Aquarius Strategies

Care Coordinator

Posted on:

May 26, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

None Required

State License:

Idaho

This is a remote position. Aquarius Strategies has been retained to find a Care Coordinator (CC) for a National company that provides access to the nation’s elite medical minds for a variety of expert medical services. This organization aims to improve the quality and appropriateness of care by ensuring that expert medical advice is at the center of care delivery. Their innovative telehealth platform creates a digital front door providing direct access to the nation’s elite medical minds. This organization facilitates the execution of virtual second opinions for clients seeking expert medical advice. They serve two distinct markets: the Business-to-Consumer (B2C), for concierge and international clients, and Business-to-Business (B2B), for professional athletes, insurance companies, self-insured employers and third party administrators. This organization has grown significantly in the worker’s compensation space, working with several large carriers to provide expert medical opinions for injured workers. This organization comprises an expert network of 450+ fellowship-trained physicians, is invitation-only, and the providers are carefully selected based on reputation, training, years of experience, involvement in academic research, and other factors. Their services are represented across 7 base specialties and 84 sub-specialties within Orthopedics, Internal Medicine, Surgery, Psychiatry, Radiology, Oncology and OBGYN.

This organization is looking for a Care Coordinator (CC) to join their team to provide exceptional support to both physicians and clients. This person will be a representation of the company as the first point of contact for all customer support. This individual will work closely with the VP of Clinical Solutions and Director of Client Success & Partnerships, as well as other members of the Care Coordination Team to ensure the highest level of care is delivered to clients for each and every consultation. The ideal candidate has an interest in the medical field, entry-level clinical experience, and is both a team player and an independent problem-solver. Every hire for this organization becomes an integral member of the team with the autonomy to make a significant impact both at the company and the clients they service. In addition, Care Coordinators have the opportunity to progress into account management roles, providing avenues for professional growth and advancement within the organization.

Passionate about healthcare The ability to handle confidential information with discretion Team player with ability to work in a fast-paced environment Excellent spoken and written communication skills Proficiency in Technological Information Systems and Google Workspace Preference given to applicants who: 4 year bachelor’s degree Have prior work experience in a healthcare environment or insurance company Are bilingual (English/Spanish, preferred) Have experience providing supportive care services for a technology platform Are open to working weekend shifts

Care Coordinators (CC) serve as the crucial link between physicians and clients, managing case coordination and ensuring seamless communication and support throughout the care coordination process. CCs are expected to perform the following tasks: Provide support to expert physicians Onboard, train and work with the nation’s most highly respected surgeons and physicians, including team physicians for the NBA, NFL, MLS, MBL, NHL and Olympics: Provide support to current and prospective clients Triage and manage client inquiries via phone and email related to services and products Assist in procurement, organization and screening of medical records and imaging Assist in client success strategies to promote referrals and increased utilization: Provide support to the Clinical Operations team Manage cases from inception to completion Analyze clinical outcomes of cases Manage quality assurance procedures Ensure high degree of customer satisfaction via individual outreach before and after each consultation Comply with all applicable regulations (i.e. URAC, HIPAA, SOC2)

CVS Health

Appeals Nurse Consultant - Remote Position

Posted on:

May 26, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Mississippi

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 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.

LifeBridge Health

Remote RN - Monitoring Prgm

Posted on:

May 26, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Maryland

As one of the largest health care providers in Maryland, with 13,000 team members, We strive to CARE BRAVELY for over 1 million patients annually. LifeBridge Health includes Sinai Hospital of Baltimore, Northwest Hospital, Carroll Hospital, Levindale Hebrew Geriatric Center and Hospital and Grace Medical Center, as well as our Community Physician Enterprise, Center for Hope, Practice Dynamics, and business partners: LifeBridge Health & Fitness, ExpressCare and HomeCare of Maryland.

CANDIDATES MUST RESIDE IN MD, DC, PA, VA OR WVA

Associate's Degree in Nursing Registered Nurse License - Current Maryland license 3-5 years of experience Rate $30 per hour

Under general supervision and according to established policies and procedures, provide remote Blood Pressure (BP) monitoring for all patients enrolled in the Remote Care program. Communicates significant blood pressure changes and patient concerns to appropriate physician. Communicate with each assigned patient at least once every month and more when blood pressure is in the alert range.

Seva Medical

Remote Night/Weekend RN- Patient Triage & Care Coordination

Posted on:

May 26, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Join the gold standard in Geriatric Mobile Primary Care. At Seva Medical, we deliver compassionate, value-based care to seniors in adult family homes, assisted living, and memory care communities—where they feel most at home.

As a Remote RN, you’ll provide after-hours triage and chronic care management (CCM) to patients with complex needs. You’ll play a critical role in reducing ER visits and ensuring seamless, patient-centered care. Shift Options Evenings: 5 PM – 1:30 AM Overnights: 12 AM – 8:30 AM Weekends All Three Shifts Including: 8 AM – 5 PM

Active RN license (unrestricted); Compact license (eNLC) preferred 2+ years of nursing experience (triage, CCM, home health, geriatrics) BLS certification Tech-savvy: EHR, secure messaging, telehealth tools Quiet home office + high-speed internet Evening, weekend, or overnight availability Preferred: 3+ years RN experience Telehealth or long-term care background Familiarity with CMS CCM billing Strong communication & patient education skills

Triage patient calls using protocols and clinical judgment Coordinate care with providers, caregivers, and facilities Manage chronic conditions like CHF, COPD, diabetes, etc. Engage in proactive CCM tasks during non-call hours Document assessments, interventions, and escalations clearly

Privia Health

Nurse Care Manager

Posted on:

May 26, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Florida

Privia Health™ is a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems to optimize physician practices, improve patient experiences, and reward doctors for delivering high-value care in both in-person and virtual settings. The Privia Platform is led by top industry talent and exceptional physician leadership, and consists of scalable operations and end-to-end, cloud-based technology that reduces unnecessary healthcare costs, achieves better outcomes, and improves the health of patients and the well-being of providers.

Privia is looking for a forward thinking, organized, energetic Nurse Care Manager that delivers on objectives and seeks an opportunity to develop, implement, and deliver change within our medical group and affiliated partners. Working closely with the population health teams, networked facility partners, primary care providers, and practice operations at Privia Health, the Nurse Care Manager will provide extensive care coordination for Privia’s highest risk patients.

BS in Nursing (or equivalent) preferred and at least 3+ years of case management or care coordination experience. Active unrestricted license in FL Strong computer and EHR skills and expertise Must comply with all HIPAA rules and regulations Technical Requirements (for remote workers only, not applicable for onsite/in office work): In order to successfully work remotely, supporting our patients and providers, we require a minimum of 5 MBPS for Download Speed and 3 MBPS for the Upload Speed. This should be acquired prior to the start of your employment. The best measure of your internet speed is to use online speed tests like https://www.speedtest.net/. This gives you an update as to how fast data transfer is with your internet connection and if it meets the minimum speed requirements. Work with your internet provider if you have questions about your connection. Employees who regularly work from home offices are eligible for expense reimbursement to offset this cost.

Develop trust and build rapport with a select Privia patient population with a goal of reduction in high cost utilization and improvement in clinical outcomes Engage patients telephonically, in office, in facility, or where needed Act as the liaison between the patient and Value-Based Care Programs Assist patients in accessing care at the appropriate source Holistic assessment of patients (medical, social, economic, behavioral) to identify opportunities or barriers to improve outcomes Work collaboratively with patient and care center teams to develop a plan of care to improve patient outcomes Provide other billable services as needed and allowed by licensure for our patient population virtually or at assigned office locations, to include assessment of vital signs, administration of vaccines, and review of past, family, and social medical history, medications, and preventive health care needs. In-person and telephonic follow up with our high risk patient populations for education and collaborative goal setting to work towards improving patient outcomes and decreasing high cost utilization Telephonic follow up with patients testing positive for COVID-19 and participating in CVFP’s and PTC’s ambulatory monitoring protocol. Where applicable all tasks, including assessments and care planning, are completed by a RN or LPN under the supervision of an RN, and follow established protocols and standing orders. Understand and utilize the Athena and Privia Applications to identify high value opportunities to decrease utilization and close quality gaps Maintain a courteous and helpful manner when working with patients, physicians, and associates Participate in special projects and perform other duties as assigned

HEALTHNET INC

Registered Nurse - Primary Care Triage (Remote)

Posted on:

May 26, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Indiana

HealthNet is a nonprofit 501 (c) (3) organization of community-based health centers located in Indianapolis and Bloomington, IN Since 1968, HealthNet has improved the health status of the neighborhoods it serves by making quality health services accessible to everyone. HealthNet annually provides affordable health care to more than 61,000 individuals through its network of 9 primary care health centers 5 dental clinics, 9 school-based clinics, a mobile health unit, and additional support services. HealthNet’s mission is to improve lives with compassionate health care and support services, regardless of ability to pay.

The Registered Nurse position is a combination of education, experience and environmental awareness that provides high quality, person-centered care to patients. When you’ll work as a Registered Nurse at HealthNet: Full-time Potential schedule includes Monday-Friday 8-5, with rotation of evening and Saturday shifts. Health centers are open until 8pm and closed on Sundays. Hours of Operation may differ between each health center location.

What you’ll need as a Registered Nurse at HealthNet: Currently not sponsoring work visa. Requires an Associates of Nursing (ASN). Bachelor of Nursing (BSN) preferred. Requires that the RN has graduated from a nationally accredited nursing program. Requires current state of Indiana license as Registered Nurse. Requires Basic Life Support certification through the AHA. Other advanced life support certifications may be required per unit/department specialty according to patient care policies The skills you’ll bring as a Registered Nurse at HealthNet: Upbeat, positive personality with a passion to serve and educate patients. Critical thinking skills. Strong customer service skills. Strong communication skills. Ability to work individually and as a team member. Reliable transportation required. May require travel between health centers. Physical Requirement: Able to be involved in degrees of prolonged standing, walking, sitting, bending, squatting, and stooping; as well as abilities of repeated bending, stooping, and squatting. Able to lift, push, and/or pull equipment, light to moderately heavy weight up to 20-30 pounds is a necessary function of this position. Able to perform duties during periods of varied and/or prolonged work hours. Will be exposed to all patient elements. Must be able to read, write, hear, and communicate effectively in the English language by both orally and written.

Assess patient’s condition by observing and recording patient behavior. Conduct accurate clinical assessments. Administer medications and other treatment options. Assist all units/staff with problem-solving to obtain necessary equipment, medications, and supplies on an as needed basis. Collaborate with providers and care teams. Assist with procedures Point of care testing Administrative duties such as patient paperwork Develop and maintain on-going relationships with patients Maintain accurate reporting to health department

HV Occupational Health & Safety

Remote Occupational Telehealth Nurse - PRN (LPN, LVN, RN)

Posted on:

May 26, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

At HV Occupational Health and Safety, we are passionate about fostering growth and embracing change to create thriving, safe work environments. As a double minority-owned company, we bring a unique perspective to workplace safety, offering exceptional services that help businesses achieve the best outcomes. Our commitment to honesty, integrity, and respect defines everything we do. We take pride in being problem solvers—delivering practical, responsive solutions to complex challenges. Our team isn’t just clinical; we’re collaborative, clear-headed professionals who value family, hard work, and doing right by people.

**This role is 100% remote and available to LVNs, LPNs, and RNs. We are looking for experienced telehealth nurses to join our case management team. Candidates should be available to work night shift hours consistently. Triage experience is highly preferred.** ike. Whether guiding a patient back to work or coordinating care across borders, you bring a calm, clinical presence that earns trust fast. Your emergency care background makes you decisive, and your case management expertise ensures those decisions lead to smart outcomes—clinically, administratively, and operationally. You move with both compassion and clarity. You’re not just checking boxes—you’re actively driving cases forward, advocating for both the employee and the employer, and ensuring every touchpoint reflects professionalism, integrity, and care.

Active RN, LVN, or LPN license (compact license required). 5+ years of clinical experience in emergency care, urgent care, or occupational health. Strong understanding of OSHA recordability, workers’ comp processes, and return-to-work strategies. High emotional intelligence—able to earn trust quickly with employees, managers, and providers. Excellent communication, documentation, and decision-making skills. Bilingual (English/Spanish or English/French) strongly preferred for international case support. Tech-savvy with the ability to manage telehealth, digital documentation, and fast-paced coordination.

Injury Intake & Assessment: Answer incoming calls during business hours. Conduct after-hours initial intakes, gathering key details such as company info, employee demographics, and medical history. Assess injuries via video (when possible) in collaboration with the Safety Manager and onsite medics. Perform nursing assessments and administer first aid treatment. Determine the best course of action: conservative treatment, telemedicine consult, or emergency care. Manage intakes for employees in Mexico and Canada. Provide FAFs (Functional Abilities Forms) and coordinate follow-ups for Canadian clients. Telemedicine & Follow-Up: Schedule telemedicine appointments with HV physicians. Review physician notes for completeness before distribution. Distribute reports and ensure accurate documentation. Conduct follow-ups for first aid cases and monitor recovery progress. Collaboration & Coordination: Partner with Safety personnel, medics, paramedics, and other nurses. Assist with clinic vetting and coordinate referrals and diagnostics. Support case management efforts, ensuring quality employee care. Communicate with workers’ comp carriers, Risk Management, and HR for proper case handling and approvals. Work closely with HV Physicians and CMAs to ensure case resolution and closure. Documentation: Maintain detailed and timely documentation for all visits and communications. Take clinical photos to support injury tracking and case documentation. Collaborate with HV Physicians for ongoing case discussions. Request and manage medical records as needed.

Guideway Care

Triage Nurse RN (Telehealth) | Weekends

Posted on:

May 26, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

California

Sequence Health is working to provide superior patient conversion solutions to healthcare organizations. Our value system is centered around continuously improving the patient healthcare experience. We pride ourselves on hiring team members who can work independently but also enjoy being part of a team and like to continuously learn and grow. We believe you exemplify these qualities and are excited to have you join our team to continue to make a difference for patients and their families. Since 2004, Sequence Health has offered a wide breadth of innovative patient engagement and patient management solutions to help optimize operational efficiency, elevate brand awareness, and grow physician practices and healthcare businesses.

We are seeking a Registered Nurse who will provide nursing and administrative support to a range of practices across the country. Candidates should have strong computer skills and excellent phone skills to work with providers, patients, and administrators. The pay range is a $25-30 hourly rate. This position is full time being offered remotely. Work Schedule Three 12-hour shifts per week: Saturdays and Sundays from 7:00 AM to 7:30 PM CT (Required) One weekday shift from 9:30 AM to 10:00 PM CT (weekday varies) Weekday shifts are assigned in advance and included in a monthly schedule

Registered Nurse Current demonstration of clinical proficiency Excellent written and oral communication skills Excellent critical thinking and problem-solving skills Ability to work within approved procedure and clinical guidelines Electronic Medical Record Experience, i.e EPIC, Cerner, Greenway Ability to use windows-based computer software including ADOBE, MS Word, MS Excel, Fax and others Minimum Requirements: Registered Nurse with Unencumbered e-NCL Licensure. Licensure in California required. Minimum of 3 years’ experience in Adult Nursing Oncology nursing experience preferred Able to work remotely at home in a private HIPAA compliant workspace Able to house company equipment needed to perform job Broadband Internet Access Immigration or work visa sponsorship will not be provided Physical Demands: Ability to hear in normal range and wear a headset / earpiece Good visual acuity to read computer screens, scripts, forms etc. May sit 100% of the time when taking calls Internet download speed must be at least 24 mbps and upload speed at least 4 mbps Immigration or work visa sponsorship will not be provided

Receive inbound calls from patients and place outbound calls to patients. Provide clinical assessment based on established protocols and triage patients by phone or through patient portal. Respond to patients’ messages in patient portal, create orders and route to appropriate parties. Provide administrative support for patients’ and providers’ needs in terms of FMLA, ADA, and LTD/STD Communicate with Health Care Provider through approved methods as needed. Any other duties necessary to drive our values, fulfill our mission, and abide by our company values

Humana

Pre-Authorization Registered Nurse

Posted on:

May 26, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Kentucky

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 Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Required Qualifications – What it takes to Succeed Licensed Registered Nurse (RN) in the state of Kentucky with no disciplinary action and ability to hold licenses in multiple states without restriction Minimum 3 years of experience as a nurse in a clinical setting Strong Proficiency with MS Office Suite Word, Excel, Power Point and ability to learn multiple systems Experience with the development and implementation of policies and procedures Preferred Qualifications: Bachelor's Degree Health Plan experience working with large carriers Previous Medicare/Medicaid experience a plus Previous experience in utilization management, case management, discharge planning and/or home health or rehab Experience working with MCG and HCG guidelines Workstyle: Remote Work at Home Location: Must reside within a 2-hour driving distance of Louisville, Kentucky office to attend meetings and trainings as needed Schedule: Must be available Monday-Friday 9:00 AM - 6:00 PM Eastern Time with very limited rotating on-call coverage and oversight during weekends and holidays. Travel: Meet quarterly in Louisville office for meetings Work At Home Requirements: WAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required Satellite and Wireless Internet service is NOT allowed for this role. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

The Pre-Authorization Nurse 2 completes medical necessity and level of care reviews for requested services using clinical judgment and refers to internal stakeholders for review depending on case findings. Educates providers on utilization and medical management processes. Enters and maintains pertinent clinical information in various medical management systems. 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.

Humana

Care Manager, Telephonic Nurse (Disease Management)

Posted on:

May 26, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Virginia

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.

Humana Healthy Horizons in Virginia is seeking a Care Manager, Telephonic Nurse 2 (Disease Management) who will assess and evaluate member’s needs with emphasis on preventing, monitoring, and managing chronic conditions effectively, in a telephonic environment. This position assists members with their health care needs and obtain the right services, skills, and supports needed to achieve optimal health and life functioning in the community.

Required Qualifications: Must reside in the Commonwealth of Virginia. Active Registered Nurse (RN) license in the Commonwealth of Virginia without disciplinary action. Three (3) years clinical RN experience including educating members/patients on chronic conditions. Intermediate to advanced computer skills and experience with Microsoft Word, Outlook, and Excel. Knowledge of community health and social service agencies and additional community resources. Exceptional oral and written communication and interpersonal skills with the ability to quickly build rapport. Ability to work with minimal supervision within the role and scope. Ability to use a variety of electronic information applications/software programs including electronic medical records. Excellent keyboard and web navigation skills. Preferred Qualifications: Bachelor's degree in nursing (BSN). Case Management Certification (CCM). Managed Care experience. Certified Diabetes Educator. Certified Asthma Educator. Motivational Interviewing Certification and/or knowledge. Experience with health promotion, coaching and wellness. Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Must be able to speak, read and write in both languages without limitations and assistance. See "Additional Information" section for additional information. Additional Information Workstyle: This is a remote position. Travel: You may be required to travel to Humana Healthy Horizons office in Glen Allen, VA for collaboration and face to face meetings. Workdays and Hours: Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST). Language Assessment Statement: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government. WAH Internet Statement: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Strengthens care management activities and support the improvement of member well-being, reducing unnecessary healthcare costs and enhancing healthcare delivery. Provides episodic care coordination that is short term (e.g., up to 12 weeks, based on member need) focusing on education and support to enhance lifestyle modifications and self-management techniques. Coordinates with Care Managers and other identified care team members as needed along with UM staff, physicians and providers as necessary and arrange services necessary to address the member’s condition and current needs. Assesses, monitors, and evaluates member’s chronic condition as well as provide and document meaningful interventions and outcomes. May contribute to interdisciplinary care planning and meetings. Meet requirements for contractual and regulatory compliance. Follows established guidelines/procedures. Other duties as required.

