients and families navigating a cancer diagnosis. You’ll use your oncology experience to understand each patient’s needs, build personalized care plans and keep everyone on the same page by working closely with doctors, nurses and other care team members. A big part of the role is helping patients move through the healthcare system, stay on track with their treatment plans and feel supported every step of the way. You’ll also provide education, answer questions and offer emotional support during what can be a very overwhelming time. Along the way, you’ll help with wellness efforts, make sure resources are being used effectively and support compliance with important guidelines. Overall, your work helps create a smoother experience and better outcomes for the oncology patients you serve. Where You’ll Work: This is a fully remote position, and we’ll provide all the necessary equipment! Work Environment: You’ll need a quiet workspace that is free from distractions. Technology: Reliable internet connection—if you can use streaming services, you’re good to go! Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software. Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA. Why You'll Love Working Here: Valenz is proud to be recognized by Inc. 5000 as one of America’s fastest-growing private companies. Our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare. With this commitment, you’ll find an engaged culture – one that stands strong, vigorous, and healthy in all we do. Benefits: Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card Spending account options: HSA, FSA, and DCFSA 401K with company match and immediate vesting Flexible working environment Generous Paid Time Off to include vacation, sick leave, and paid holidays Employee Assistance Program that includes professional counseling, referrals, and additional services Paid maternity and paternity leave Pet insurance Employee discounts on phone plans, car rentals and computers Community giveback opportunities, including paid time off for philanthropic endeavors

RN License with an active and unrestricted license to practice in the state of primary residence. Experience in a clinical oncology setting with an understanding of complex care. 3+ years of direct case management experience, with a demonstrated ability to develop, implement, and monitor personalized care plans, coordinate healthcare services, and collaborate with multidisciplinary teams for optimal patient outcomes. Experience with NCCN guidelines. Experience in a deadline driven environment with a knack for organization and detail. Ability to comprehend the consequences of various problem situations and to refer such problems to the appropriate individual (or supervisor) for decision-making. Excellent communication skills to liaise between patients, families, and healthcare professionals. Patience and resilience, especially when faced with challenging situations. A plus if you have: Compact State Nursing License (if not already held). Certifications: CCM, CCP, related case management certs or willingness to obtain CCM in 18 months of hire. Bilingual in Spanish

Coordinate and manage healthcare services for oncology patients, ensuring comprehensive care delivery and effective communication among healthcare providers. Assess patients' healthcare needs and develop personalized care plans based on their conditions and goals. Advocate for patients' rights, preferences, and needs, and help them navigate the healthcare system. Monitor patients' progress, adherence to treatment plans, and evaluate the effectiveness of interventions. Maintain accurate documentation of patient assessments, care plans, and outcomes. Generate reports on patient progress, outcomes, and utilization of healthcare resources. Provide patient education on medication administration, and self-care techniques. Offer emotional support and counseling to patients and their families, addressing their concerns and fears. Promote health and wellness by encouraging preventive measures and healthy lifestyle choices. Adhere to the applicable URAC Standards, CMSA’s Standards of Practice, state, local, and federal laws and Valenz’s policies and procedures. Partner with internal teams to identify health plan coverage savings as appropriate. Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

CVS Health

Transition of Care Management - Registered Nurse

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

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

Help us elevate our member care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Fully Integrated Dual Eligible Plan (FIDE) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand to change lives in new markets across the country. The Transition of Care CM plays a critical role in ensuring that our high-risk, medically complex, and vulnerable members—those enrolled in HIDE/FIDE SNP and other Medicaid waiver programs—experience safe, effective, and seamless transitions across care settings. The TOC CM ensures the member experiences a seamless transition to their next care setting. This includes members undergoing significant changes in health status that result in emergency department visits, inpatient admissions, or stays in skilled nursing or rehabilitative facilities. This position provides comprehensive care coordination, assists with the development and implementation of care plans, facilitates communication with interdisciplinary teams, and supports members and families to reduce readmissions, promote health equity and improve health outcomes. Through person-centered planning and timely interventions, the TOC CM ensures that all necessary care, supports, and services are in place at discharge to maintain continuity of care and support optimal recovery.