Sutter Health

Clinical Triage Nurse, Work From Home

Posted on:

May 26, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

California

Aids patients in obtaining the correct level of care with the appropriate provider at the right time. Provides advance clinical telephone support to Sutter Health patients, other callers, in-basket and other remote support for physicians, and limited in-clinic support. Uses the nursing process, input from physicians, and Sutter Health's approved telephone nursing guidelines and protocols to maintain highly efficient operations, to provide quality care, and to ensure positive patient outcomes. Assesses patients' needs, appropriately dispositions cases, collaborates with the clinic and hospital-based providers to renew electronic prescriptions, identifies hospital and community resources, consultations and referrals, and preforms nursing follow-up activities. Clinical support includes assisting physician partners with message management and other communications within the electronic medical record (EMR) system, as well as limited patient care in an outpatient setting. DISCLAIMER Applicants must be a resident of one of the following states to be eligible for consideration for this position: Utah, Idaho, Arizona, Arkansas, Tennessee, Missouri, Montana, or South Carolina. DISCLAIMER 2 This is a Work from Home position, therefore internet minimum speeds of 15 mbps download and 5 mbps upload are required.

EDUCATION: Graduate of an accredited school of nursing CERTIFICATION & LICENSURE: RN-Registered Nurse of California (You can submit application without the CA RN license, but must acquire it prior to your start date if selected RN-Registered Nurse in State of Residence PREFERRED EXPERIENCE AS TYPICALLY ACQUIRED IN: 2 years' experience of practical nursing in a hospital, clinic, urgent care, or emergency room/department 2 years' experience with several specialties and subspecialties. OB/GYN experience necessary

Professional knowledge of clinical nursing protocols, regulations and institutional standards of care and risk management with an emphasis in the areas of disease processes, emergencies, health sciences and pharmacology. Advanced clinical knowledge of medical diagnoses, procedures, protocols, treatments, and terminology, including a working knowledge of state and federal regulations and guidelines. Solid analytical and project management skills, including the ability to analyze problems, situations, practices, and procedures, reach practical conclusions, recognize alternatives, provide solutions, and institute effective changes. Communication, interpersonal, and interviewing skills, including the ability to build rapport and explain medical lab results or sensitive information clearly and professionally to diverse audiences (patients). Proficient computer skills, including Microsoft Office Suite and experience working electronic medical/health records. Work independently, as well as part of a multidisciplinary team, while demonstrating exceptional attention to detail and organizational skills. Manage multiple priorities/projects simultaneously, sometimes with rapidly changing priorities, while maintaining event/project schedules. Recognize unsafe or emergency situations and respond appropriately and professionally. Ensure the privacy of each patient’s protected health information (phi). Analyze possible solutions using precedents, existing departmental guidelines and policies, experience and good judgment to identify and solve standard problems. Build collaborative relationships with peers, physicians, nurses, administrators, and public to provide the highest quality of patient care.

Intermountain Health

Registered Nurse Triage and Transition Ambulatory Care PRN

Posted on:

May 25, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

This position functions as a vital member of the healthcare team who contributes to the success of the practice by demonstrating customer/patient focus, effective communication, professionalism, and teamwork. Utilizes the nursing process to assess, plan, implement, and evaluate comprehensive care provided to selected patient populations and their families. This position is responsible for timely and effective management of patient calls requiring medical triage and coordinating care during the transition of care following an inpatient medical stay. Provides guidance, education and facilitates resources for the management of the at-risk population. This is a virtual position, serving a region of the health system. This position is a remote position. If you are currently an internal caregiver for Intermountain Health, you must reside in either CO or MT close to an Intermountain care site. If you are not a current caregiver for Intermountain Health and are applying externally, you must currently reside in Colorado or Montana near an Intermountain Health care site.

Minimum Qualifications: ASN / ADN from an accredited program with the ability to obtain your BSN from an accredited program within four (4) years of hire unless you possess a minimum of fifteen (15) years of proven continuous Registered Nurse experience in an acute care setting, required Current Colorado ( or Montana if living in MT) RN license or compact license with the ability to obtain Colorado or Montana RN license, required Current BLS certification endorsed by the American Heart Association required Preferred Qualifications: Bachelor's Degree in Nursing (BSN). Education must be obtained from an accredited institution. Degree will be verified. One year experience in a clinic setting or inpatient acute hospital setting is strongly preferred KNOWLEDGE, SKILLS, AND ABILITIES: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements list must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Regular attendance to perform work on site during regularly scheduled business hours or scheduled shifts is required Ability to work nights and/or weekends is required for identified positions

Performs clinical triage, including a comprehensive assessment, disposition and education using established triage protocols and guidelines Manages transitions of care to ensure appropriate follow up care and mitigate risks associated with readmission. Contacts patients following emergency department visits to ensure appropriate follow up Uses registry data to identify gaps in services and initiates intervention Refers patients to a variety of resources, including behavioral health, transportation services, nutrition, etc. Educates patients and families about health status, health maintenance, and management of acute and chronic conditions. Provides patient care based on practice guidelines, standards of care, and federal/state laws and regulations. Documents patient assessment and intervention data using established medical record forms/automated systems and documentation practices. Participates in multidisciplinary teams to improve patient care processes and outcomes. Interacts with all staff, colleagues and team members in a professional and collegial manner Promotes mission, vision, and values of SCL Health, and abides by service behavior standards. Performs other duties as assigned

CareXM

Registered Nurse – Hospice - Remote (Sunday, Tuesday, Thursday, Saturday, 4:00 pm to 9:00 pm MST)

Posted on:

May 25, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Remote Status: Remote Job Title: Registered Nurse Location: Remote Pay: $26/hour Training Schedule: The training is four weeks long. You will meet each week, Monday, Wednesday & Friday from 5:00 pm to 8:30 pm (MST) for two weeks On the third week, you will meet on Thursday + one additional weekday that will be assigned by your Trainer In your fourth week, you will work two weekdays that will be assigned by your Trainer Work Schedule: Sunday, Tuesday, Thursday, Saturday, 4:00 pm to 9:00 pm MST States we are currently not entertaining applications from: Alaska, California, Connecticut, DC, Hawaii, Illinois, Massachusetts, Michigan, Minnesota, Nevada, New York, Oregon, Pennsylvania, Rhode Island, Washington or any US territories (e.g.Puerto Rico). Summary: CareXM is seeking a remote Registered Nurse (RN) to provide after-hours telephone triage care to patients and caregivers of hospice and home health partners. This is a flexible position that offers the opportunity to work from home while making a meaningful difference in the lives of others.

RN license in a compact state (in good standing) 4+ years of clinical nursing experience required. Experience in home health, palliative, med-surg, geriatrics, ICU, ER, and/or hospice care is preferred but not required English fluency is required. Spanish is a plus Proficiency with computers and telecommunications equipment Ability to work independently and as part of a team Ability to work flexible hours, including evenings and weekends Must be able to pass a background check and drug test for pre-employment screening Must be able to meet California RN Required Prerequisites for RN Examination and Endorsements as outlined here: https://www.rn.ca.gov/status.shtml Personal Computer Requirements: You will use your Personal Computer to work. As each system configuration is unique, our requirement specialist and IT team will confirm your configuration will meet the necessary standards. Internet connection (Satellite broadband and mobile hotspots are NOT permitted) Webcam Windows: 11 or MAC OS: 14 (Sonoma) or newer CPU: 2.5 GHz RAM: 6GB

Provide fast access to quality, compassionate after-hours RN telephone triage care to patients and caregivers of hospice and home health partners Communicate with empathy and understanding, especially when callers are experiencing a difficult situation Assess patient needs and provide appropriate care instructions Coordinate care with other members of the healthcare team Document patient care in the electronic health record (EHR)

Maximus

Consultant - Nurse (remote)

Posted on:

May 25, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Virginia

Maximus is currently hiring for a Consultant - Nurse to join our QIC Part B team. This is a remote opportunity. *Position is contingent upon contract award*

Minimum Requirements: Bachelor's degree with 3 - 5 years of experience, OR Associate's degree with 5-7 years of experience. Bachelor's degree or in lieu of degree equivalent experience Registered Nurse (RN) license required Three Years of Medicare experience preferred Medicare work experience in both Part A and Part B Must be US Citizen or have lived the last 5 years working continuously for 3 Please note: For this position Maximus will provide equipment to use. Home Office Requirements: Internet speed of 20mbps or higher required / 50 Mpbs for shared internet connectivity (you can test this by going to www.speedtest.net) Minimum 5mpbs upload speed Connectivity to the internet via either Wi-Fi or Category 5 or 6 ethernet patch cable to the home router Private work area and adequate power source Must currently and permanently reside in the Continental US

Responsible for reviewing favorable and partially favorable determinations in accordance with applicable regulations. Render determinations for cases assigned. Resolve all other technical issues within reconsideration assigned. Review cases or sites assigned to determine and summarize facts and assess any issues identified. Perform other special projects not related to a specific case such as general legal research, general medical research, drafting proposal sections, or acting as a liaison for a specific project, when necessary. Perform other duties as assigned by management. Render medical necessity determinations for Medicare Part B QIC reconsideration cases assigned. Resolve all other technical issues within Medicare Part B QIC reconsiderations assigned Review cases to determine and summarize facts of each case assigned and assesses issues involved in the case Review file to determine whether all relevant information has been submitted Research issues using federal and state law, federal and state regulations, relevant contract law and other sources as defined by the client contract Perform other special projects not related to a specific case such as general legal research, general medical research, drafting proposal sections, or acting as a liaison for a specific project, when necessary Meet or exceed all performance standards established for this position Perform other duties as assigned by management

HV Health and Safety

Remote Occupational Telehealth Nurse - PRN (LVN or RN)

Posted on:

May 25, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Compact / Multi-State

At HV Occupational Health and Safety, we are passionate about fostering growth and embracing change to create thriving, safe work environments. As a double minority-owned company, we bring a unique perspective to workplace safety, offering exceptional services that help businesses achieve the best outcomes. Our commitment to honesty, integrity, and respect defines everything we do. We take pride in being problem solvers—delivering practical, responsive solutions to complex challenges. Our team isn’t just clinical; we’re collaborative, clear-headed professionals who value family, hard work, and doing right by people.

**This role is 100% remote and available to LVNs, LPNs, and RNs. We are looking for experienced telehealth nurses to join our case management team. Candidates should be able to work at least 2 12-hour night or day shifts per week. Triage experience is highly preferred.** You’re an experienced telehealth nurse who thrives in fast-moving environments where no two days are alike. Whether guiding a patient back to work or coordinating care across borders, you bring a calm, clinical presence that earns trust fast. Your emergency care background makes you decisive, and your case management expertise ensures those decisions lead to smart outcomes—clinically, administratively, and operationally. You move with both compassion and clarity. You’re not just checking boxes—you’re actively driving care forward, advocating for both the employee and the employer, and ensuring every touchpoint reflects professionalism, integrity, and care.

Active RN, LVN, or LPN license (compact license required). Able to work occaisional 10-12 hour night or weekend shifts consistently 5+ years of clinical experience in emergency care, urgent care, or occupational health. Strong understanding of OSHA recordability, workers’ comp processes, and return-to-work strategies. High emotional intelligence—able to earn trust quickly with employees, managers, and providers. Excellent communication, documentation, and decision-making skills. Bilingual (English/Spanish or English/French) strongly preferred for international case support. Tech-savvy with the ability to manage telehealth, digital documentation, and fast-paced coordination.

Answer incoming calls during business hours. Conduct after-hours initial intakes, gathering key details such as company info, employee demographics, and medical history. Assess injuries via video (when possible) in collaboration with the Safety Manager and onsite medics. Perform nursing assessments and administer first aid treatment. Determine the best course of action: conservative treatment, telemedicine consult, or emergency care. Manage intakes for employees in Mexico and Canada. Provide FAFs (Functional Abilities Forms) and coordinate follow-ups for Canadian clients. Schedule telemedicine appointments with HV physicians. Review physician notes for completeness before distribution. Distribute reports and ensure accurate documentation. Conduct follow-ups for first aid cases and monitor recovery progress. Partner with Safety personnel, medics, paramedics, and other nurses. Assist with clinic vetting and coordinate referrals and diagnostics. Support case management efforts, ensuring quality employee care. Communicate with workers’ comp carriers, Risk Management, and HR for proper case handling and approvals. Work closely with HV Physicians and CMAs to ensure case resolution and closure. Maintain detailed and timely documentation for all visits and communications. Take clinical photos to support injury tracking and case documentation. Collaborate with HV Physicians for ongoing case discussions. Request and manage medical records as needed.

HV Health and Safety

Occupational Telehealth Nurse - Night Shift (Remote)

Posted on:

May 25, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

At HV Occupational Health and Safety, we are passionate about fostering growth and embracing change to create thriving, safe work environments. As a double minority-owned company, we bring a unique perspective to workplace safety, offering exceptional services that help businesses achieve the best outcomes. Our commitment to honesty, integrity, and respect defines everything we do. We take pride in being problem solvers—delivering practical, responsive solutions to complex challenges. Our team isn’t just clinical; we’re collaborative, clear-headed professionals who value family, hard work, and doing right by people.

**We are looking for experienced telehealth nurses to join our case management team. This role is 100% remote and available to LVNs, LPNs, and RNs. We are looking for nurses who want to work the night shift consistently. Triage experience is highly preferred.** You’re an experienced telehealth nurse who thrives in fast-moving environments where no two days are alike. Whether guiding a patient back to work or coordinating care across borders, you bring a calm, clinical presence that earns trust fast. Your emergency care background makes you decisive, and your case management expertise ensures those decisions lead to smart outcomes—clinically, administratively, and operationally. You move with both compassion and clarity. You’re not just checking boxes—you’re actively driving care forward, advocating for both the employee and the employer, and ensuring every touchpoint reflects professionalism, integrity, and care.

Active RN, LVN, or LPN license (compact license required). Able to work 10-12 hour night shifts consistently 5+ years of clinical experience in emergency care, urgent care, or occupational health. Strong understanding of OSHA recordability, workers’ comp processes, and return-to-work strategies. High emotional intelligence—able to earn trust quickly with employees, managers, and providers. Excellent communication, documentation, and decision-making skills. Bilingual (English/Spanish or English/French) strongly preferred for international case support. Tech-savvy with the ability to manage telehealth, digital documentation, and fast-paced coordination.

Answer incoming calls during business hours. Conduct after-hours initial intakes, gathering key details such as company info, employee demographics, and medical history. Assess injuries via video (when possible) in collaboration with the Safety Manager and onsite medics. Perform nursing assessments and administer first aid treatment. Determine the best course of action: conservative treatment, telemedicine consult, or emergency care. Manage intakes for employees in Mexico and Canada. Provide FAFs (Functional Abilities Forms) and coordinate follow-ups for Canadian clients. Schedule telemedicine appointments with HV physicians. Review physician notes for completeness before distribution. Distribute reports and ensure accurate documentation. Conduct follow-ups for first aid cases and monitor recovery progress. Partner with Safety personnel, medics, paramedics, and other nurses. Assist with clinic vetting and coordinate referrals and diagnostics. Support case management efforts, ensuring quality employee care. Communicate with workers’ comp carriers, Risk Management, and HR for proper case handling and approvals. Work closely with HV Physicians and CMAs to ensure case resolution and closure. Maintain detailed and timely documentation for all visits and communications. Take clinical photos to support injury tracking and case documentation. Collaborate with HV Physicians for ongoing case discussions. Request and manage medical records as needed.

HV Health and Safety

Occupational Telehealth Nurse - (Remote)

Posted on:

May 25, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

At HV Occupational Health and Safety, we are passionate about fostering growth and embracing change to create thriving, safe work environments. As a double minority-owned company, we bring a unique perspective to workplace safety, offering exceptional services that help businesses achieve the best outcomes. Our commitment to honesty, integrity, and respect defines everything we do. We take pride in being problem solvers—delivering practical, responsive solutions to complex challenges. Our team isn’t just clinical; we’re collaborative, clear-headed professionals who value family, hard work, and doing right by people.

**We are looking for experienced telehealth nurses to join our case management team. This role is 100% remote and available to LVNs, LPNs, and RNs. Triage experience is highly preferred.** You’re an experienced telehealth nurse who thrives in fast-moving environments where no two days are alike. Whether guiding a patient back to work or coordinating care across borders, you bring a calm, clinical presence that earns trust fast. Your emergency care background makes you decisive, and your case management expertise ensures those decisions lead to smart outcomes—clinically, administratively, and operationally. You move with both compassion and clarity. You’re not just checking boxes—you’re actively driving care forward, advocating for both the employee and the employer, and ensuring every touchpoint reflects professionalism, integrity, and care.

Active RN, LVN, or LPN license (compact license required). Able to work 10-12 hour night shifts consistently 5+ years of clinical experience in emergency care, urgent care, or occupational health. Strong understanding of OSHA recordability, workers’ comp processes, and return-to-work strategies. High emotional intelligence—able to earn trust quickly with employees, managers, and providers. Excellent communication, documentation, and decision-making skills. Bilingual (English/Spanish or English/French) strongly preferred for international case support. Tech-savvy with the ability to manage telehealth, digital documentation, and fast-paced coordination.

Answer incoming calls during business hours. Conduct after-hours initial intakes, gathering key details such as company info, employee demographics, and medical history. Assess injuries via video (when possible) in collaboration with the Safety Manager and onsite medics. Perform nursing assessments and administer first aid treatment. Determine the best course of action: conservative treatment, telemedicine consult, or emergency care. Manage intakes for employees in Mexico and Canada. Provide FAFs (Functional Abilities Forms) and coordinate follow-ups for Canadian clients. Schedule telemedicine appointments with HV physicians. Review physician notes for completeness before distribution. Distribute reports and ensure accurate documentation. Conduct follow-ups for first aid cases and monitor recovery progress. Partner with Safety personnel, medics, paramedics, and other nurses. Assist with clinic vetting and coordinate referrals and diagnostics. Support case management efforts, ensuring quality employee care. Communicate with workers’ comp carriers, Risk Management, and HR for proper case handling and approvals. Work closely with HV Physicians and CMAs to ensure case resolution and closure. Maintain detailed and timely documentation for all visits and communications. Take clinical photos to support injury tracking and case documentation. Collaborate with HV Physicians for ongoing case discussions. Request and manage medical records as needed.