Required Qualifications: Candidate must have an active and unrestricted Registered Nurse (RN) License in Virginia OR Compact Registered Nurse (RN) License in state of residence 3+ years of clinical practice experience 1+ year(s) of experience in care coordination or working with high-risk populations Proficient in Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams, with the ability to effectively utilize these tools Confidence working at home / independent thinker, using tools to collaborate and connect with teams virtually Access to a private, dedicated space to conduct work effectively to meet the requirements of the position Preferred Qualifications: Certified Case Manager 3+ years Care Management, Discharge Planning and/or Home Health Care Coordination experience preferred Working knowledge of LTSS and HCBS options, Chronic disease management, Medication side effects, Health equity and cultural competency and Community-based services and public benefits Excellent analytical and problem-solving skills Effective communications, organizational, and interpersonal skills. Ability to work independently multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care Bilingual Education: Associate’s Degree in Nursing (REQUIRED) Bachelor’s Degree in Nursing (PREFERRED) License: Active and unrestricted Registered Nurse (RN) License in Virginia OR Compact Registered Nurse (RN) License in state of residence

Complete a market specific post discharge assessment to identify member’s needs, including Health Related Social Needs and Social Determinants of Health (SDoH). Providing comprehensive discharge planning, including facilitating transitions of care between institutional and community settings, ensuring continuity and quality of care. Ensuring the member has filled/received their medication(s) and has an understanding on how to take their ordered medications. Providing clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports) Identifying and engaging barriers to achieving optimal member health Utilizing discretion to apply strategies to reduce member risk Lead and coordinate the Interdisciplinary Care Team (ICT) to develop and implement Individualized Care Plans (ICPs). Facilitating overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage Coordinating post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up Provide education to members and caregivers on care plans, medications, and available community resources, as needed. Understanding Payer/Plan benefits, policies, procedures, and articulating them effectively to providers, members, and other key personnel Updating the Care Plan for any change in condition or behavioral health status Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality. Responsibilities: Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines. Schedule follow-up appointments and ensure medication reconciliation is completed. Identify and address barriers to care such as transportation, housing, or access to medications. Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions. Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community. Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions. Ensure compliance with state and federal regulations, including NCQA standards.

Molina Healthcare

Telephonic Care Manager, LTSS (RN) - OB/Women's Health - TX ONLY

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Texas

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.

Opportunity for a TX licensed RN with experience working in women’s health; specifically, OB, L&D, or postpartum, to join our Texas Health Plan as a Case Manager. Your caseload will consist of members who are pregnant, many of them high risk. Telephonically you will complete assessments needed for determining the types of services we need to provide and managing their care until they are discharged from your service. The ideal candidate will have experience as a Case Manager within a managed care organization (MCO) like Molina, but we also consider RNs with a strong background in women’s health. Hours are Monday – Friday, 8 AM – 5 PM CST working from home. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, and Teams as well as being confident in moving between different programs to complete the necessary forms and documentation. Excellent computer skills and attention to detail are very important to multitask between systems and talk with members on the phone while entering accurate contact notes. This is a fast-paced position and productivity is important. Job Summary: Provides support for care management/care coordination long-term services and supports specific activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care.

At least 2 years experience in health care, including at least 1 year experience in care management, managed care, and/or experience in a medical or behavioral health setting, and at least 1 year of experience working with persons with disabilities, chronic conditions, substance abuse disorders, and long-term services and supports (LTSS), or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. Ability to operate proactively and demonstrate detail-oriented work. Demonstrated knowledge of community resources. Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations. Ability to work independently, with minimal supervision and demonstrate self-motivation. Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. Ability to develop and maintain professional relationships. Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. Excellent problem-solving and critical-thinking skills. Strong verbal and written communication skills. Microsoft Office suite/applicable software program(s) proficiency. In some states, must have at least one year of experience working directly with individuals with substance use disorders. Preferred Qualifications: Certified Case Manager (CCM). Experience working with populations that receive waiver services.