UnitedHealthcare

Field Based HSS Clinical Coordinator RN - Southwest Kansas - Multiple Counties

Posted on:

May 25, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Kansas

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

The Long-Term Services and Supports (LTSS) Care Coordinator RN is responsible for establishing a set of person-centered goal-oriented, culturally relevant, and logical steps to ensure that a person receiving LTSS receives services in a supportive, effective, efficient, timely and cost-effective manner. Care coordination includes case management, disease management, discharge planning, transition planning, and addressing social determinants of health and integration into community. This position is a Field-Based position with a Home Based office. Expected travelling 2-3 days per week within 30-60 mile radius. The counties covered by this position are Barton, Stafford, Pawnee, Edwards, Kiowa, Komache, Hodgeman, Ford, Clark, Gray, Meade, Seward, Haskell, Finney, Lane, Scott, Wichita, Greeley, Hamilton, Kearny, Grant, Stanton, Morton, Stevens. If you reside locally to or within 30 miles of one of these counties, KS or surrounding area, you’ll enjoy the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Current, unrestricted independent licensure as a Registered Nurse in Kansas 2+ years of experience working within the community health setting in a health care role 1+ years of experience working with persons with long-term care needs 1+ years of experience working with persons receiving services on one of the homes and community-based waivers in KS 1+ years of experience working with MS Word, Excel and Outlook Ability to travel in assigned region to visit Medicaid members in their homes and / or other settings, including community centers, hospitals, or providers’ offices Must reside in or within 30 miles of one of the following Kansas Counties – Barton, Stafford, Pawnee, Edwards, Kiowa, Komache, Hodgeman, Ford, Clark, Gray, Meade, Seward, Haskell, Finney, Lane, Scott, Wichita, Greeley, Hamilton, Kearny, Grant, Stanton, Morton, Stevens Preferred Qualifications: Licensed Social Worker or clinical degree Background in managing populations with complex medical or behavioral needs Experience with electronic charting Experience with arranging community resources

Assess, plan, and implement care strategies that are individualized by the individual and directed toward the most appropriate, least restrictive level of care Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services Manage the person-centered service/support plan throughout the continuum of care Communicate with all stakeholders the required health – related information to ensure quality coordinated care and services are provided expeditiously to all persons Advocate for persons and families as needed to ensure the persons needs and choices are fully represented and supported by the health care team Conduct home visits in coordination with person and care team, which may include a community service coordinator Conduct in-person visits which may include nursing homes, assisted living, hospital or home Serve as a resource for community care coordinator, if applicable

Availity

UM Nurse Analyst (Remote)

Posted on:

May 25, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Florida

Availity delivers revenue cycle and related business solutions for health care professionals who want to build healthy, thriving organizations. Availity has the powerful tools, actionable insights and expansive network reach that medical businesses need to get an edge in an industry constantly redefined by change. At Availity, we're not just another Healthcare Technology company; we're pioneers reshaping the future of healthcare! With our headquarters in vibrant Jacksonville, FL, and an exciting office in Bangalore, India, along with an exceptional remote workforce across the United States, we're a global team united by a powerful mission. We're on a mission to bring the focus back to what truly matters – patient care. As the leading healthcare engagement platform, we're the heartbeat of an industry that impacts millions. With over 2 million providers connected to health plans, and processing over 13 billion transactions annually, our influence is continually expanding. Join our energetic, dynamic, and forward-thinking team where your ideas are celebrated, innovation is encouraged, and every contribution counts. We're transforming the healthcare landscape, solving communication challenges, and creating connections that empower the nation's premier healthcare ecosystem.

The position of UM Nurse Analyst will report to the Medical Director of Availity’s Auth AI solution. The UM Nursing Analyst is responsible for the interpretation of payer medical policy guidelines and the construction of NLP/AI–enabled decision trees that accurately reflect medical necessity criteria. The role requires in-depth knowledge of utilization management principles, the role and purpose of medical necessity guidelines and prior authorization adjudication practices. This individual will work in a team environment and will be expected to perform highly complex tasks while collaborating with team members with both clinical and engineering/programming backgrounds. The successful candidate will be detail oriented with strong analytic reasoning skills, demonstrate strong communication and organizational skills while remaining open-minded, embracing change and the spirit of innovation. Sponsorship, in any form, is not available for this position. Location: Remote, US

Bachelor’s degree in nursing. At least 3+ years of experience in an outpatient Utilization Management program, either with an insurer or with a healthcare provider OR equivalent clinical experience with familiarity with prior authorization submission practices. Additional experience in fields of billing / coding, claims review or inpatient utilization management, while not necessary, would enhance the application. “Computer smart” – General power user of technology and confident with navigating new technologies and applications. Familiarity and understanding of interpreting medical records to be able to identify how physicians may document conditions and findings. You will set yourself apart: If you have exceptional critical thinking and reasoning skills. If you can synthesize complex, abstract problems, and collaborate effectively with team members with diverse skillsets to create solutions. If you are self-motivated and a quick learner with an ability to multi-task.

Reviewing payer Medical Policy Guidelines to identify pertinent medical necessity criteria related to specific Procedural codes or CPT codes. Use programming language to construct attestation questions that reflect medical necessity criteria. Assign coded medical constructs to attestation trees based on clinical relevance to facilitate automation of responses to the questions. Identify medical terms that should be added to the existing vocabulary of coded medical concepts. Serve as Subject Matter Expert and general medical resource to engineering teams and developers

IntePros

Part-Time Utilization Management RN

Posted on:

May 25, 2025

Job Type:

Part-Time

Role Type:

Utilization Review

License:

RN

State License:

Pennsylvania

Part-Time Utilization Management RN (Remote – Saturdays Only) Schedule: Saturdays, 9:00 AM – 5:00 PM (Mandatory weekday training prior to start) Location: Fully Remote Employment Type: Part-Time We are actively seeking a Part-Time Utilization Management Registered Nurse (RN) to join our team. This role is ideal for an experienced RN with a background in utilization review who is looking for consistent weekend work in a fully remote setting. Position Summary: Under the direction of a designated Manager, the Utilization Management RN performs telephonic reviews of inpatient hospital admissions, evaluating the medical necessity of continued stays and identifying opportunities for timely discharge planning. This role plays a vital part in promoting high-quality, cost-effective healthcare and facilitating optimal transitions of care.

Education: Registered Nurse required; BSN preferred. Experience: Minimum of 3 years of clinical experience in an acute care hospital setting. Required Background: Prior experience in utilization management and/or discharge planning. Licensure: Active RN license in good standing. Skills and Competencies: Strong verbal and written communication skills Ability to assess complex clinical situations and recommend appropriate levels of care Proficiency with medical software and electronic documentation systems Exceptional organizational and time management skills Collaborative, team-oriented approach with a customer-service mindset

Conduct telephonic utilization reviews of inpatient admissions using established criteria. Assess medical necessity for inpatient and continued stay; recommend alternative levels of care when appropriate. Collaborate with attending physicians, hospital utilization departments, and discharge planners to support care coordination. Refer cases to Medical Directors when admissions do not meet criteria. Support early identification of discharge planning needs and help coordinate transitions to home or alternative settings. Refer patients to Case Management or Disease Management as needed. Identify quality of care concerns and refer to Quality Management when applicable. Ensure timely and accurate documentation in compliance with regulatory and accreditation standards. Provide outstanding customer service and contribute to ongoing provider education. Participate in reporting and trend analysis for utilization patterns or issues.

Integrated Resources, Inc ( IRI )

Nurse Case Manager II

Posted on:

May 25, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Illinois

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, LCSW, or LCPC with unrestricted active license. Experience with case management and IL waiver services is 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 Position Summary: 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 unrestricted driver's license and car. Requires RN, LCSW, or LCPC with unrestricted active license.

MUST HAVE: IL resident who lives in one of the counties listed below and is interested in doing field case management with the elderly and individuals with disabilities who are approved for in-home or nursing facility care. We have 1 position total. ***On each resume, please clearly list which county/counties the candidate is applying for.*** **CM that lives on the Southside of Chicago, Suburban Cook (Chicago Heights, South Chicago Heights, Lynwood, Ford Heights, Sauk Village, Matteson Olympia Fields, Park Forest, Richton Park) Position will require travel to members' homes up to 50-75% travel. Must live near areas listed due to travel requirement and will work at home in between visits. We want someone who is organized, efficient, and can work independently. RN, LCSW, or LCPC with current unrestricted state licensure in IL. REQUIRED Experience: Minimum 3-5 years clinical practical experience preferred Minimum 2-3 years Care Management, discharge planning and/or home health care coordination experience preferred Confidence working at home/independent thinker, using tools to collaborate and connect with teams virtually Excellent analytical and problem-solving skills Effective communications, organizational, and interpersonal skills. Ability to work independently Effective computer skills including navigating multiple systems and keyboarding Demonstrates proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications

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.

Recora

Remote Cardiac Rehab Intake Specialist - Contractor

Posted on:

May 24, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

None Required

State License:

New York

Recora was founded in 2020 by seasoned digital health entrepreneurs. In past roles, we've founded and scaled high-growth startups, run large health systems, advised government programs, built technology you use every day, and provided healthcare for millions of lives. We're backed by leading VCs including SignalFire, Pear, GFC , 2048, Great Oaks, MGV and more. Over the last year, we've built the leading virtual cardiac recovery and management platform for members with cardiac conditions. For every member we serve, we add an average of five years to their lifespan. We're growing – fast. Our member base is doubling every month and we're looking to 3x our team size quickly. This will allow us to scale nationally and accelerate product development across the continuum of heart health.

Recora is hiring a Cardiac Rehab Intake Specialist to join our cardiac recovery program to partner with our users to provide personalized care for cardiac recovery patients. In this role, you will partner with our exercise physiologists, patient experience, product, and marketing teams to support patients via video calls, track individual progress, and provide feedback and support for patients. The right person for this role is familiar with the management of cardiac conditions, CHF, other chronic conditions, smoking cessation, women’s health, substance abuse, mental health, or recent nutrition, and exercise trends.

A minimum of three years of experience helping people manage their health, ideally in a clinical setting and/or a remote health coaching setting A degree in a health-related field Experience with counseling or education of disease management in a medical setting as well as recent nutrition and exercise trends. Passion and enthusiasm for helping people change their lives A diversity- and inclusion-first mindset Detail-oriented and team-first mindset A resourceful nature, and creativity to help people engage in their health Fluent in English (written and verbal) Bilingual in English and Spanish a huge plus Some experience in a clinical setting Some knowledge of cardiac rehabilitation Experience working with an elderly patient population Bonus Points Experience - coaching in smoking cessation, diabetes management, and special populations.

Conducting initial assessments for patients who are enrolling in our virtual cardiac recovery program. Educating patients on program benefits and the importance of risk factor modification. Coaching individuals through electronic (chat) messaging and video sessions. Problem-solving and supporting individuals’ current and evolving goals. Adapting in-clinic best practices to a remote-care delivery model. Completing individualized treatment plans for patients starting the program to include: nutrition assessment, psychosocial assessment, fitness assessment, and co-morbidities assessment. Translating the latest up-to-date, evidence-based best practices for chronic condition management into a relatable and empowering approach. Motivating and encouraging patients during initial visits. Basic understanding of cardiac procedures and medications. Reviewing medical history. Goal setting and motivational interviewing for special populations. Basic understanding of clinical documentation

Recora

Intake Specialist (Care Management and Navigation)

Posted on:

May 24, 2025

Job Type:

Part-Time

Role Type:

Care Management

License:

None Required

State License:

New York

Recora was founded in 2020 by seasoned digital health entrepreneurs. In past roles, we've founded and scaled high-growth startups, run large health systems, advised government programs, built technology you use every day, and provided healthcare for millions of lives. We're backed by leading VCs including SignalFire, Pear, GFC , 2048, Great Oaks, MGV and more. Over the last year, we've built the leading virtual cardiac recovery and management platform for members with cardiac conditions. For every member we serve, we add an average of five years to their lifespan. We're growing – fast. Our member base is doubling every month and we're looking to 3x our team size quickly. This will allow us to scale nationally and accelerate product development across the continuum of heart health.

Recora is hiring an Intake Specialist to join our cardiac recovery program to partner with our users to provide personalized care for cardiac recovery patients. In this role, you will partner with our exercise physiologists, patient experience, product, and marketing teams to support patients via video calls, track individual progress, and provide feedback and support for patients. The right person for this role is familiar with the management of cardiac conditions, CHF, other chronic conditions, smoking cessation, women’s health, substance abuse, mental health, or recent nutrition, and exercise trends.

A minimum of three years of experience helping people manage their health, ideally in a clinical setting and/or a remote health coaching setting A degree in a health-related field Experience with counseling or education of disease management in a medical setting as well as recent nutrition and exercise trends. Passion and enthusiasm for helping people change their lives A diversity- and inclusion-first mindset Detail-oriented and team-first mindset A resourceful nature, and creativity to help people engage in their health Fluent in English (written and verbal) Bilingual in English and Spanish a huge plus Some experience in a clinical setting Some knowledge of cardiac rehabilitation Experience working with an elderly patient population Bonus Points Experience - coaching in smoking cessation, diabetes management, and special populations.

Conducting initial assessments for patients who are enrolling in our virtual cardiac recovery program. Educating patients on program benefits and the importance of risk factor modification. Coaching individuals through electronic (chat) messaging and video sessions. Problem-solving and supporting individuals’ current and evolving goals. Adapting in-clinic best practices to a remote-care delivery model. Completing individualized treatment plans for patients starting the program to include: nutrition assessment, psychosocial assessment, fitness assessment, and co-morbidities assessment. Translating the latest up-to-date, evidence-based best practices for chronic condition management into a relatable and empowering approach. Motivating and encouraging patients during initial visits. Basic understanding of cardiac procedures and medications. Reviewing medical history. Goal setting and motivational interviewing for special populations. Basic understanding of clinical documentation

Recora

Healthcare Advocate - Nurse Patient Advocate

Posted on:

May 24, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

New York

Our mission is to empower individuals facing health challenges by providing compassionate, expert-guided care advocacy services. We are dedicated to ensuring that every patient receives personalized support, clear guidance, and seamless care coordination. Healthcare is complicated and overwhelming. We are committed to helping our patients navigate these complexities with clarity, empathy, and unwavering support.

You are deeply committed to ensuring that patients receive the care, guidance, and support they need to navigate their health journey with confidence. You believe in breaking down barriers to care, advocating for patients' needs, and making high-quality care more accessible—especially from the comfort of home. You’re known for your empathy, strong communication skills, and ability to build trust with patients and caregivers. Your problem-solving mindset and ability to collaborate with clinical teams fuel your success in helping patients overcome obstacles, access critical resources, and actively participate in their own care. Patient Advocates will act as a liaison between patients with chronic conditions and the healthcare system. This role focuses on ensuring patients receive comprehensive, coordinated care, and that they are empowered to make informed decisions about their health.

Education & Licensure: Registered Nurse (RN) with an active and unrestricted state license. Bachelor of Science in Nursing (BSN) preferred, but Associate Degree in Nursing (ADN) with relevant experience considered. Experience: Minimum of 2 years of clinical nursing experience, preferably in case management, patient advocacy, home health, chronic disease management, or a similar role. Experience working with Medicare patients and high-risk populations preferred. Skills & Competencies: Strong knowledge of healthcare systems, care coordination, and patient advocacy principles. Excellent communication and interpersonal skills to engage with patients, families, and healthcare providers. Ability to assess patients' health needs, develop care plans, and educate patients on self-management strategies. Familiarity with social determinants of health and ability to connect patients to community resources. Critical thinking and problem-solving abilities to navigate complex healthcare situations. Proficiency in electronic health records (EHR) and telehealth platforms preferred. Other Requirements: Ability to work independently while collaborating within a multidisciplinary care team. Empathy, patience, and a commitment to patient-centered care. Flexibility to adapt to a fast-paced and evolving healthcare environment

Conduct detailed assessments of patients' health status, needs, and preferences. Develop and coordinate individualized care plans in collaboration with the healthcare team. Educate patients and their families about disease processes, treatment options, and self-care strategies. Advocate for patients' needs within the healthcare system, ensuring timely access to services and treatments. Assist patients in scheduling appointments, managing referrals, and coordinating among multiple healthcare providers.

EPITEC

Nurse

Posted on:

May 24, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Michigan

Remote in Michigan *Must have an active RN License in the state of Michigan* Holidays: department is open 365 – all contractors are required to work “minor holidays” such as the day after thanksgiving, Christmas eve, NYE, - They do work Christmas day, New Years Day, Labor Day, memorial day Weekend time: rotating schedule for weekends – it’s typically 4 weekend days per quarter is the bare minimum. A sign up sheet is sent out months prior for folks to sign up for weekends they are and are not available. Stays at 40 hours each week.

Top 3 Required Skills/Experience – Strong Clinical Background - Ability to critically evaluate clinical data and medical records to ensure accuracy and compliance with utilization management/clinical decision support for Medicare Advantage member Attention to detail and organization skills - Reviewing the medical documents across multiple programs. Advanced Computer Skills - Proficiency in using various software tools and platforms for data analysis and reporting Required Skills/Experience – The rest of the required skills/experience. Include: Certification in Case Management or Utilization Review - experience in the review process for post acute care settings ie Skilled Nursing Facility, Long Term Acute Care and / or Home Health Care. Time Management Skill - Ability to manage multiple reviews and meet deadlines in a fast-paced environment. Advanced Computer Skills – experience with various software tools, Microsoft Office and utilization of multiple monitors with WPM at minimum of 45-50.

Otsuka Pharmaceutical Companies (U.S.)

Senior Manager, Clinical Management

Posted on:

May 24, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New Jersey

Under the direction of the Director/Associate Director of Clinical Management, the Senior Clinical Study Manager is responsible for the oversight and management of Otsuka clinical studies, including coordination with other relevant parties (e.g., other Otsuka departments, external service providers (ESPs), etc.). Responsibilities include the planning, execution and completion of clinical trials according to applicable regulations and guidance; ICH Guidelines Good Clinical Practices (GCP), and Otsuka SOPs, within agreed-upon timeframes and budget.

Knowledge/ Experience and Skills: Comprehensive knowledge of clinical operations, drug development process, roles, and responsibilities of individuals within the project team, standard operating procedures (SOPs) and GCP/ICH regulations. Thorough knowledge of contract research organizations (CROs), outsourcing, and evaluation of work performed against vendor Statement of Work (SOW). Strong understanding of the clinical and scientific basis for assigned clinical program, with the ability to translate that knowledge in operational management. Strong understanding of global regulatory requirements. Strong communication, organization, planning, analytical, problem solving, and people management skills. Demonstrated experience with working with the Microsoft suite of programs (e.g., Word, Excel, PowerPoint, Outlook, etc.) Good understanding of clinical trial related software (e.g., eCRFs, IRT, CTMS, etc.). Ability to travel up to 25%. Educational Qualifications Required: Bachelor’s Degree or Registered Nurse (RN). Minimum of 10 years industry experience with seven (7) years in clinical trial management experience. Preferred: Previous supervisory experience. Competencies Accountability for Results - Stay focused on key strategic objectives, be accountable for high standards of performance, and take an active role in leading change. Strategic Thinking & Problem Solving - Make decisions considering the long-term impact to customers, patients, employees, and the business. Patient & Customer Centricity - Maintain an ongoing focus on the needs of our customers and/or key stakeholders. Impactful Communication - Communicate with logic, clarity, and respect. Influence at all levels to achieve the best results for Otsuka. Respectful Collaboration - Seek and value others’ perspectives and strive for diverse partnerships to enhance work toward common goals. Empowered Development - Play an active role in professional development as a business imperative.

Provides oversight and management of clinical studies at Otsuka, including planning, execution, and completion of clinical trials according to all applicable regulations and guidance, ICH/GCP, and Otsuka SOPs. Contribute to the development and review of all critical clinical study documents, including clinical protocols, informed consent forms, or other study-related clinical documents. Provide input into and approval of the identification, evaluation, and selection of CROs, outside vendors (e.g., central labs, central IRB, IVRS, etc.), and investigative sites. Provide leadership and guidance to clinical team to ensure all clinical study activities are completed in accordance with applicable regulations and guidance; ICH GCP, and Otsuka SOPs. Communicates and coordinates clinical project-related activities and progress across all relevant cross-functional departments. Provide management personnel with timely updates on progress and changes in scope, schedule, and resources as required. Participate in forecasting study expenditures and resourcing needs. Ensure internal clinical team and vendors manage and monitor study-related budget and expenses to meet forecast. Provide timely communication of any variances in budget forecast to the Director/Associate Director. Establish communication flow with CRO and investigative sites to maximize compliance with study protocol. Provide oversight of ESP in its conduct of the day-to-day operations of assigned trial(s), as assigned. Participates in ongoing review of clinical trial data focusing on data integrity, trending and consistency. Supports project level inspection readiness activities, including responsibility for ensuring the completeness, timeliness and quality of the TMF. Serve as Clinical Management representative for review of protocols within and across portfolios, as assigned. Participate in program-level risk mitigation strategies and collaborate with ESPs on study-level risk mitigation and management activities. Represent Clinical Management in departmental and cross-functional initiatives, as assigned. Leads and/or contributes to assigned departmental, ESP and corporate standardization and continuous improvement efforts. May have supervisory responsibilities including: Coordinating the training and onboarding of new employee(s) on corporate culture, corporate goals/vision and departmental policies and processes. Assuring compliance with departmental, SOP, compliance, and corporate training Ensuring assigned staff have access to all required materials, systems, and training to complete job responsibilities. Setting clear performance expectations and individual development plans and providing specific and frequent feedback to the employee on his/her performance.

Otsuka Pharmaceutical Companies (U.S.)

Associate Director, Thought Leader Liaison, Renal Rare Disease - Southeast

Posted on:

May 24, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

New Jersey

The Associate Director, TLL, Renal Rare Disease, is a field-based, customer facing, non-sales position on Otsuka’s Rare Renal team focused on enhancing and improving interactions with Renal Key Opinion Leaders (KOLs) at academic centers and leading community practices. The TLL will work closely with cross-functional leaders from Marketing, Medical Affairs, Sales, Key Accounts, Market Access, Patient Access and the Renal Leadership Team to ensure alignment with overall strategy and tactical execution. The attributes that are critical for success include leadership, strategic thinking, clinical and disease state acumen, strong collaboration, communication, and the ability to execute key initiatives and provide timely feedback. Position Overview: The Thought Leader Liaison (TLL) is a senior, field-based role within the commercial organization, responsible for engaging with Key Opinion Leaders (KOLs) to support strategic marketing initiatives, insight generation, and promotional activities. This role serves as a critical link between the company and KOLs ensuring alignment with business objectives and compliance with regulatory guidelines.

Education: Understand, interpret, present and educate/present to KOLs and customer groups on complex and scientific/clinical information. Assess and understand KOL level of clinical acumen of complex and clinical topics. Qualifications: Bachelor’s degree required; advanced degree preferred (MD, PharmD, PhD, RN/BSN, PA). Experience in the biotechnology/pharmaceutical industry. Experience in product marketing, field sales, clinical roles, or thought leader engagement. Strong clinical, technical, and scientific knowledge in complex disease states. Ability to travel extensively (>50% of the time) including overnight and weekend travel. Skills and Competencies: Excellent communication and interpersonal skills. Strong analytical and strategic thinking abilities. Proven ability to build and maintain professional relationships. Experience working cross-functionally in a matrixed environment. Ability to manage multiple projects compliantly, efficiently, and effectively. Proficiency in developing and executing field-based marketing initiatives. Experience with thought leader engagement, advisory boards, and speaker bureau management. Other Requirements: Willingness to travel >50% of the time, including significant overnight and weekend travel. Ability to travel for meetings, conferences, and KOL engagements. Candidates must live within the stated geography or be willing to relocate. Competencies Accountability for Results - Stay focused on key strategic objectives, be accountable for high standards of performance, and take an active role in leading change. Strategic Thinking & Problem Solving - Make decisions considering the long-term impact to customers, patients, employees, and the business. Patient & Customer Centricity - Maintain an ongoing focus on the needs of our customers and/or key stakeholders. Impactful Communication - Communicate with logic, clarity, and respect. Influence at all levels to achieve the best results for Otsuka. Respectful Collaboration - Seek and value others’ perspectives and strive for diverse partnerships to enhance work toward common goals. Empowered Development - Play an active role in professional development as a business imperative.

KOL Development and Advocacy: From a Commercial perspective identify, build and maintain relationships with KOLs and Renal organizations. Develop and maintain KOL engagement plans. Plan and execute national and regional congress engagement plans with a focus on meaningful engagements with senior leadership. Support commercial KOL influence mapping initiatives by developing profiles. Monitor KOL insights about current and future treatment patterns that may impact the commercial strategy and provide feedback for consideration. Act as a liaison between KOLs and the company for on-label activities, including office-based cross-functional colleagues and teams (Marketing, Medical, Diagnostics, and Executive leadership). Assist in the facilitation and execution of commercial advisory boards through the identification of key advisors equipped to provide compelling insights. Promotional Speaker Bureau Management: Identify and recruit KOLs for National and Regional faculty and speaker bureaus. Train, evaluate, and educate physician speakers to provide high-quality compliant focused branded and unbranded education. Ensure appropriate and compliant execution of speaker programs. Monitor speaker performance at live programs. Work with marketing and contracted speakers to gain and synthesize feedback in support of the evolution of promotional programming content, case studies for potential publications, and other commercial projects. Insight Generation: Collaborate with cross-functional commercial teams to provide KOL insights to help shape brand strategy. Identify market and brand gaps and provide feedback for content development or change of strategic direction. Disseminate KOL insights to broader stakeholders, including marketing, sales, and market access teams. Initiate and pursue opportunities to involve the company in meaningful programs with thought leaders. Congress and Event Leadership: Identify, sponsor, attend and gather intelligence and KOL insights at all relevant congresses and society meetings. Lead, plan and execute KOL engagement plans at all relevant Congresses Facilitate clinical and commercial conversations and provide guidance & updates to on label scientific content and materials with KOLs through 1:1 and group engagements.

Otsuka Pharmaceutical Companies (U.S.)

Patient Nurse Case Manager

Posted on:

May 24, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

New Jersey

The Patient Nurse Case Manager (PNCM) is a dynamic, field-based role that serves as a crucial educator for patients. This position helps to execute against a “patient empowerment” care model, and combines the responsibilities of patient disease-state and education, injection training support, and access management to provide comprehensive support throughout the patient journey. The PNCM is an empathetic and trusted resource, responsible for engaging with the patient community, and addressing barriers to treatment adherence.

Minimum Requirements: Bachelor's degree Nursing degree 5+ years of business experience in the healthcare or biotech industry Experience engaging with patients and caregivers, preferably in the relevant therapy area Familiarity with legal and regulatory components of the pharmaceutical and biotech industries (e.g., FDA regulations, Anti-Kickback Statute, HIPAA) Valid driver's license and ability to travel 60-80% of the time, including evenings and weekends Preferred Qualifications: Advanced degree in a related field Background in advocacy, counseling, nursing, or social work Case management experience in the specific therapy area Bilingual skills, particularly Spanish Key Skills: Exceptional empathy and active listening abilities Excellent written and verbal communication Problem-solving and critical thinking capabilities Ability to influence without authority and collaborate across teams Adaptability and positive attitude in a fast-paced environment Superior organizational and time management skills Customer service focus and professionalism Physical Requirements: This role requires the ability to travel by various means of transportation, work comfortably in clinical settings, use computers and communication devices, engage in complex problem-solving, and maintain general availability during standard business hours. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job. Join our team and make a meaningful impact on patients' lives by combining education, advocacy, and access support in this rewarding role! Competencies: Accountability for Results - Stay focused on key strategic objectives, be accountable for high standards of performance, and take an active role in leading change. Strategic Thinking & Problem Solving - Make decisions considering the long-term impact to customers, patients, employees, and the business. Patient & Customer Centricity - Maintain an ongoing focus on the needs of our customers and/or key stakeholders. Impactful Communication - Communicate with logic, clarity, and respect. Influence at all levels to achieve the best results for Otsuka. Respectful Collaboration - Seek and value others’ perspectives and strive for diverse partnerships to enhance work toward common goals. Empowered Development - Play an active role in professional development as a business imperative.

Develop and execute regional patient engagement plans that align with commercial priorities, in collaboration with Patient Advocacy Educate patients and caregivers in 1:1 sessions about disease state, how to understand their bodies and navigate their lifestyle to manage their disease, and recommending advocacy programs Conduct comprehensive assessments of individual patient needs inclusive of understanding of their disease state, if they are “injection naïve” and their comfort with their support system Build and maintain relationships with patients and their caregivers to promote patient empowerment Serve as the primary point of contact for resolving issues impacting treatment initiation and ongoing therapy Coordinate with cross-functional teams to ensure compliant and effective patient outreach and support Track and communicate progress on data-driven performance objectives to leadership and stakeholders

Syneos Health

Research Nurse - Corpus Christi, Texas (per-diem)

Posted on:

May 24, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

Illingworth Research Group provides a range of patient focused clinical services to the pharmaceutical, healthcare, biotechnology and medical device industries. These include mobile research nursing, patient concierge, medical photography and clinical research services. Illingworth are experts with experience across all study phases and in a diverse range of therapeutic areas. Illingworth Research Group is a global organization operating in over 45 countries, bringing clinical research directly into the home of the patient, to improve the experience of patients involved in clinical trials and the quality of their lives.

Are you a Registered Nurse who would like to be involved in working in a variety of research projects for ground-breaking patient treatments? We are looking for motivated and enthusiastic nurses who combine high quality clinical skills with a compassionate, engaging personality and a dedication to ensure exceptional patient outcomes.

Experienced Registered Nurse (Adult or Pediatric) Experience and knowledge of working in clinical research trials with ICH-GCP (Good Clinical Practice) Certification - (Training can be provided) Attention to detail and highly organized Ability to prioritize and manage multiple tasks Excellent verbal and written communication skills in English and the ability to complete detailed data Ability to work with initiative independently and as part of a wider team Good IT (Information Technology) skills and a working knowledge of computer software Trained in Handling and Transport of Hazardous Substances (preferable- training can be provided) Our studies require a variety of Clinical skills (some desirable and not all essential, depending on project requirements). Phlebotomy skills (Venipuncture) and handling, processing of blood. Sub cutaneous injections ECGs, observations and taking specimen collections. Cannulation and administration of Intravenous Therapies Experience working with central venous access PLEASE NOTE This role will require you to travel, a driving license and access to a vehicle is essential.

Netsmart

Clinical Appeals Nurse (PRN)

Posted on:

May 24, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Kansas

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.

Responsible for reviewing medical records and preparing clinical appeals in response to medical necessity denials and diagnosis-related groups (DRG) reassignments

Required: Bachelor's of Science in Nursing (BSN) or equivalent degree Current and unrestricted RN license At least 5 years of clinical experience in acute care settings At least 3 years of experience in case management, utilization review, or clinical appeals Exceptional written and verbal communication skills Proficiency with MS Office suite, particularly Word and Excel Strong analytical and problem-solving skills with attention to detail Preferred: Experience with payer-side case management or medical director-level review Expectations: Comfortable with remote work arrangements and virtual collaboration tools May require occasional travel for conferences, client meetings, or in-person hearings Physical demands include extended periods of sitting, computer use, and telephone communication

Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to support appeal arguments Participate in Administrative Law Judge (ALJ) Hearings, presenting oral arguments to support the reversal of Medicare denials Analyze denial patterns and contribute insights to help reduce future denials Collaborate with the appeals team and hospital clients to provide updates on appeal statuses and outcomes Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to the appeals process

Alignment Health

RN Case Manager – Transition of Care (Outpatient, Bilingual Spanish or Vietnamese) – Remote

Posted on:

May 24, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

Alignment Health is seeking a remote, bilingual Spanish or Vietnamese, RN Case Manager, TOC (Transition of Care) to join the case management team (Must have California RN License). The Case Manager – Transitions of Care (Outpatient) ensures a smooth transition for members after a hospital or Skilled nursing facility discharge by coordinating care, providing resources, and educating members/families about the post discharge care plan to support optimal health outcomes. Responsibilities include all aspects and activities responsible for monitoring the delivery of care to Alignment Healthcare members. Performs duties mostly telephonically. Schedule: Must be willing to work Mon - Fri, 8am - 5pm Pacific Time

Job Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Experience Required: 2-3 years of clinical care management experience; or any combination of education and experience, which would provide an equivalent background. Preferred: 3-5 years of clinical care management experience; or any combination of education and experience, which would provide an equivalent background. Education/Licensure Required: Active, valid, and unrestricted Registered Nursing (RN) license in California (non-compact) Willing to obtain licensure in other designated states (Non-compact: NV; Compact: AZ, NC, TX) within the first 6 months of employment (licensure fees reimbursed by the company) Preferred: Case Management Certification. Knowledge: Knowledge of Medicare Managed Care Plans, insurance regulations and community resources Specialized Skills Required: Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others. Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors; Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. Report Analysis Skills: Comprehend and analyze statistical reports. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Develop and implement individualized discharge plans in collaboration with the interdisciplinary team, patients, and families. Coordinate with healthcare providers, home health agencies, rehabilitation facilities, and community resources to ensure continuity of care. Facilitate timely referrals to necessary services, including home health, physical therapy, occupational therapy, and social support. Monitor patient progress and adjust discharge plans as needed. Provide comprehensive education to patients and families regarding their medical condition, treatment plan, medications, and post-discharge care instructions. Answer questions and address concerns related to discharge planning and post-discharge care. Empower patients and families to actively participate in their care and self-management. Identify and access appropriate resources and services for patients and families, including financial assistance, transportation, and community support programs. Advocate for patients' needs and ensure access to necessary resources. Maintain accurate and up-to-date patient records and documentation related to discharge planning and post-discharge care. Communicate effectively with all members of the interdisciplinary team, patients, and families. Participate in care conferences and team meetings to ensure effective communication and coordination of care. Participate in quality improvement activities to identify areas for improvement in discharge planning and post-discharge care. Stay current with best practices and trends in care management and discharge planning.

Alignment Health

Inpatient SNF Review Nurse (RN or LVN California License Required)

Posted on:

May 24, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

Alignment Health is seeking a remote Inpatient SNF Review Nurse (RN or LVN California License Required) to join the utilization management team. The Inpatient SNF Review Nurse assists patients through the continuum of care in collaboration with the patient’s primary care physician, facility case manager, discharge planner and employing contracted ancillary service providers and community resources as needed. Assures that services are provided at the most appropriate, cost effective level of care needed to meet the patient’s medical needs while maintaining safety and quality.

Experience: Required: Minimum 3 years of general case management skills. Minimum of two years of experience utilizing Milliman Care Guidelines to justify Inpatient versus Observation Length of stay: including review of diagnosis and length of stay. Two consecutive years related experience in a managed care setting as an inpatient case manager Preferred: Experience with a Senior population. Education Required: Successful completion of an accredited Licensed Vocational Nursing Program Preferred: Associates or Bachelors Degree Specialized Skills Required: Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others. Excellent critical thinking skills related to nursing utilization review Knowledge of Medicare Managed Care Plans Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors; Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. Report Analysis Skills: Comprehend and analyze statistical reports. Preferred: Knowledge and experience in complex/catastrophic case management preferred Licensure Required: Current, Active and Unrestricted California (Non-Compact) Licensed Vocational Nurse. Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company. Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, hand, or feel and talk or hear. The employee is frequently required to reach with hands and arms The employee is occasionally required to climb or balance and stoop, or kneel The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Performs reviews of inpatients with complex medical and social problems. Generates referrals to contracted ancillary service providers and community agencies with the agreement of the patient’s primary care physician. Performs follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting. Reviews inpatient admissions timely and identifies appropriate level of care and continued stay based on acceptable evidence-based guidelines used by AHC. Effectively communicates with patients, their families and or support systems, and collaborates with physicians and ancillary service providers to coordinate care activities. Identifies Members who may need complex or chronic case management post discharge and warm handoff to appropriate staff for ambulatory follow up, as necessary. Communicates and collaborates with IPA/MG as necessary for effective management of Members. Assigns and provides daily oversight of the activities and tasks of the CCIP Coordinator. Records communications in EZ-Cap and/or case management database. Arranges and participates in multi-disciplinary patient care conferences or rounds. Monitors, documents, and reports pertinent clinical criteria as established per UM policy and procedure. Monitors for any over utilization or underutilization activities. Generates referrals as appropriate to the QM department. Enters data as necessary for the generation of reports related to case management. Reports the progress of all open cases to the Medical Director, Director of Healthcare Services and Manager of Utilization Management. Performs other duties as assigned.

Bluestone Physician Services

Behavioral Health Care Manager / Dementia Case Manager - Part-time 24 hrs/week

Posted on:

May 24, 2025

Job Type:

Part-Time

Role Type:

Behavioral Health

License:

None Required

State License:

Florida

Bluestone Physician Services delivers great outcomes by bringing exceptional care to patients living with complex, chronic conditions and disabilities. Our unique, robust model of care goes beyond primary care services — our multidisciplinary care teams collaborate with patients, their families and other healthcare providers to deliver care that is preventative, proactive and tailored to their unique needs. Using an evidence-based approach focused on quality care management and data-driven medical decisions, Bluestone care teams collaborate to manage patients’ chronic conditions, address social determinants of health, manage transitions to and from inpatient settings, provide behavioral health support and more. Under our model of care, Bluestone patients experienced 21% fewer ER visits, 36% fewer hospitalizations and 41% fewer hospital readmissions compared to patients with similar conditions and complexities over the same time period. Our care teams travel directly to patients who reside in Assisted Living, Memory Care and Group Home communities throughout Minnesota, Wisconsin and Florida and are supported by clinical operations and administrative colleagues who work remotely or at our corporate offices in Stillwater, Minnesota, and Tampa, Florida. Our success is only possible through the hard work of our employees who bring our core values of Dedication, Excellence, Collaboration and Caring to life every day. Bluestone has been named to the Star Tribune's Top Workplace list for the 12th year in a row! Bluestone also achieved Top Workplace USA 2021-2024! In 2022, Bluestone Accountable Care Organization (ACO) was the best performing ACO in the country as measured by the overall savings per Medicare beneficiary.