Completes comprehensive member assessments within regulated timelines, including in-person home visits as required. Facilitates comprehensive waiver enrollment and disenrollment processes. Develops and implements care plans, including a waiver service plan in collaboration with members, caregivers, physicians and/or other appropriate health care professionals and member support network to address the member needs and goals. Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Promotes integration of services for members including behavioral health care and long-term services and supports (LTSS) and home and community resources to enhance continuity of care. Assesses for medical necessity and authorizes all appropriate waiver services. Evaluates covered benefits and advises appropriately regarding funding sources. Facilitates interdisciplinary care team (ICT) meetings for approval or denial of services and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care and provides care coordination and assistance to members to address psycho/social, financial, and medical obstacles concerns. Identifies critical incidents and develops prevention plans to assure member health and welfare. May provide consultation, resources and recommendations to peers as needed. Care manager RNs may be assigned complex member cases and medication regimens. Care manager RNs may conduct medication reconciliation as needed. 25-40% estimated local travel may be required (based upon state/contractual requirements).

HealthCare Support

DRG Appeals Nurse - Remote

Posted on:

December 12, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Florida

HealthCare Support is a national niche recruitment firm that has a singular focus - placing top talent in the dynamic healthcare industry. We place administrative to executive level professionals in the clinical and non-clinical healthcare arena. Servicing local providers to national organizations our delivery model is tailored to meet our client;s unique needs. We developed an innovative approach that offers unmatched value-added service capabilities. At HealthCare Support our name says it all - we specialize in healthcare and provide full-cycle support to our clients and talent.

DRG Appeals Nurse with CCS or CIC Certification- Remote We’re looking for a Registered Nurse with coding experience to join a respected organization consistently recognized as a certified great workplace, known for its strong sense of purpose, inclusive culture, and commitment to employee growth. This full-time, remote role is ideal for individuals who are detail-oriented, thrive in coding/auditing environments, value remote flexibility, and want to grow within a specialized payment integrity team. Schedule Monday – Friday, 8:00 AM – 5:00 PM Compensation: $90,000 - $96,000 Annually Benefits 100% Remote! Medical (HDHP) with pharmacy, dental, and vision coverage Health Savings Account (HSA) with employer contribution and FSA options 100% coverage for imaging, therapy, DME, and home health Employee Assistance Program (EAP) 401(k) with employer contribution potential Basic Life & AD&D, Core LTD, and Buy-Up LTD Voluntary Life & AD&D Voluntary Accident, Critical Illness, Hospital Indemnity, and Whole Life insurance options

Registered Nurse (RN) Inpatient Coding Experience DRG Coding and Validation Expertise Certification: CCS or CIC required

Audit inpatient claims to ensure accurate DRG assignment and compliance with CMS guidelines Prepare appeals and documentation with clear, professional rationales to support reimbursement integrity

Midi Health

Nurse Practitioner - California (REMOTE)

Posted on:

December 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

NP/APP

State License:

Compact / Multi-State

At Midi Health, we're on a mission to revolutionize healthcare for women at midlife—to relieve their symptoms, support their wellbeing, and ensure they feel seen, heard, and cared for. Our care is personalized, evidence-based, and covered by insurance, making it more accessible to women across the country. Wherever they live. Whatever their health story. We’re rapidly growing and looking for passionate full-time Nurse Practitioners to join our dedicated clinical team. You’ll help close the gender health gap by guiding women through perimenopause, menopause, and other midlife transitions with compassionate, evidence-based care.

Why Work With Midi? Mission-Driven Impact: Join us in transforming healthcare for women in midlife—making a meaningful difference every day. Remote Role with Structured Hours: Work fully remote with patient-facing hours scheduled between 7:00 AM and 7:30 PM, adjusted by patient location and licensure. For clinicians with licenses in multiple states, start times reflect the furthest west time zone to align with patient needs. Continuous Learning: Access weekly clinical education to stay sharp and advance your expertise in women’s midlife health. Purposeful Visits: Our appointments provide you with time to listen, educate, and deliver personalized care that truly supports your patients. Technology + Clinical Support: Benefit from structured onboarding, user-friendly tech, and operational assistance—including elements of logistics, scheduling, and clinical operations—so you can focus on care without being on your own. Community of Care: Be part of a collaborative, respectful team passionate about women’s health and dedicated to your professional growth.