The Behavioral Health Care Manager / Dementia Case Manager (Part-time 24 hrs./week) is a core member of the collaborative care team, which includes a Bluestone's Primary Care Providers, Nurses, Care Managers and other medical professionals. The Behavioral Health Care Manager is a patient-focused role, primarily working with a complex geriatric population and their families within their home environment (Assisted Living, Memory Care, and/or Independent Living). Additionally, this role is an expert in the field of dementia care, Alzheimer's, memory loss, and/or mental health targeting interventions that improve the patient's overall quality of life. Schedule: Part-time position, day shift hours, no evenings, weekends or holidays. Location: This position entails a mix of remote work, as well as direct patient care mainly throughout Apopka, Celebration, Mount Dora, Ocoee, Orlando, Tavares, Winter Garden. Salary Range: $33,000 - $39,000, Salary will be commensurate with experience.

Education/Certification/Experience: Formal education or specialized training in behavioral health, including social work, nursing, psychology, gerontology, music therapy or related fields One or more years of experience in memory care and/or dementia-related care Valid driver’s license required Knowledge/Skills/Abilities: Knowledge of behavioral health, dementia, and care planning Knowledge of assessments, screenings, and care planning for mental health disorders Ability to engage patients in a therapeutic relationship when appropriate Ability to work independently with excellent time-management and organizational skills Ability to maintain professional relationships with patients and other members of the care team Ability to communicate effectively and professionally, both verbally and in writing, with diverse populations Intermediate-level computer proficiency with email, fax, word processing, spreadsheets, and databases Excellent customer service skills Demonstrated ability to read, write, speak, and understand the English language

Provide ongoing necessary education and support to patient's care team on Alzheimer's disease and related memory loss/dementia and their impact on cognitive function Provide ongoing necessary education and support to patient’s care team on Mental Illness diagnoses and their impact on cognitive function Establish care plans that outline interventions to reduce behavioral episodes and improve function and safety Provide behavioral interventions using evidence-based techniques such as motivational interviewing, problem-solving, modeling, active listening, other techniques as appropriate Identify and provide de-escalation strategies and crisis resources for caregivers, patients, and families Provide effective non-pharmacological behavior prevention and reduction solutions Identify strategies to anticipate and calmly de-escalate distress behaviors Systematically track treatment response and monitor patients for changes in clinical symptoms and treatment side effects or complications Complete validated rating scales monthly to monitor and assess response to care plan interventions Participate in weekly caseload consultations with psychiatric consultants Facilitate referrals for the clinically indicated services outside of the organization (e.g. mental health specialty care, social services, support groups, etc.) Act as a Bluestone ambassador for community staff through education and relationship building

Bluestone Physician Services

Clinical Liaison, LPN or CMA (Remote in MN, WI or FL)

Posted on:

May 24, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Minnesota

Bluestone Physician Services delivers great outcomes by bringing exceptional care to patients living with complex, chronic conditions and disabilities. Our unique, robust model of care goes beyond primary care services — our multidisciplinary care teams collaborate with patients, their families and other healthcare providers to deliver care that is preventative, proactive and tailored to their unique needs. Using an evidence-based approach focused on quality care management and data-driven medical decisions, Bluestone care teams collaborate to manage patients’ chronic conditions, address social determinants of health, manage transitions to and from inpatient settings, provide behavioral health support and more. Under our model of care, Bluestone patients experienced 21% fewer ER visits, 36% fewer hospitalizations and 41% fewer hospital readmissions compared to patients with similar conditions and complexities over the same time period. Our care teams travel directly to patients who reside in Assisted Living, Memory Care and Group Home communities throughout Minnesota, Wisconsin and Florida and are supported by clinical operations and administrative colleagues who work remotely or at our corporate offices in Stillwater, Minnesota, and Tampa, Florida. Our success is only possible through the hard work of our employees who bring our core values of Dedication, Excellence, Collaboration and Caring to life every day. Bluestone has been named to the Star Tribune's Top Workplace list for the 12th year in a row! Bluestone also achieved Top Workplace USA 2021-2024! In 2022, Bluestone Accountable Care Organization (ACO) was the best performing ACO in the country as measured by the overall savings per Medicare beneficiary.

The Clinical Liaison plays a pivotal role in coordinating clinical care for our geriatric and disabled patient population. They are responsible for and assist with the delivery of high-quality healthcare services to meet the needs of our patients. The Clinical Liaison will work collaboratively with internal and external customers to facilitate needed services. Facilitate the coordination of care for patients, ensuring a comprehensive and patient-centered approach. Clinical Liaisons work remotely and provide support during our regular business hours. Schedule: Full time position, day shift hours, no evenings, weekends or holidays. Hours are 8am to 4:30pm Monday thru Thursday & 8am to 3pm on Fridays. Location: This remote role must be located in one of the Bluestone Markets (Minnesota, Wisconsin or Florida). Salary: $23.00 - $25.00 per hour. Salary will be commensurate with experience.

Education/Certification/Experience: Medical certification or license required; CMA, LPN 3-5 years of relevant medical office experience Knowledge/Skills/Abilities: Proficient in navigating electronic medical record systems and working with patient care Clear and effective verbal and written communication skills Excellent interpersonal and customer service skills Detail oriented and accurate Demonstrated ability to work independently Ability to work with Site Supervisors, Providers and others on the care team Computer proficient Medical terminology knowledge and understanding of patient care notes Demonstrated ability to read, write, speak, and understand the English language

The main responsibility of this Clinical Liaison role is to support the clinical call line to address clinical inquiries and provide necessary information to patients, families, external healthcare agencies, etc. Foster clear and efficient communication channels within the internal and external healthcare team. Provide continuity of care for our patient care team by connecting patients to resources and services Monitors continuous quality improvement for optimal patient outcomes Maintain a good working relationship and effective communication both within the department and with other departments for the benefit of the patient Additional duties include: Schedule and coordinate appointments with specialty providers. Assist in medication refill process and support pharmacy inquiries. Complete prior authorizations for medications, specialty visits and durable medical equipment. Assist with the durable medical equipment process and ensure timely order submission and follow-up. Maintain records and enter lab, diagnostic imaging, and immunization history. Complete home-health reviews. Provide education about healthcare directives and assist with completion as needed Complete health plan delegated annual chart reviews to assess for gaps in care

Amerit Consulting

Medicare Clinical Appeals RN ** 100% Remote for California Residents **

Posted on:

May 24, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

California

Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally, as well as small to mid-sized organizations on a local & regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients’ businesses forward.

Our client, a mutual benefit corporation and health plan provider, seeks an accomplished Medicare Clinical Appeals RN. *** Candidate must be authorized to work in USA without requiring sponsorship *** *** Location: Rancho Cordova, CA (100% Remote acceptable) *** Duration: 5 months contract w/ possible extension or conversion to FTE role Notes: Work hours: 08:00am – 05:00pm PT or 08:30am – 05:30pm PT. 100% remote for California residents.

Qualifications: The ideal candidate will have previous insurance/managed care experience and hold at least a Bachelor’s Degree in Nursing. Higher-level certifications are highly desirable. Knowledge of Medicare benefits and appeal reviews. Requires 2-4 years of health insurance or related experience. Demonstrate the ability to act independently using sound clinical judgement. Preferred Qualifications: Experience with pharmacy clinical reviews. Works well in a fast-paced team environment. Excellent communication skills.

The Medicare Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either preservice, post service or claim denial. In this role you will be responsible for performing first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, pharmacy policies and nationally recognized sources such as MCG, NCCN, and ACOG. Reviews may also be performed for medical necessity, non-covered benefits and to meet the criteria for the coding billed.

Florida Blue

Concurrent/Post-Acute Review Nurse RN - Remote

Posted on:

May 24, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Join our team as a Concurrent/ Acute Review Nurse RN, where you'll play a vital role in ensuring our members receive the right care at the right time. As a CRN, you'll build strong relationships with facility case managers, identify opportunities for care transitions, and help reduce hospital readmissions - all while making a meaningful impact on the lives of our members.

2+ years’ recent experience (within the past 3-5 years) clinical experience in a hospital, LTAC, Rehab, Skilled Nursing Facility setting evaluating hospital benefit determination, medical necessity and appropriate level of care RN - Registered Nurse - State Licensure And/Or Compact State Licensure Florida Experience in one or more of the following: home health care, rehab, SNF, utilization review, discharge planning or case management Referrals for possible Case Management activities that focus on acute and non-acute services, outpatient services and/or community resources Experience with the Healthcare industry and Managed Care Related Bachelor’s degree or additional related equivalent work experience Nursing What is Preferred: Experience in post-acute care admission Bachelor’s degree Nursing, Healthcare or Business General Physical Demands Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

Serve as a point of contact for providers to assist in navigating members them through the continuum, educate regarding benefits, identify candidates for Care Programs and provide information pertaining to the network and network access Evaluate members in the Hospital, Skilled Nursing Facility, LTAC, Acute Inpatient Rehab for benefit determination, medical necessity and appropriate level of care utilizing member benefits and InterQual or other medical necessity criteria. Determine member's discharge status and identify and coordinate any additional needs and services that require ongoing Care Coordination services Collaborate with Medical Directors, Managers, Co-workers and other departments including Case Management and Care Partners and participate in weekly case review

Corewell Health

PA/NP - Virtual Urgent Care - Remote

Posted on:

May 23, 2025

Job Type:

Full-Time

Role Type:

License:

NP/APP

State License:

Michigan

he Corewell Health West Medical Group is part of a not-for-profit health system serving 13 counties in West Michigan. Corewell Health West is a region of Corewell Health™, formerly the BHSH System (Beaumont Health and Spectrum Health) that provides care and coverage with an exceptional team of 60,000+ dedicated people—including more than 11,500 physicians and advanced practice providers and more than 15,000 nurses providing care and services in 22 hospitals, 300+ outpatient locations and several post-acute facilities—and Priority Health, a provider-sponsored health plan serving over 1.2 million members. Through experience and collaboration, we are reimagining a better, more equitable model of health and wellness.

Our Virtual Urgent Care team is looking for an experienced Physician Assistant or Nurse Practitioner to join their team. In this role, you will be providing virtual medical care to patients of varying type and acuity. This is a full-time position. As we care for patients of all ages, we cannot consider Adult/Gerontology trained Nurse Practitioners.

Physician Assistant: Required Master's Degree Graduate of an accredited Physician Assistant educational program LIC-Physician Assistant - STATE_MI State of Michigan Upon Hire required CRT-Physician Asst Certified (PA-C) - NCCPA National Commission on Certification of Physician Assistants Upon Hire required CRT-Basic Life Support (BLS) - AHA American Heart Association 90 Days required Or CRT-Basic Life Support (BLS) - ARC American Red Cross 90 Days required CRT-Pediatric Adv Life Support (PALS) - AHA American Heart Association 120 Days required CRT-Adv Cardiovascular Life Support (ACLS) - AHA American Heart Association 120 Days required Nurse Practitioner: Required Master's Degree Nurse Practitioners who obtained their education and certification after 2000 must show evidence of completion of a master’s, post-master’s or doctorate from a Nurse Practitioner program that is accredited by the Commission on the Collegiate of Nursing Education or the National League for Nursing Accrediting Commission 3 years of relevant experience current, relevant clinical experience Previous experience functioning in a collaborative role as a Nurse Practitioner LIC-Nurse Practitioner (NP) - State of Michigan CRT-Basic Life Support (BLS) CRT-Neonatal Resuscitation Program (NRP) CRT-Pediatric Adv Life Support (PALS)

CVS Health

Appeals Nurse Consultant - Fully Remote

Posted on:

May 23, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

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 8:00am-5:00pm 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.

Valor Health

Remote Program Manager - Nurse Call Center

Posted on:

May 23, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

None Required

State License:

Texas

Valor Healthcare is looking for a call center program manager to join our proposal team for a government contract to support the Global Nurse Advice Line (NAL) which is a service to Military Health System (MHS) eligible beneficiaries. Position Summary: The Global NAL will provide access to telehealth registered nurses for triage services, self-care advice, and general health inquiries 24 hours a day, 7 days a week. The NAL also offers customer service and care coordination services to include, provider locator support, specified military treatment facility appointing services, urgent care referral submissions, and customized military treatment facility transfers to support the military treatment facility’s capability for eligible MHS beneficiaries. The ideal candidate will have extensive experience in supervisory healthcare call centers or nurse triage positions with strong leadership and communication skills in implementing programs and projects. Schedule and Remote Eligibility: This position is remote eligible as long as you are living in one of the US states. The schedule will be a general 40 hour work week on a day shift, Monday through Friday.

Bachelor’s degree in healthcare management, business administration, communication, IT, social science, or a related field 5 years of experience with managing multiple call centers. Demonstrate knowledge of URAC Health Call Center Standards, experience in customer service, performance evaluation, and process improvement. Demonstrate experience in large volume staff training and coaching. Demonstrated strong interpersonal and communication skills.

Works with partners to develop and drive service solutions and business case development across functional groups. Involved in the coordination of translating business strategy into work programs and processes. Reviews and provides input to high-level project planning and management. Accountable for the creation and development of technology solutions appropriate to business needs and objectives Oversees implementation of program, projects, or processes Creates and delivers monthly Program Management Reviews Ensures all business functions are appropriately and consistently defined and that these functions meet the objectives of the client. Drives stream of work reporting to customer. Develops status reports, controls project scope and economics, approves changes, and manages and resolves issues, risks, and conflicts. Serves as a single point of contact and the escalation point between technical teams. Demonstrates abilities as a leader, creating a positive work environment by monitoring workloads of the team while meeting client expectations. Accountable for senior level customer relationships and satisfaction Serve in a variety of roles to include, but not limited to proposal management, proposal writing, editing, and pricing.

Cambia Health Solutions

Care Management Nurse - Idaho

Posted on:

May 23, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Idaho

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

Work from home within Idaho Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system. Who We Are Looking For: Every day, Cambia’s dedicated team of Care Management RN's are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our Care Management RN's provide clinical care management (such as case management, disease management, and/or care coordination) to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes. Oversees a collaborative process with the member and those involved in the member’s care to assess, plan, implement, coordinate, monitor and evaluate care as needed - all in service of creating a person-focused health care experience. Are you a Registered Nurse looking to transition out of bedside care and into a role that still utilizes your clinical expertise, but offers a fresh challenge? Is your goal to promote quality, cost-effective outcomes and improve overall health and wellbeing? Then this role may be the perfect fit.

Associates or Bachelor's Degree in Nursing or related field 3 years experience in case management, utilization management, disease management, or behavioral health case management Equivalent combination of education and experience will be considered Current licensure or certification in a U.S. state or territory in a health/human services discipline that permits independent assessment within the scope of practice (medical or behavioral health) Minimum 3 years (or full-time equivalent) direct clinical care experience Must possess at least ONE of the following: Certification as a case manager from the URAC-approved list Bachelor's degree or higher in health/human services-related field (psychiatric RN or Master's in Behavioral Health preferred for behavioral health positions) Current unrestricted Registered Nurse (RN) license (required for medical care management) Skills and Attributes: Knowledge of health insurance industry trends, technology and contractual arrangements. General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems. Strong oral, written and interpersonal communication and customer service skills. Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively. Strong organization and time management skills with the ability to manage workload independently. Ability to think critically and make decision within individual role and responsibility.

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

Cambia Health Solutions

Supervisor Clinical Appeals

Posted on:

May 23, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Oregon

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

Work from home within Oregon, Washington, Idaho or Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system. Who We Are Looking For: Every day, Cambia’s dedicated team of clinical leaders are living our mission to make health care easier and lives better. As a member of the initial review team, our Supervisor Clinical Appeals supervises the team and acts as a resource for nursing professionals and support staff. This role oversees and coordinates team activities to achieve business objectives and ensures that clinical appeal decisions are accurate and consistent with medical policies, reimbursement policies, provider contracts, member benefits and supported by the medical record. The position may also assist in planning, coordinating, conducting and reporting on clinical appeals – all in service of making our members’ health journeys easier. As a people leader, you are willing to learn and grow, understanding that leadership is a craft that is continuously honed as you support your team and the lives that depend upon us. Do you thrive on mentoring and supporting nursing professionals? Are you skilled at analyzing medical policies and ensuring consistency in decision-making? Then this role may be the perfect fit.

Bachelor’s degree in nursing or a related field 4 years of leadership experience 7 years of clinical experience or an equivalent combination of education and experience RN License within one of the four operating states (ID, OR, UT, WA) Certified Coder certified with the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) preferred Skills and Attributes: Demonstrated competency in setting priorities for a team and overseeing work outputs and timelines. Ability to communicate effectively, verbally and in writing to a variety of recipients/audiences. Ability to effectively develop and lead a team (including employees who may be in multiple locations or work remotely). Demonstrated experience in recognizing problems and effectively resolving complex issues. Familiarity with health insurance industry trends and technology. Demonstrated competency related to appeal procedures and clinical practices. Ability to apply best practices and designated standards. Knowledge of CPT, ICD-9 and HCPCS coding and MCG (Milliman Care Guidelines). Medicare regulations knowledge is preferred. Familiarity rules applied to appeals by accrediting bodies, state and federal governments, and employer groups.

Manages team operations including work prioritization, goal setting, and performance monitoring while ensuring compliance with medical policies and guidelines Leads staff development through coaching, training, performance reviews, and regular communication via meetings and 1:1s Partners with physician advisors and other departments to resolve complex cases and remove operational barriers Develops and maintains process documentation, implements improvements, and ensures quality standards are met Maintains clinical competency while staying current on medical practices and industry trends Provides educational updates and serves as a technical resource for staff and other departments Manages special projects and provides backup support as needed while seeking continuous improvement opportunities

Cambia Health Solutions

Care Management Nurse - Idaho

Posted on:

May 23, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Idaho

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through. At Cambia, you can: Work alongside diverse teams building cutting-edge solutions to transform health care. Earn a competitive salary and enjoy generous benefits while doing work that changes lives. Grow your career with a company committed to helping you succeed. Give back to your community by participating in Cambia-supported outreach programs. Connect with colleagues who share similar interests and backgrounds through our employee resource groups.

Care Management Nurse - Idaho Work from home within Idaho Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system. Who We Are Looking For: Every day, Cambia’s dedicated team of Care Management RN's are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our Care Management RN's provide clinical care management (such as case management, disease management, and/or care coordination) to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes. Oversees a collaborative process with the member and those involved in the member’s care to assess, plan, implement, coordinate, monitor and evaluate care as needed - all in service of creating a person-focused health care experience. Are you a Registered Nurse looking to transition out of bedside care and into a role that still utilizes your clinical expertise, but offers a fresh challenge? Is your goal to promote quality, cost-effective outcomes and improve overall health and wellbeing? Then this role may be the perfect fit.

Associates or Bachelor's Degree in Nursing or related field 3 years experience in case management, utilization management, disease management, or behavioral health case management Equivalent combination of education and experience will be considered Current licensure or certification in a U.S. state or territory in a health/human services discipline that permits independent assessment within the scope of practice (medical or behavioral health) Minimum 3 years (or full-time equivalent) direct clinical care experience Must possess at least ONE of the following: Certification as a case manager from the URAC-approved list Bachelor's degree or higher in health/human services-related field (psychiatric RN or Master's in Behavioral Health preferred for behavioral health positions) Current unrestricted Registered Nurse (RN) license (required for medical care management) Skills and Attributes: Knowledge of health insurance industry trends, technology and contractual arrangements. General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems. Strong oral, written and interpersonal communication and customer service skills. Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively. Strong organization and time management skills with the ability to manage workload independently. Ability to think critically and make decision within individual role and responsibility.

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

Centene Corporation

TeleHealth Registered Nurse - Registry

Posted on:

May 23, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Compact RN License Required PRN - At Least 29 Hours Per Month - Nights 6 - 4 hr On-Call Shifts Per Month Must be able to pass DFPS Background Check for Texas Position Purpose: Triage inbound calls, gather information, select appropriate triage guidelines, and disposition and care advice based on database protocols and department policies and procedures for a 24 hour per day/7 day a week operation. Provide clinical information and education for inbound and outbound calls providing oversight and support to the non-clinical staff.

Education/Experience: Graduate certificate from an accredited nursing program. 3+ years combined experience in critical care, pediatric, obstetrics, home health, school nursing, or emergency nursing. 5 years experience strongly preferred. Licenses/Certifications: Registered Nurse (RN) State Licensure in the State of residence and Compact State Licensure required Multiple State RN Licensures required

Conduct assessments of callers’ presenting symptoms. Develop, implement, and evaluate a plan of care for each caller presenting symptoms. Answer all calls in a timely manner. Maintain confidentiality of all caller and personnel issues. Document all call inquiries according to department policies and procedures. Participate in the collection of data for department quality projects. Promote recovery concepts and inspire hope. Possess and maintain a thorough grasp of clinical knowledge pertaining to various disease states, medications, treatments, etc. Comply with Federal and respective state’s laws regulating health management organizations and telephone information centers and all department standards and policies and procedures. Apply primary nursing knowledge while performing all aspects of assigned tasks. Performs other duties as assigned Complies with all policies and standards

CVS Health

Telehealth Registered Nurse

Posted on:

May 23, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

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

••work from Home- Candidate must reside in Texas•• At CVS Health, we believe we can change the world by improving patient lives, one call at a time. Our Telephonic Registered Nurses (RN) have patient contact in the uniqueness of a telephonic practice setting, where they are impacting lives across the country. You will continue to experience the reasons you became a nurse without having to be in a bedside patient care environment. Our Registered Nurses redefine the way health care is delivered every day. When you join our team, you'll play an integral role in educating patients with medication adherence and disease state training. As a national leader in the healthcare industry and a Fortune 7 company, we seek special RNs who not only possess strong clinical expertise with innovative ideas, but who have the deep compassion and sensitivity it takes to treat our patients. Shift and Hours for our TX Telehealth Registered Nurse role: ****This is a Monday-Friday role with hours starting from 10:30am -7:00 pm (CST) These are set hours, and this is a fulltime hourly position. Learn more about us: https:J/www.youtube.com/watch?v=4Cr04QVn3IQ&list=PLLUzEQYSggzJqVUcnROBLdpspUTuvw7_k&index=2 RN, Registered Nurse, Case Manager, Nurse, Home Health, Autoimmune, Oncology, Telehealth, Telephone, Telephonic, Health Management, Assessment, Education, Training

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

Working from home, you will be part of a specialized team on the cutting edge of patient care. Working collaboratively with health care professionals, you will provide a meaningful patient experience, while using your critical thinking skills to develop, implement, and evaluate comprehensive plans of care for multiple disease state patients. As a Telephonic Registered Nurse, you will a profound effect on the lives of the patients and caregivers via each outbound call, providing education and support for their new medication. Along with the Compliance and Persistency team, you are the continuity of care supporting defined patient populations through the use of our state-of-the-art telecommunications nursing outreach programs. To be successful in this Registered Nurse position, you must have excellent written and verbal customer service skills, as well as advanced computer skills in order to interact with patients.

ChenMed

Registered Nurse, CareLine (Telehealth) (Bilingual Spanish) (Remote)

Posted on:

May 22, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

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

The Registered Nurse 1, Care Line, is responsible for providing telephonic triage directional patient care advice for general and specific illnesses, health related issues, client counseling, patient advocacy, health education and referral and resource management to ChenMed patients and their families. Providing on-call coverage, the incumbent in this role provides remote clinical advice and assessments within license and as possible given technology and medium. The registered nurse collaborates with primary caregivers and others on the interdisciplinary care plan team to provide a team approach of care. The schedule for this position is as follows each week: Fridays 1630-0800 Saturdays 2000-0800 Sundays 2030-0830

Associate Degree in Nursing required, Bachelor’s Degree in Nursing preferred Nurse Licensure Compact license required Michigan and Illinois Nurse Licensure reguired within 90 days of hire, ability to obtain additional licenses as requested by the organization within 90 days of hire Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required Minimum of 3 years acute clinical nursing work experience preferred Minimum of 1 year virtual care experience preferred Minimum of 2 years experience in Emergency Nursing Services and Emergency Triage with older adult populations required

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

UnitedHealthcare

Clinical Appeals RN - Remote in US

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

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

As a Clinical Appeals RN for UHC Clinical Services, you will work on post-service appeals for Medicare-based claims.

Required Qualifications: Undergraduate degree or equivalent experience Unrestricted, active RN license 2+ years of RN experience in acute setting Proven working knowledge of Clinical Criteria and CMS Guidelines Proven proficiency in basic computer skills Demonstrated ability to have high speed internet installed in home for Secure Job use only Proven designated HIPPA compliant home workspace Preferred Qualifications: Undergraduate degree (BSN) Proven utilization management, prior authorization, case management or prior appeals experience Proven claims and coding experience

Review provider post-service appeals for Medicare and Retirement Gather clinical information including medical records and coverage criteria as it pertains to Medicare guidelines Discuss cases with medical directors when applicable Ability to communicate and collaborate with other teams in order to gather medical information to process cases Communicate effectively in both verbal and written documentation Must meet quality and productivity metrics Ability to work independently and prioritize Attend mandatory trainings and scheduled staff meetings Engage in respectful and courteous team dialog via email, IM and in staff meeting

Maximus

Registered Nurse

Posted on:

May 22, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

Maximus is HIRING 100 % REMOTE Position as a Registered Nurse for Medical Expert Reviewer Peer Review for Quality Management may only be used for improving the quality of health care or utilization of health care 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. Provider must have access to their own computer to complete online training, complete written reviews using MS word software, be able to access VA EMR system to review medical records and be able to access Maximus’s secure email system to receive encrypted emails. Provider can accept or decline cases; must do so within 24 hrs. Once accepted the review must be submitted within 3-5 business days, expedited cases are within 24 hours. Rate Description of Service per case: $50 to $150 per case. Case normally takes about 30 minutes to an hour + to complete either. Provider can accept or decline cases; must do so within 24 hrs. Once accepted the review must be submitted within 3-5 business days, expedited cases are within 24 hours **There is training provided for the systems used.

Active license in any state 20 hours of direct patient care per month Board Certification within exact specialty requested MUST have National Provider Identifier (NPI) number CANNOT be a VA employee, active-duty military, or provide care in military facilities 3-year experience in appropriate specialty post training (non-MD/DO) 5-year experience in appropriate specialty post training (MD/DO)

AccentCare

Territory Patient Admission Coordinator (Clinical) - Weekends Remote

Posted on:

May 22, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

California

At AccentCare, our care is most compassionate when we empathize and engage with everyone, and we are at our best when we value diverse perspectives, foster open dialogue, and enact change. And we are stronger when each of us is empowered to grow, be our unique selves, and feel a sense of inclusion and belonging. AccentCare is proud of how we are building a culture and inclusive infrastructure to help elevate the voice of all our employees with a special focus on the underrepresented and marginalized. We offer equal employment opportunities regardless of a person’s race, ethnicity, sex, sexual orientation, gender identity or expression, religion, national origin, color, creed, age, mental disability, physical disability, or any other protected classification.

Find Your Passion and Purpose as a Territory Patient Admissions Coordinator Clinical Reimagine Your Career in Corporate Healthcare As a professional, you know that what you do impacts you as much as our patients and their families, and at AccentCare, we are united in our relentless drive to reimagine care because we want to provide the service we would seek for our own families. We think it’s really special to be a part of our patient’s health journey and create incredible memories while providing world-class patient care. Friday-Monday or Saturday-Tuesday, 8:00a-7:00p PST, must be willing to work Pacific Time Zone This is a fully Remote opportunity

Licensed RN, LVN or PT in practicing state. 3-7 years of experience in facility/physician relationships with a deep understanding of facility discharge processes, preferred. Minimum of one year experience in home care, hospice, or personal care services, preferred Prior use of Electronic Medical Records (EMR), preferred Experience in dealing with a variety of payors in healthcare, e.g., Medicare, Medicaid, and commercial payers, preferred.

The Territory Patient Admission Coordinator is responsible for the timely acceptance or decline of the referral based of the predetermined criteria set by the Agency. This position’s assigned territory, may encompass one or more states in AccentCare’s operation and may change with the needs of the Company. The Territory Patient Admission Coordinator establishes and maintains communication with the clients, family members and referral sources. This role is responsible for partnering with agency staff, referral sources, and sales to achieve optimal patient satisfaction & outcomes. The Territory Patient Admission Coordinator facilitates obtaining all information and documentation necessary to complete a referral through follow up with the Agency, the Referral Source and the Client.

AccentCare

LVN Clinical Scheduler / Part-Time / Remote Weekends

Posted on:

May 22, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Georgia

At AccentCare, our care is most compassionate when we empathize and engage with everyone, and we are at our best when we value diverse perspectives, foster open dialogue, and enact change. And we are stronger when each of us is empowered to grow, be our unique selves, and feel a sense of inclusion and belonging. AccentCare is proud of how we are building a culture and inclusive infrastructure to help elevate the voice of all our employees with a special focus on the underrepresented and marginalized. We offer equal employment opportunities regardless of a person’s race, ethnicity, sex, sexual orientation, gender identity or expression, religion, national origin, color, creed, age, mental disability, physical disability, or any other protected classification.

Find Your Passion and Purpose as a LVN Clinical Scheduler, Part-Time Weekends / Remote Reimagine Your Career in Home Health As a medical professional, you know that what you do impacts you as much as your patients and their families, and at AccentCare, we are united in our relentless drive to reimagine care because we want to provide the service we would seek for our own families. We think it’s really special to be a part of our patient’s health journey and create incredible memories while providing world-class patient care. Offer Based on Years of Experience Part-time Schedule Sat & Sun: 2p-10p CST One weeknight: 5p-10p CST (to be discussed during interview) Pay range: $23-$25 per hour, based on years of experience

LVN/LPN license preferred High School Diploma or equivalent Experience with scheduling in the medical field; homecare scheduling experience preferred Required Certifications and Licensures: Minimum of one year data entry, word processing and/or medical records maintenance experience in a medical customer service environment generally required Home Health Scheduling experience preferred

Netsmart

Utilization Review Nurse, Full-Time, Multiple Shifts Available, Remote

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Kansas

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.

Are you a detail-oriented and experienced RN with a passion for ensuring quality care and appropriate resource utilization? We’re seeking a Utilization Review Nurse to join our fully remote team. In this role, you’ll conduct utilization reviews for emergency admissions and continued stays, applying InterQual criteria to support clinical decision-making and ensure compliance with healthcare standards. As a key member of our Clinical Services team, you’ll collaborate with emergency department physicians, review electronic medical records, and contribute to the efficient delivery of care. This is a full-time, 40-hour-per-week position offering flexibility within a supportive and dynamic work environment. Note: Recent experience with InterQual is required. Experience with MCG is a plus.

Required: Current and unrestricted RN license At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 2 years utilization management experience in acute admission and concurrent reviews Intermediate level experience with InterQual and/or MCG criteria within the last two years Proficiency in medical record review in an electronic medical record (EMR) Experience in Microsoft Suite including Office and basic Excel Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs Passing score(s) on job-related pre-employment assessment(s) Preferred: At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 3 years utilization management experience within the hospital setting Bachelor's of Science in Nursing (BSN) Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC) Work Schedule Requirements: This is a full-time position requiring a total of 40 hours per week, with shifts scheduled within the 9:00 AM – 9:00 PM EST window to best support our clients. Shift Options: (Varies) 8-hour shifts: 9:00 AM – 5:00 PM 1:00 PM – 9:00 PM 12-hour shifts may also be available, depending on business needs. Expectations: Comfortable with remote work arrangements and virtual collaboration tools Physical demands include extended periods of sitting, computer use, and telephone communication

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

Netsmart

Utilization Review Nurse, PRN, Remote

Posted on:

May 22, 2025

Job Type:

Part-Time

Role Type:

Utilization Review

License:

RN

State License:

Kansas

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.

Are you a detail-oriented and experienced RN with a passion for ensuring quality care and appropriate resource utilization? We’re seeking a Utilization Review Nurse to join our fully remote team. In this role, you’ll conduct utilization reviews for emergency admissions and continued stays, applying InterQual criteria to support clinical decision-making and ensure compliance with healthcare standards. As a key member of our Clinical Services team, you’ll collaborate with emergency department physicians, review electronic medical records, and contribute to the efficient delivery of care. This is a full-time, 40-hour-per-week position offering flexibility within a supportive and dynamic work environment. Note: Recent experience with InterQual is required. Experience with MCG is a plus.

Required: Current and unrestricted RN license At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 2 years utilization management experience in acute admission and concurrent reviews Intermediate level experience with InterQual and/or MCG criteria within the last two years Proficiency in medical record review in an electronic medical record (EMR) Experience in Microsoft Suite including Office and basic Excel Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs Passing score(s) on job-related pre-employment assessment(s) Preferred: At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 3 years utilization management experience within the hospital setting Bachelor's of Science in Nursing (BSN) Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC) Work Schedule Requirements: This is a PRN position requiring a total of 48 hours per month. 16 hours must be worked on the weekend per month, weekends are Sat/Sun. Required to work 4 hours on 4 Holidays per year Expectations: Comfortable with remote work arrangements and virtual collaboration tools Physical demands include extended periods of sitting, computer use, and telephone communication

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

Netsmart

Utilization Review Nurse, Part-Time, Remote (Evergreen) (Open)

Posted on:

May 22, 2025

Job Type:

Part-Time

Role Type:

Utilization Review

License:

RN

State License:

Kansas

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.

Are you a detail-oriented and experienced RN with a passion for ensuring quality care and appropriate resource utilization? We’re seeking a Utilization Review Nurse to join our fully remote team. In this role, you’ll conduct utilization reviews for emergency admissions and continued stays, applying InterQual criteria to support clinical decision-making and ensure compliance with healthcare standards. As a key member of our Clinical Services team, you’ll collaborate with emergency department physicians, review electronic medical records, and contribute to the efficient delivery of care. This is a full-time, 40-hour-per-week position offering flexibility within a supportive and dynamic work environment. Note: Recent experience with InterQual is required. Experience with MCG is a plus.

Required: Current and unrestricted RN license At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 2 years utilization management experience in acute admission and concurrent reviews Intermediate level experience with InterQual and/or MCG criteria within the last two years Proficiency in medical record review in an electronic medical record (EMR) Experience in Microsoft Suite including Office and basic Excel Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs Passing score(s) on job-related pre-employment assessment(s) Preferred: At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 3 years utilization management experience within the hospital setting Bachelor's of Science in Nursing (BSN) Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC) Work Schedule Requirements: This is a Part-time position requiring a total of 64 hours per month, minimum of 16 hours per week. 16 hours must be worked on the weekend per month, weekends are Sat/Sun. Required to work 4 Holidays per year Expectations: Comfortable with remote work arrangements and virtual collaboration tools Physical demands include extended periods of sitting, computer use, and telephone communication

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

Elevance Health

Advanced Practice Provider - Nurse Practitioner - 100% Virtual - Bilingual - Carebridge

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

Carebridge Health is a proud member of the Elevance Health family of companies within our Carelon business. Carebridge Health exists to enable individuals in home and community-based settings to maximize their health, independence, and quality of life through home care and community-based services.

Seeking Bilingual Spanish Nurse Practitioners licensed in either of the following states: MA, VA, TN, FL, IN, OH, TX, KS, AZ, IA, NM, and must have an active RN Compact license. Location: Virtual - This role enables associates to work virtually full-time, with the exception of required in-person training sessions (when indicated), providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Work Shift: 11am – 11pm CST; The NP will work six (6) 12-hour shifts and one (1) 8-hour shift in a two-week period, including Saturday and Sunday every other weekend. The Advanced Practice Provider is responsible for collaborating with company physicians, the patient’s other physicians and providers, and their family members to develop complex plans of care in accordance with the patient’s health status and overall goals and values. Provides clinical and non-clinical support to patients.

Position Requirements: Requires an MS in Nursing. Requires an active national NP certification. Requires valid, current, active and unrestricted Family or Adult Nurse Practitioner (NP) license in applicable states. Experience working with Electronic Medical Records (EMR) required. Requires 2+ years of experience in managing complex care cases. Bilingual or Multi-language skills required. Preferred qualifications, skills and experiences: Emergency Room and/or Urgent Care experience is strongly preferred. Possession of DEA registration or eligibility preferred. Experience in managing complex care cases for developmental disabilities and chronically ill patients is strongly preferred.

Provides primary and urgent health care via telephone and tele video modalities to patients who receive home and community-based services through state Medicaid programs, dual eligible members and other membership as assigned by our MCO partners. Develops and implements clinical plans of care for adult patients facing chronic and complex conditions (e.g., co-morbid medical and mental health diagnoses, limited personal resources, chronic medical conditions.). Gathers history and physical exam and diagnostics as needed and then develops and implements treatment plans given the patient’s goals of care and current conditions. Identifies and closes gaps in care. Meets the patient’s and family’s physical and psychosocial needs with support and input from the company’s inter-disciplinary team. Educates patients and families about medication usage, side effects, illness progression, diet and nutrition, medical adherence and crisis anticipation and prevention. Maintains contact with other clinical team members, patients’ other physicians and patients’ other medical providers to coordinate optimal care and resources for the patient and his or her family in a timely basis and consistent with state regulations and company health standards and policy. Maintains patient medical records and medical documentation consistent with state regulations and company standards and policy. Participates in continuing education as required by state and certifying body. Prescribes medication as permitted by state prescribing authority.