Active, unrestricted, and unencumbered Nurse Practitioner license in at least one U.S. state. *Multiple state licenses are highly preferred. Prescriptive authority as a Nurse Practitioner. Active national board certification (FNP, WHNP, AGNP, or similar). Minimum 3 years of recent experience (within the last 5 years) practicing as a Nurse Practitioner in Primary Care, Women’s Health, or Gynecology. Ability to work independently and make sound clinical decisions. High proficiency and efficiency with technology (telehealth platforms, EMRs, communication tools). A strong passion for caring for women navigating menopause and midlife health transitions.

Quality visits, better conversations: Appointments designed to allow time to listen, educate, and personalize care. Evidence-based protocols: Trained in expert-developed clinical pathways combining hormonal therapy, lifestyle coaching, and medication when appropriate. Care beyond the screen: Patients receive labs, prescriptions, supplements, and referrals as needed—our platform makes it seamless. You’re never alone: Supported by a collaborative team of clinicians, care coordinators, and clinical leaders, with opportunities to grow and specialize over time. Meaningful specialty focus: Practice in women’s midlife health, a critically underserved area where you help close one of the most persistent gaps in care. Mission-aligned, patient-centered culture: Join a team dedicated to empathy, equity, and clinical excellence.

Midi Health

Nurse Practitioner - New Jersey (Remote)

Posted on:

December 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

NP/APP

State License:

Compact / Multi-State

At Midi Health, we're on a mission to revolutionize healthcare for women at midlife—to relieve their symptoms, support their wellbeing, and ensure they feel seen, heard, and cared for. Our care is personalized, evidence-based, and covered by insurance, making it more accessible to women across the country. Wherever they live. Whatever their health story. We’re rapidly growing and looking for passionate full-time Nurse Practitioners to join our dedicated clinical team. You’ll help close the gender health gap by guiding women through perimenopause, menopause, and other midlife transitions with compassionate, evidence-based care.

Mission-Driven Impact: Join us in transforming healthcare for women in midlife—making a meaningful difference every day. Remote Role with Structured Hours: Work fully remote with patient-facing hours scheduled between 7:00 AM and 7:30 PM, adjusted by patient location and licensure. For clinicians with licenses in multiple states, start times reflect the furthest west time zone to align with patient needs. Continuous Learning: Access weekly clinical education to stay sharp and advance your expertise in women’s midlife health. Purposeful Visits: Our appointments provide you with time to listen, educate, and deliver personalized care that truly supports your patients. Technology + Clinical Support: Benefit from structured onboarding, user-friendly tech, and operational assistance—including elements of logistics, scheduling, and clinical operations—so you can focus on care without being on your own. Community of Care: Be part of a collaborative, respectful team passionate about women’s health and dedicated to your professional growth.

Active, unrestricted, and unencumbered Nurse Practitioner license in at least one U.S. state.*Multiple state licenses are highly preferred. Prescriptive authority as a Nurse Practitioner. Active national board certification (FNP, WHNP, AGNP, or similar). Minimum 3 years of recent experience (within the last 5 years) practicing as a Nurse Practitioner in Primary Care, Women’s Health, or Gynecology. Ability to work independently and make sound clinical decisions. High proficiency and efficiency with technology (telehealth platforms, EMRs, communication tools). A strong passion for caring for women navigating menopause and midlife health transitions.

Quality visits, better conversations: Appointments designed to allow time to listen, educate, and personalize care. Evidence-based protocols: Trained in expert-developed clinical pathways combining hormonal therapy, lifestyle coaching, and medication when appropriate. Care beyond the screen: Patients receive labs, prescriptions, supplements, and referrals as needed—our platform makes it seamless. You’re never alone: Supported by a collaborative team of clinicians, care coordinators, and clinical leaders, with opportunities to grow and specialize over time. Meaningful specialty focus: Practice in women’s midlife health, a critically underserved area where you help close one of the most persistent gaps in care. Mission-aligned, patient-centered culture: Join a team dedicated to empathy, equity, and clinical excellence.