Elevance Health

Transitions of Care RN- 100% Remote, CareBridge

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Texas

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

Location: Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development Work shift: 4/10 works shift with rotating weekends and holidays per business needs. The Transitions of Care RN- 100% Virtual is responsible for participating in delivery of patient education and disease management interventions and for performing health coaching for members, across multiple lines, for health improvement/management programs for chronic diseases.

Minimum Requirements: Requires AS in nursing and minimum of 2 years of condition specific clinical or home health/discharge planning experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required. Preferred Skills, Capabilities and Experiences: Bilingual strongly preferred. Current, unrestricted, Compact RN license in applicable state(s) is highly preferred. Experience in care of adult, chronically ill patients, chronically ill pediatric patients, and patients with IDD. Home Health, Utilization Management or Case Management experience strongly preferred. Previous Transitions of Care experience a plus. Working knowledge of computers and ability to document effectively and efficiently in an electronic system. Expert communicator over the telephone, providing timely, appropriate advice and/or guidance with health care issues. Experience in care of members with multiple chronic medical conditions such as COPD, CHF, CKD, Catheters, Wounds, Psych, Special Needs Population.

Conducts behavioral or clinical assessments to identify individual member knowledge, skills and behavioral needs. Identifies and/or coordinates specific health coaching plan needs to address objectives and goals identified during assessments. Interfaces with provider and other health professionals to coordinate health coaching plan for the member. Implements and/or coordinates coaching and/or care plans by educating members regarding clinical needs and facilitating referrals to health professionals for behavioral health needs. Uses motivational interviewing to facilitate health behavior change. Monitors and evaluates effectiveness of interventions and/or health coaching plans and modifies as needed. Directs members to facilities, community agencies and appropriate provider/network. Refers member to catastrophic case management.

TriOptus

SMH Level 2 RN 192 Med Surg Psych

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

New York

Schedule- D/E/N ROTATING SHIFT SCHEDULES, Weekends/Holidays/On-Call/Callback/Charge per Unit Needs URMC will consider 48 hours straight time HCP must have recent med surg experience Great opportunity to become a member of a unique unit, only a handful of similar units in the country. Adult medical/surgical unit for patients with active co-morbid psychiatric and/or behavioral issues. This expanding unit is looking for flexible, enthusiastic and committed nurses to help us grow. Med/surg acute care experience a plus. Willingness to care for a varied patient population in a changing environment a must! Nurses are eligible for dual-certification in both medical/surgical nursing and psychiatric nursing after experience requirement attained.

RN License (NY License ONLY) Psychology Experience Required Telemetry Experience Certifications: BLS (AHA ONLY) Required/Desired Skills: SkillRequired /DesiredAmountof ExperienceTwo (2) years RN ExperienceRequired0RN License (New York ONLY)Required0BLS (American Heart Association ONLY)Required0

AltaMed Health Services

Licensed Vocational Nurse, Out-Patient Case Manager

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

LPN/LVN

State License:

California

If you are as passionate about helping those in need as you are about growing your career, consider AltaMed. At AltaMed, your passion for helping others isn’t just welcomed – it’s nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. We don’t just serve our communities; we are an integral part of them. By raising the expectations of what a community clinic can deliver, we demonstrate our belief that quality care is for everyone. Our commitment to providing exceptional care, despite any challenges, goes beyond just a job; it’s a calling that drives us forward every day.

Graduation from an accredited LVN nursing program. Current valid License as a Licensed Vocational Nurse Experience in and willingness to be part of a multi-disciplinary team. The LVN CM is part of a cohort of LVNs, Social Workers, and Care Coordinators that are supported and guided by an RN Case Manager. Experience with physically or mentally impaired adults and/or the geriatric population. Three years' experience in public health nursing, acute care, case management, and/or in-home health care required; minimum of 2 years of managed care experience in case management with a focus on inpatient and/or outpatient ambulatory care preferred. Bilingual in English and Spanish preferred. A minimum requirement of a valid BLS certification or higher, following the American Heart Association (AHA) or the American Red Cross guidelines.

The LVN Case Manager may provide daily care coordination, case management, coaching, consultation, and intervention to patients with one or more chronic diseases. Is responsible for identifying said population via provider/clinic referral, utilization management referral, disease registry reporting mechanisms, and patient self-referral. This position will also provide case management to patients who are discharged from the hospital and those who may need to be enrolled in ambulatory case management. Works as part of an interdisciplinary care team coordinating social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc. The LVN Case Manager effectively collaborates with the members of the interdisciplinary care team and with the physician in the clinic.

AltaMed Health Services

Registered Nurse, Case Manager

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

If you are as passionate about helping those in need as you are about growing your career, consider AltaMed. At AltaMed, your passion for helping others isn’t just welcomed – it’s nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. We don’t just serve our communities; we are an integral part of them. By raising the expectations of what a community clinic can deliver, we demonstrate our belief that quality care is for everyone. Our commitment to providing exceptional care, despite any challenges, goes beyond just a job; it’s a calling that drives us forward every day.

Graduation from an accredited nursing program. Current valid License as a Registered Nurse through the California Board of Registered Nursing; Bachelor’s degree in social work, nursing, or another health or human services field with the appropriate licensure preferred. Experience in and willingness to be part of multi-disciplinary team. Experience with physically or mentally impaired adults and/or geriatric population. Three years experience in public health nursing, acute care, case management and/or in-home health care required; minimum of 2 years of managed care experience in case management with focus in inpatient and/or outpatient ambulatory care preferred. Bilingual in English and Spanish preferred.

The Nurse Case Manager may provide daily care coordination, case management, coaching, consultation and intervention to patients with one or more chronic diseases. May also be responsible for identifying said population via provider/clinic referral, utilization management referral, disease registry reporting mechanisms and patient self-referral. This position may also provide case management to patients who are admitted to the hospital and those patients who may need to be enrolled in ambulatory case management. The case manager will be responsible for identifying (California Children Services) CCS cases, handle transfers, and retro reviews. Works as part of an interdisciplinary care team coordinating social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc. The Nurse Case Manager effectively collaborates with the hospitalist, the hospital nursing personnel, with members of the interdisciplinary care team and with the physician in the clinic.

TRIUNE Health Group

Nurse Case Manager

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

TRIUNE Health Group is a nationally recognized managed healthcare company with over 35 years of experience. As a mission-driven, second-generation family-owned business, we are dedicated to improving lives by reducing the impact of injuries, enhancing health and wellness, and lowering healthcare and workers' compensation costs. At TRIUNE, we believe that every team member is essential to our success. We foster a supportive and collaborative environment where employees are valued, empowered, and provided with the tools they need to thrive—both professionally and personally. Why Join TRIUNE Health Group as a Nurse Case Manager? Be part of a well-established, family-owned company that prioritizes people over profits. Experience our culture of People Helping People, where every team member is treated with dignity and respect. Enjoy the stability, support, and resources needed to succeed while maintaining a healthy work-life balance.

The Nurse Case Manager coordinates resources and creates flexible, cost-effective options for catastrophically or chronically ill or injured individuals to facilitate quality, individualized, holistic treatment goals, including timely return to work when appropriate.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Skills and Abilities: Proven leadership skills. Excellent verbal and written communication skills, including the ability to interact effectively with patients, customers, and fellow employees via phone, email, in-person, and formal presentations. Methodical in accomplishing job-related goals. Strong analytical and organizational skills, including the ability to multitask with attention to detail. In-depth knowledge of multi-software packages, notably Microsoft Office Suite (Word, Excel, PowerPoint, Outlook) and the Internet. Maintain a friendly, professional attitude at all times. Exercise initiative and be solution-oriented, while keeping management up-to-date on current situations or opportunities. Dependability and adaptability. Education and Experience: Graduate of an accredited school of nursing. Current RN licensure in the state of operation. Fluency in English (speaking, reading, and writing). Three or more years of recent clinical experience, preferably in trauma, psychology, emergency, orthopedics, rehabilitation, occupational health, and neurology. CCM preferred. Certificates, Licenses, Registrations: While not mandatory, individuals with one or a combination of the following certifications are preferred: COHN, COHN-S, and CDMS.

Provide medical case management to individuals through coordination with the patient, physicians, other health care providers, the employer, and the referral source. Utilize the steps of Case Management to provide assessment, planning, implementation, evaluation, and outcome of an individual’s progress. Evaluate individual treatment plans for appropriateness, medical necessity, and cost-effectiveness. Facilitate care, such as negotiating and coordinating the delivery of durable medical equipment and home health services, ensuring clear communication. Assess rehabilitation facilities for appropriateness of care, facilitate transportation, and coordinate architectural assessments of patients’ homes when required. Communicate medical information clearly and compassionately to patients and families. Stay current with medical terminology and the federal and state laws related to health care, Workers’ Compensation, ADA, HIPAA, FMLA, STD, LTD, SSDI, and SSA. Utilize technology (computer, cell phone, fax, and scanning machine) to prepare organized, timely reports while complying with safety rules and regulations in conjunction with HIPAA. Research medical and community resources for individuals with catastrophic or chronic diagnoses, such as but not limited to AIDS, cancer, spinal cord injuries, diabetes, head injuries, back injuries, hand injuries, and burns, ensuring accessibility for individuals. Possess a valid driver’s license with the ability to travel 90% of the time. Perform other duties as assigned.

CareVitality, Inc.

Care Coordinator LPN / LVN Work from Home

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Texas

We are a Chronic Care Management company that assists Physicians/Practitioners who treat Medicare patients with chronic conditions. We are a Chronic Care Management company that assists Physicians/Practitioners who treat Medicare patients with chronic conditions.

We are seeking Licensed Practical Nurse or Licensed Vocational Nurse to join our team! A Care Coordinator working remotely from home - to be working with Medicare patients with multiple chronic conditions. Hours are from 8:30am CST to 5pm MST. Job Starts: 3 Full Time Positions Available for June and July start dates

Must have 1+ years experience to be considered as an LPN/ LVN working with Medicare patients with multiple chronic conditions Multi-tasking is required as the Care Coordinator will need to be able to navigate the platform of their EHR, the internet, Microsoft Office (Excel, Word ) Email as well as document their time spent with each patient and manage and monitor that each patient under your management receives the required time and scope of service to meet the Chronic Care Management billing requirements. A positive attitude, comfortable talking on the phone, be a self-starter, and willing to receive instruction and guidance from the supervisor Job duties may be expanded as needs arise. Care Coordinator further agrees to render and provide said work, services, labor, and/or materials in accordance with the specifications in a workmanlike manner. All services are to be consistent with applicable Medicare regulations for billing CCM services

Assist Physicians/Practitioners who treat Medicare patients with chronic conditions. Each chronic care patient must receive a minimum of 20 minutes or more spent on their case each month based on the time needed to fulfill the scope of the billing code for all of their chronic conditions. This time includes wellness checks by phone, education on their conditions, care coordination, assistance with appointments, prescription refills, and referrals, etc.…. The Care Coordinator will be responsible to manage a caseload of 12 to 14 patients on a daily basis. This job is telephonic and employees work at their designated home office. The Care Coordinator must have excellent phone skills, be comfortable calling patients to discuss care, make appointments, and provide education without direct supervision. Care Coordinators must have superior time management and communication skills, show initiative, and be self-motivated. A positive attitude, comfortable talking on the phone, be self-starter, and willing to receive instruction and guidance from supervisor Follow Up on a monthly basis with the patient by reviewing the patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues). Provide CCM patients with appropriate education materials or resources to enhance their knowledge and skills related to health or lifestyle management. Contact patients with gaps in preventive health care services and assist them in schedule required screening or diagnostic tests with their providers. Review patient’s current medication profile; conduct medication with a review of adherence and potential interactions, and address with the patient and providers as necessary. Additionally, as the Care Coordinator, you will oversee the patient’s self-management of medications. Successfully engage patients by reviewing their care plan monthly that promotes healthy lifestyles, closes gaps in care, and reduces unnecessary ER utilization and hospital readmissions. Coordinates the care plan with patients, caregivers, PCP, specialists, community resources, behavioral health contractors, and other health plan and system departments as appropriate. Document all activities in the EHR and time elements in a report to be submitted daily following CareVitality's standards and identify trends and opportunities for improvement based on information obtained from interaction with patients, providers and technology solutions utilized. Health Risk Assessments or the non-face-to-face portion of annual wellness visits may be added in the future as well. If at any time the patient needs a reassessment the Care Coordinator would need to immediately escalate this patient to the Care Manager that is assigned to the practice.

Understood Care

Clinical Lead - NP (Remote - Multiple States)

Posted on:

May 22, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Ohio

Most Medicare patients are not comfortable with navigating the US healthcare system alone. patients often have questions like “how does my deductible work?” or “how do I make an appointment online?”. At Understood Care (formerly known as Kible Health), our mission is to bridge the healthcare gap for Medicare patients who would like some help navigating the complex healthcare system.

We are seeking a Clinical Lead: a compassionate Nurse Practitioner to join our team to provide telehealth services. You will be working with our talented care advocates to understand patient navigation needs and solve individualized problems related to access of care. You will meet patients for their initial intake appointment. You will learn about their medical history and understand the Social Determinants of Health (SDOH) that the patient is experiencing. Then, you will collaborate with our advocates to make sure the patient is able to access the care they need. Please note, you will not need to diagnose or prescribe in this role. Ideal Candidate Profile: Prior experience delivering care via telehealth Thrives in a fast-paced, startup environment Cares deeply about patient advocacy Prior experience working with Medicare patients Very well versed in technology and can learn new technologies quickly Positive attitude and bias towards action Strong communication and interpersonal skills This is a part time role. We would prefer a minimum of 15 hours a week of availability between the hours of 9am-5pm EST weekly. Morning hours are preferred. Rate: $50/hour. We will pay for admin time.

Active APRN license in Ohio, with at least 3 other licenses in other states. Preferred states (TX, AZ, FL WA, MA, MI, CO, CT, OR) 5+ years of clinical experience PTAN/PECOS account (registration and enrollment with Medicare)

See patients for their initial telehealth E&M visit Review care plans developed by care advocates Provide clinical support to care advocates and patients as needed

CareXM

Registered Nurse – Hospice - Remote (Friday to Monday, 2:00 pm to 7:00 pm MST)

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Remote Status: Remote Job Title: Registered Nurse Location: Remote Pay: $26/hour Training Schedule: The training is four weeks long. You will meet each week, Monday, Wednesday & Friday from 5:00 pm to 8:30 pm (MST) for two weeks On the third week, you will meet on Thursday + one additional weekday that will be assigned by your Trainer In your fourth week, you will work two weekdays that will be assigned by your Trainer Work Schedule: Friday to Monday, 2:00 pm to 7:00 pm MST States we are currently not entertaining applications from: Alaska, California, Connecticut, DC, Hawaii, Illinois, Massachusetts, Michigan, Minnesota, Nevada, New York, Oregon, Pennsylvania, Rhode Island, Washington or any US territories (e.g.Puerto Rico). Summary: CareXM is seeking a remote Registered Nurse (RN) to provide after-hours telephone triage care to patients and caregivers of hospice and home health partners. This is a flexible position that offers the opportunity to work from home while making a meaningful difference in the lives of others.

RN license in a compact state (in good standing) 4+ years of clinical nursing experience required. Experience in home health, palliative, med-surg, geriatrics, ICU, ER, and/or hospice care is preferred but not required English fluency is required. Spanish is a plus Proficiency with computers and telecommunications equipment Ability to work independently and as part of a team Ability to work flexible hours, including evenings and weekends Must be able to pass a background check and drug test for pre-employment screening Must be able to meet California RN Required Prerequisites for RN Examination and Endorsements as outlined here: https://www.rn.ca.gov/status.shtml Personal Computer Requirements: You will use your Personal Computer to work. As each system configuration is unique, our requirement specialist and IT team will confirm your configuration will meet the necessary standards. Internet connection Webcam Windows: 11 or MAC OS: 14 (Sonoma) or newer CPU: 2.5 GHz RAM: 6GB

Provide fast access to quality, compassionate after-hours RN telephone triage care to patients and caregivers of hospice and home health partners Communicate with empathy and understanding, especially when callers are experiencing a difficult situation Assess patient needs and provide appropriate care instructions Coordinate care with other members of the healthcare team Document patient care in the electronic health record (EHR)

CareXM

Registered Nurse – Hospice - Remote (Thursday to Sunday, 4:00 pm to 9:00 pm MST)

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Remote Status: Remote Job Title: Registered Nurse Location: Remote Pay: $26/hour Training Schedule: The training is four weeks long. You will meet each week, Monday, Wednesday & Friday from 5:00 pm to 8:30 pm (MST) for two weeks On the third week, you will meet on Thursday + one additional weekday that will be assigned by your Trainer In your fourth week, you will work two weekdays that will be assigned by your Trainer Work Schedule: Thursday to Sunday, 4:00 pm to 9:00 pm MST States we are currently not entertaining applications from: Alaska, California, Connecticut, DC, Hawaii, Illinois, Massachusetts, Michigan, Minnesota, Nevada, New York, Oregon, Pennsylvania, Rhode Island, Washington or any US territories (e.g.Puerto Rico). Summary: CareXM is seeking a remote Registered Nurse (RN) to provide after-hours telephone triage care to patients and caregivers of hospice and home health partners. This is a flexible position that offers the opportunity to work from home while making a meaningful difference in the lives of others.

RN license in a compact state (in good standing) 4+ years of clinical nursing experience required. Experience in home health, palliative, med-surg, geriatrics, ICU, ER, and/or hospice care is preferred but not required English fluency is required. Spanish is a plus Proficiency with computers and telecommunications equipment Ability to work independently and as part of a team Ability to work flexible hours, including evenings and weekends Must be able to pass a background check and drug test for pre-employment screening Must be able to meet California RN Required Prerequisites for RN Examination and Endorsements as outlined here: https://www.rn.ca.gov/status.shtml Personal Computer Requirements: You will use your Personal Computer to work. As each system configuration is unique, our requirement specialist and IT team will confirm your configuration will meet the necessary standards. Internet connection Webcam Windows: 11 or MAC OS: 14 (Sonoma) or newer CPU: 2.5 GHz RAM: 6GB

Provide fast access to quality, compassionate after-hours RN telephone triage care to patients and caregivers of hospice and home health partners Communicate with empathy and understanding, especially when callers are experiencing a difficult situation Assess patient needs and provide appropriate care instructions Coordinate care with other members of the healthcare team Document patient care in the electronic health record (EHR)

The Judge Group

Prior Authorization RN

Posted on:

May 22, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Job Title: Prior Authorization Registered Nurse (RN) Location: Remote (Candidates must reside in NJ, PA, NY, MD, or CT) Schedule: Monday-Friday, 8:00 AM - 5:00 PM EST Caseload: 10-35 cases per day, depending on demand Job Overview: This role is responsible for ensuring patients receive appropriate, high-quality, and cost-effective care throughout their healthcare journey. The RN will assess medical appropriateness, coordinate patient care, advocate for members, and ensure compliance with established guidelines.