Wheeler Staffing Partners

Prior Authorization Nurse, LVN

Posted on:

December 11, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

LPN/LVN

State License:

California

Wheeler Staffing Partners is a professional staffing firm that connects skilled professionals with top employers across the country. We are committed to supporting healthcare providers and organizations with high-quality staffing solutions.

Job Title: Prior Authorization Nurse (LVN/RN – California License) Employment Type: Contract Location: Fully Remote Schedule: Monday – Friday | 8:00 AM – 5:00 PM PST Pay Rate: $30 – $34 per hour License Requirement: Active LVN or RN License (California) Job Summary: Wheeler Staffing Partners is hiring a Prior Authorization Nurse for a fully remote contract position. This role supports medical management functions by reviewing, screening, coordinating, and processing referrals for medical services. The nurse will utilize review criteria, policies, and guidelines to ensure appropriate, cost-effective, and high-quality care is delivered to members in the correct setting.

Active LVN or RN license in the state of California 3–5 years of utilization review experience 2 years of managed care or medical management experience preferred ICD-9 and CPT coding knowledge preferred Experience with EZ-CAP system preferred Proficiency in Microsoft Word, Excel, Outlook Effective verbal and written communication skills Ability to work independently in a remote setting Education and Experience Minimum Education: LVN License (California) Preferred Education: Bachelor’s Degree in Nursing (BA or BSN) Minimum Experience: 3–5 years acute care experience 2 years health plan utilization review or equivalent Preferred Experience: 5 years of utilization review in a health plan setting 5 years acute care experience 1 year ICU or Emergency Room experience

Process referral determinations using Milliman Care Guidelines Identify and refer complex cases to medical director Ensure accurate coding and letter documentation (denials, deferrals, modifications) Select appropriate, contracted providers Verify member eligibility and health plan benefits Route records and trigger appropriate determination notices Maintain compliance with turnaround time standards (ICE TAT) Meet or exceed quality and productivity standards Collaborate with providers and medical directors Identify and refer members to case management or disease management programs Attend required training and team meetings Maintain confidentiality of records and documentation Communicate and collaborate across internal departments

CenterWell Home Health

Care Manager, Telephonic Nurse - FT Evenings & Every Other Weekend

Posted on:

December 11, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

CenterWell Home Health specializes in personalized, comprehensive home care for patients managing a chronic condition or recovering from injury, illness, surgery or hospitalization. Our care teams include nurses, physical therapists, occupational therapists, speech-language pathologists, home health aides, and medical social workers – all working together to help patients rehabilitate, recover and regain their independence so they can live healthier and happier lives.

Clinical call center. High volume. Fast paced. Shift details: Full time 40 hours a week. The schedule will be 8 hour shifts, Monday-Friday from 3pm-11:30pm EST. Required weekend coverage every other Saturday & Sunday from 6am-2:30pm EST. When working weekends, it will allow for off-days during the week. Required to work every other holiday. The Clinical Care Coordinator helps to ensure optimal continuity of care for patients transitioning into and out of our services. They are responsible for being highly knowledgeable regarding post-acute levels of care, and an expert regarding CenterWell Home Health services including home health, hospice, and palliative care. The Clinical Care Coordinator is expected to communicate with the CenterWell Home Health clinical team and help facilitate timely patient follow-up for patients in need of (additional) services when appropriate. The Clinical Care Coordinator is under the general supervision of the Manager of Care Coordination and under established performance criteria. This is a work-from-home telephonic nurse position

Required Experience/Skills: Associates Degree required. BSN preferred. RN license in a compact state is required. May be required to obtain licensure in additional states as dictated by business needs. At least 3 years post-acute experience. Home Care or hospice experience preferred. Nursing background working across multiple areas of post-acute care. Extensive nursing experience in post-acute care. Current CPR certification. Good working knowledge of home health, hospice, and palliative care services. Good time management skills. Ability to learn and master information related to locations and services of clients. Excellent analytical and problem-solving skills. Excellent verbal and interpersonal skills. Able to communicate effectively with empathy over the phone and while interacting with others. Must read, write and speak fluent English. Preferred Qualifications: Experience with case management, discharge planning and patient education for adult acute care Managed care experience Home Health Care experience Telephonic triage experience Bachelor's degree HCHB experience To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Home or Hybrid Home/Office employees will be provided 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.

Act as CenterWell Home Health representative in supporting patients who have been discharged from service or for those who may need post-acute services. Able to navigate healthcare options; care services post-acute offerings, Medicare coverage, billing issues, as well as accessing healthcare resources. Utilize a variety of tools and methods to quickly provide patient options and education including but not limited to sites of service, specialty offerings, post-acute care, and other related questions. Appropriately handle a variety of customer issues including location lookup, directions, and complaints. Makes clinical level of care determination based on discussion, medical records, and any other pertinent clinical data. Matches these needs to a service site location or, if not available, look up and provide alternative services. Act as customer advocate throughout the referral process to ensure timely response and to maximize referral to admission conversion rate. Follow-up and track referral and admission outcomes. Maintains awareness and orientation to department performance objectives, meets standards, and assures patient satisfaction goals are met. Assists in the admissions process by acting as an ambassador for patients who meet the admissions requirements. Focus on placing the right patient to the right care setting at the right time Adheres to and participates in Company’s mandatory training which includes but is not limited to HIPAA privacy program/practices, Business Ethics and Compliance programs/practices, and Company policies and procedures. Reviews and adheres to all Company policies and procedures. Provide education regarding Home Health, Hospice, and Palliative Care Services. Assist with clinical eligibility review for alternate services Participates in special projects and performs other duties as assigned.

Henry Ford Health System

RN Coordinator-Utilization Review/Full Time/Remote

Posted on:

December 11, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Michigan

Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers .

This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above. Additional Information Organization: Corporate Services Department: Ascension Central Util Mgt Shift: Day Job Union Code: Not Applicable

Education/Experience Required: Registered Nurse required. Minimum 3-5 years of clinical experience required. Bachelor of Science Nursing required OR four (4) years Case Management/ Appeal/Utilization Management experience in lieu of bachelor's degree. Certifications/Licensures Required: Registered Nurse with a valid, unrestricted State of Michigan License.

Under minimal supervision, reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered. Combines clinical, business, regulatory knowledge, and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments from admission through discharge, problem identification and education, facilitates the quality of health care delivery in the most cost effective and efficient manner. Utilizes best practice workflows, evidence-based screening criteria and critical thinking to maximize reimbursement.

Humana

Appeals Nurse

Posted on:

December 11, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Texas

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

The Appeals Nurse 2 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. Coordinates the clinical resolution with internal/external clinician support as required. Documents and summarizes to all parties involved in the case the investigation's results. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. Additional Information Work Style: Remote Work Days/Hours: Monday – Friday; 8:00 a.m.-5 p.m. Eastern Standard Time

Our Department of Defense contract requires U.S. Citizenship Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing) HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico. Active unrestricted RN license 3 years of clinical RN Experience Appeals nursing experience Claims experience Proficient with Microsoft Office products including Word, Excel and Outlook Preferred Qualifications: Utilization Review/Quality Management experience Experience working with MCG guidelines Working knowledge of ICD-9 or ICD-10, HCPCS, DRG use Experience with TRICARE contracts and/or the military health care delivery system Knowledge of TRICARE policies and programs Bachelor's degree Work at Home Requirements: To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home associates must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested Satellite, cellular and microwave connection can be used only if approved by leadership Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Review medical documentation, obtain additional information that may be needed including timeframes when physician is available for peer to peer review, and forward to physician review companies or TQMC. Monitor and follow up for timeliness and review response and determination to insure follows TRICARE policy requirements. If discrepancies found will send back for follow up review and correction as needed. Review, coordinate, arrange and maintain Second level Review /Reconsideration records and patient and provider response letters Provide education to beneficiaries and providers regarding second level review time frames, process and review determinations. If needed provide education on alternatives for services that may be not be approved Maintain knowledge of TRICARE, all HGB policies and procedures as well as medical necessity review criteria and privacy requirements