Active NJ or Compact RN license Reside in NJ, PA, NY, MD, or CT Minimum of 3 years of clinical RN experience At least 2 years working in a Health Plan within Prior Authorization or Utilization Review Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint) and other Windows-based software Strong understanding of hospital structures and payment systems Knowledge of case, care, and disease management principles and operations

Prior Authorization & Medical Appropriateness: Evaluate clinical needs against guidelines to determine the medical necessity of inpatient stays, services, and procedures. Care Coordination & Planning: Develop and implement patient care plans, facilitating seamless care transitions and service delivery. Quality & Cost-Effectiveness: Monitor and optimize care to ensure adherence to clinical guidelines and positive patient outcomes. Participate in quality improvement initiatives. Patient Advocacy: Support members and families, coordinate resource utilization, and assess services across various healthcare settings. Program Referrals & Compliance: Encourage member participation in case and disease management programs through appropriate referrals. Documentation & Communication: Maintain accurate documentation and facilitate efficient communication with multidisciplinary teams through telephonic and in-person interactions. Fiscal Accountability: Ensure responsible resource utilization while supporting self-care outcomes and maintaining financial responsibility.

Froedtert Health

RN UTILIZATION REVIEW LEAD

Posted on:

May 22, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

EXPERIENCE DESCRIPTION: Five (5) or more years acute care nursing experience, required. Two (2) or more years UR experience in an acute hospital setting, required. Utilization of Interqual, MCG care web QI or Indicia evidence-based guidelines, required. EDUCATION DESCRIPTION: Professional knowledge of nursing theory and practice at a level normally acquired through completion of a program at an accredited School of Nursing is required. Bachelor’s Degree in nursing is preferred. SPECIAL SKILLS DESCRIPTION: Knowledge of Medicare inpatient only surgical list, Medicare guidelines for admission, working DRG, and some familiarity with hospital coding. Ability to read and correlate an extensive variety of medical / surgical medical treatments and monitoring to clinical conditions. Requires excellent observation, negotiation, verbal and written communication and presentation skills, analytical thinking, and problem-solving skills. Requires strong interpersonal skills including ability to interact with all levels of organization including executive leadership and develop strategies to present to senior leadership. Efficient use of MS Office products (Excel, Outlook, Word), WebEx and Epic (or similar EMR). Advanced knowledge of reporting, statistical principles, and processes. Expert knowledge payer trends and rules Expert knowledge of level of care guidelines Ability to document and maintain process documentation. Excellent follow-through from initiation to conclusion. LICENSURE DESCRIPTION: Requires current state of Wisconsin Registered Nurse License or a Multi-state Nursing License from a participating state in the NLC (Nurse Licensure Compact). MCG certification is required. Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification preferred.

The RN Utilization Review Lead provides support to the Utilization Review (UR) team to ensure workflows and training support program goals and deliver efficient day-to-day operational outcomes. In collaboration with departmental leadership, physician advisors, and internal customers maintain standards in accordance with state, federal, and national regulations for accurate and ethical documentation capture to facilitate coding and billing. Participates in the design, implementation and evaluation of staff orientation, development, and continuing education related to Utilization Review (UR). Develops, analyzes, and monitors metrics to demonstrate UR program initiatives. Develops and maintains working relationships with hospital departments and team members.

Lehigh Valley Health Network

Clinical Record Reviewer (RN) - Home Health Remote

Posted on:

May 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

Lehigh Valley Health Network (LVHN) is home to nearly 23,000 colleagues who make up our talented, vibrant and diverse workforce. Join our team and experience firsthand what it's like to be part of a health care organization that's nationally recognized, forward-thinking and offers plenty of opportunity to do great work. Imagine a career at one of the nation's most advanced health networks. Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work. LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day.

Manages and supports quality and performance improvement by assisting staff to implement strategies that identify, prioritize, measure, and improve key clinical processes and outcomes. Reviews patient records to determine the complete, accurate, and timely documentation of all conditions that support home health/hospice care and treatment of the patient.

Minimum Qualifications: Associate’s Degree in Nursing. 2 years Experience as a Registered Nurse. Ability to work cross functionally across remote teams. Demonstrates a working knowledge of Medicare guidelines for hospice coverage. Demonstrated track record of continuous quality improvement. Proficient in prioritizing work and delegating where indicated. HCS-D - Home Care Coding Specialist-Diagnosis - Board of Medical Specialty Coding and Compliance Within 1 Year or HCS-O - Home Care Clinical Spec-OASIS - Board of Medical Specialty Coding and Compliance Within 1 Year or COS-C - Certificate OASIS Specialist-Clinical - OASIS Certificate & Competency Board Within 1 Year and RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire Preferred Qualifications: Bachelor’s Degree in Nursing. 2 years Hospice experience and 1 year Hospice documentation experience or 2 years Home Care experience and 1 year Home Health OASIS documentation or 1 year ICD-9/ICD-10 coding experience HCS-D - Home Care Coding Specialist-Diagnosis - Board of Medical Specialty Coding and Compliance Upon Hire or HCS-O - Home Care Clinical Spec-OASIS - Board of Medical Specialty Coding and Compliance Upon Hire or COS-C - Certificate OASIS Specialist-Clinical - OASIS Certificate & Competency Board Upon Hire

Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care Consults with providers, management, and operations to ensure consistency within the application of clinical criteria Utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements Maintains current knowledge of clinical indicators and compliance requirements Manages tools to collect outcome data and provides regular feedback to individuals, managers, and leaders Provides concurrent medical record review to assess documentation compliance. Facilitates recommended interventions Reviews deficiencies in documentation with involved staff and facilitates corrective action Participates in the ongoing development and implementation of an established performance improvement plan Reviews orders for data entry, completeness, and appropriateness for admission to home health/hospice services Promotes, obtains, and reviews appropriate documentation for any home health/hospice specific quality data

Peraton

Fraud Nurse Reviewer - Medicaid

Posted on:

May 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

Peraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the world’s leading mission capability integrator and transformative enterprise IT provider, we deliver trusted, highly differentiated solutions and technologies to protect our nation and allies. Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace. The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces. Each day, our employees do the can’t be done by solving the most daunting challenges facing our customers. Visit peraton.com to learn how we’re keeping people around the world safe and secure.

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse. We are looking to add a Fraud Nurse Reviewer to our SGS team of talented professionals.

Basic Qualifications: 2 years with BS/BA; 0 years with MS/MA; 6 years with no degree Experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity. Current nursing license. Strong investigative skills Strong communication and organization skills Strong PC knowledge and skills Applicant must be a U.S. citizen Desirable Qualifications: Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases Have a CPC (Certified Professional Coder) certificate. Bilingual with ability to speak and write English and Spanish (Preferred) Essential Functions: This position may require the incumbent to appear in court to testify about work findings. Ability to compose correspondence, reports, and referral summary letters. Ability to communicate effectively, internally and externally Ability to handle confidential material. Ability to report work activity on a timely basis. Ability to work independently and as a member of a team to deliver high quality work Ability to attend meetings, training, and conferences, overnight travel required

The position requires the individual to conduct medical record reviews and to apply sound clinical judgment to claim payment decisions. Responsibilities may include additional research on medical claims data and other sources of information to identify problems, review sophisticated data model output, and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. The incumbent will use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, over payment recovery. Will work with external agencies to develop cases and corrective actions as well as respond to requests for data and support. Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government Research regulations and cite violations. Conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers. Make claim payment decisions based on clinical knowledge Telework available from contiguous United States

Actalent

Licensed Vocational Nurse - Remote

Posted on:

May 21, 2025

Job Type:

Full-Time

Role Type:

License:

LPN/LVN

State License:

Texas

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

Immediate Hiring for Remote LVN's in San Antonio ,Texas! *Must be located Closer to San Antonio, Texas* Workplace Type: This is a fully remote position.

1+ years LVN experience in Prior authorization and DME is must Active LVN License in the state of Texas is Must

Identify special needs members through the completion of health screens and other resources. Work with community outreach/member advocates to coordinate member care. Educate providers and community resources on program components and available support services. Assist with modification and management of care plans under the direction of a Registered Nurse in conjunction with member, medical consenter or caregiver .

Actalent

Registered Nurse Remote

Posted on:

May 21, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

California

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

The Commercial Appeals and Grievance Registered Nurse (RN) reviews and processes appeals resulting from member-generated pre-service or post-service concerns or complaints. The RN is responsible for reviewing all medical records and documentation concurrently while processing these appeals. The role involves performing accurate and timely first-level reviews according to company and regulatory standards, utilizing National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines, and other nationally recognized sources such as NCCN and ACOG. The RN reviews appeals for benefits, medical necessity, coding accuracy, and medical policy compliance. Collaboration with medical directors, coordinators, and leadership is essential to review, process, and provide a final determination for all clinical appeals with clear rationales and any follow-up actions necessary to ensure members have quality access to provider care.

Essential Skills: 1 year of Utilization Review/Management experience Proficiency in Utilization Management and Utilization Review Knowledge of MCG and prior authorization processes Experience in acute and inpatient settings Proficiency in Microsoft Office Additional Skills & Qualifications: CA RN License 2+ years of Managed Care experience 2 years minimum of Acute or Sub-Acute Clinical Experience Associate Degree of Nursing (ADN) preferred Bachelor of Science in Nursing (BSN) preferred Work Environment: This is a remote position with a work schedule from Monday to Friday, 8:30 am to 5:00 pm.

Review and process member-generated appeals and grievances. Ensure accurate and timely first-level reviews according to company and regulatory standards. Utilize NCD, LCD, Milliman Care guidelines, and other recognized sources for review. Assess appeals for benefits, medical necessity, coding accuracy, and policy compliance. Collaborate with medical directors, coordinators, and leadership to provide final determinations. Communicate clear rationales and necessary follow-up actions to ensure quality care access.

Gulfside Hospice

Registered Nurse Triage Days - Remote

Posted on:

May 21, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Florida

Job Details apply at: https://www.gulfside.org/join-our-team.html Requisition Number: REGIS001242Description Reporting to the Clinical Care Manager, the Triage RN is responsible for identifying, prioritizing, and coordinating patient/family needs for the purpose of providing preventative and supportive care to the terminally ill patient/family unit with the collaboration of the interdisciplinary team. This position is primarily performed at employee’s home. Work environment may be stressful at times, as overall activities and work levels fluctuate. Shift: Monday - Friday 8am - 5pm

Currently licensed in the State of Florida as a registered nurse Minimum of two (2) years nursing experience Hospice, oncology, or home health nursing experience preferable Minimum of one (1) year experience in an acute care unit is desirable Minimum of one (1) year experience in caring for terminally ill patients is desirable Should have training in palliative care and symptom management Qualifications Experience Preferred: Minimum of one (1) years nursing experience in a hospital, home health or hospice setting Preferred Licenses & CertificationsRequired: RN

Attends to patient/family complaints and concerns Takes a proactive approach to identifying and resolving potential issues Educates the community regarding hospice care, philosophy, and concept through individual consultation with persons in the community Performs other duties as requested by the Clinical Care Manager. Provides assessment of the physical, psychological, social, and spiritual needs of the patient/family unit and initiates appropriate intervention Determines the health status of the patient based on hospice criteria and identifies patient/family issues Provides follow-up for information related to patient care issues and continuity of care to the appropriate CCM/RN Case Manager Receives and returns telephone calls during non-business hours Accesses and supplements patient data via current computer program Communicates pertinent information to the CCM and necessary disciplines to ensure continuity of care Coordinates and identifies services needed by patient/family unit after hours regarding continuous care, transfers, staffing, physician’s orders, referrals, pharmacy, and durable medical equipment Demonstrates knowledge of Gulfside Hospice policies and procedures and pertinent federal and state regulations Considers financial implications in rendering cost-effective nursing care Ensures professional standards of nursing practice are maintained Performs other duties as requested by the Clinical Care Manager.

CVS Health

Case Manager - Registered Nurse

Posted on:

May 21, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

Community Care Case Manager use a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost effective outcomes.

Required Qualifications: 3 years clinical practical experience: (Diabetes, CHF, CKD, Post-Acute Care, Hospice, Palliative Care, Cardiac) with Medicare members. Registered Nurse with active state license in good standing within the region where job duties are performed is required. Ability to occasionally travel within a designated geographic area for in-person case management activities as directed by Leadership and/or as business needs arise Preferred Qualifications: 2 years CM, Discharge Planning, and/or Home Healthcare coordination experience preferred Excellent analytical and problem-solving skills Effective communications, organizational, and interpersonal skills. Ability to work independently (may require working from home). Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications. Efficient and Effective computer skills including navigating multiple systems and keyboarding Compact RN licensure Certified Case Manager Additional national professional certification (CRC, CDMS, CRRN, COHN, or CCM) Bachelors of Science in Nursing Education: Associates Degree in Nursing Anticipated Weekly Hours

Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate. Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care. Interacts with members/clients telephonically or in person. May be required to meet with members/clients in their homes, worksites, or physician’s office to provide ongoing case management services. Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client’s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate. Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person. Prepares all required documentation of case work activities as appropriate. Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes. May make outreach to treating physician or specialists concerning course of care and treatment as appropriate. Provides educational and prevention information for best medical outcomes. Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources. Testifies as required to substantiate any relevant case work or reports. Conducts an evaluation of members/clients’ needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data. Utilizes case management processes in compliance with regulatory and company policies and procedures. Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work. Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes, as well as opportunities to enhance a member’s/client’s overall wellness through integration. Monitors member/client progress toward desired outcomes through assessment and evaluation.

CVS Health

Case Management Nurse

Posted on:

May 21, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Illinois

Nurse Case Manager II 12+ Months Contract Remote

RN with current unrestricted state licensure in IL. REQUIRED Experience: Minimum 3-5 years clinical practical experience preference: (diabetes, CHF, CKD, postacute care, hospice, palliative care, cardiac) with Medicare members. Minimum 2-3 years CM, discharge planning and/or home health care coordination experience Excellent analytical and problem-solving skills Effective communications, organizational, and interpersonal skills. Ability to work independently (may require working from home). Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications. Efficient and Effective computer skills including navigating multiple systems and keyboarding Education: Registered Nurse with active state license in good standing within the region where job duties are performed is required. Associates degree with equivalent experience, applicant would be required to obtain a bachelor’s degree within 3-5 years as part of role development, state licensing laws may apply Certified Case Manager is preferred.

CVS Health

Diabetes Educator - Registered Nurse - Case Management

Posted on:

May 21, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

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

Must have 3 current years of experience working with Diabetes Education, or your CDES. Please make sure this experience is clearly indicated on your resume. This is a full-time , Remote, Telehealth position Working schedule is Monday-Friday, standard business hours in time zone of residence with one to two days per week until 7 PM. Position Summary: This is an exciting team to join because we specialize in engaging and advocating for disengaged, vulnerable members who often have multiple medical, behavioral, and social challenges. We’re uniquely positioned to meaningfully improve health outcomes and costs. As Case Manager RN, you will be responsible for assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member and facilitate the member’s overall wellness. You will develop a proactive course of action to address the issues presented to enhance their short and long-term outcomes as well as opportunities to enhance a member’s overall wellness through integration.

Required Qualifications: Registered Nurse that must reside in the Continental United States and hold an unrestricted nursing license with multi-state/compact privileges and have the ability to be licensed in all non-compact states. 3+ years clinical/nursing practice experience 3+ years of Diabetes management experience 1+ year(s) of experience in care coordination or discharge planning High speed internet- ability to hard wire computer. 3+ years of experience with personal computers, keyboarding, multi-systems navigation, and MS Office Suite applications Preferred Qualifications: Telephonic case management experience Excellent communication and interpersonal skills Education Associate's degree in nursing required BSN preferred

Use clinical tools and information/data review to conduct an evaluation of members’ needs and benefits. Apply clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning. Conduct assessments that consider information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Use a holistic approach to assess the need for a referral to clinical resources and other interdisciplinary team members. Collaborate with supervisor and other key stakeholders in the member’s healthcare in overcoming barriers in meeting goals and objectives. Utilize case management processes in compliance with regulatory and company policies and procedures. Utilize motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation. Work on behalf of the client and the member's provider.

LanceSoft Inc.,

Registered Nurse Case Manager

Posted on:

May 21, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Illinois

Estimated Length of Assignment: 06/16/2025 to 09/15/2025. Est. Pay Range: $34.00/hr. to $36.00/hr. Work Type: Fully remote (never coming onsite) Position Summary: 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 RN with unrestricted IL active license.

Experience: Minimum 3-5 years clinical practical experience preference: (diabetes, CHF, CKD, post-acute care, hospice, palliative care, cardiac) with Medicare members. Minimum 2-3 years CM, discharge planning and/or home health care coordination experience Excellent analytical and problem-solving skills Effective communications, organizational, and interpersonal skills. Ability to work independently (may require working from home). Proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications. Efficient and Effective computer skills including navigating multiple systems and keyboarding Education: Registered Nurse with active state license in good standing within the region where job duties are performed is required.

Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate. Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care. Interacts with members/clients telephonically or in person. May be required to meet with members/clients in their homes, worksites, or physician’s office to provide ongoing case management services. Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client’s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate. Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person. Prepares all required documentation of case work activities as appropriate. Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes. May make outreach to treating physician or specialists concerning course of care and treatment as appropriate. Provides educational and prevention information for best medical outcomes. Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources. Testifies as required to substantiate any relevant case work or reports. Conducts an evaluation of members/clients’ needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data. Utilizes case management processes in compliance with regulatory and company policies and procedures. Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work. Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes, as well as opportunities to enhance a member’s/client’s overall wellness through integration. Monitors member/client progress toward desired outcomes through assessment and evaluation.

The Hartford

Nurse Case Manager

Posted on:

May 21, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Conneticut

We’re determined to make a difference and are proud to be an insurance company that goes well beyond coverages and policies. Working here means having every opportunity to achieve your goals – and to help others accomplish theirs, too. Join our team as we help shape the future.

As Nurse Case Manager, we seek to improve on our patients’ abilities! This position is part of a dynamic, fast-paced team of experienced Nurse Case Manager located remotely across the United States. The ideal candidate for the Nurse Case Manager role will oversee Workers’ Compensation claims with complex medical conditions referred for medical assessment, clarification of limitations/restrictions or case management. On average, a Nurse Case Manager shall handle 50-60 cases with a moderate degree of complexity and acuity of medical condition. This individual will have the opportunity to collaborate with claims staff, the injured worker, an employer, and other healthcare professionals to promote quality medical care with a focus on returning our patients back to work. Our goal is to achieve optimum, cost-effective medical and vocational outcomes.

Qualifications: RN with current unrestricted state licensure required Associate degree in Nursing required 3 years clinical practice experience required Bachelor’s degree in nursing preferred, but not required Certification as a CCM (CDMS, CRC, CVE and/or current CRRN), or willingness to pursue Workers Compensation case management experience preferred Key Competencies: Basic Computer proficiency (Microsoft Office Products including Word, Outlook, Excel, Power Point); which includes navigating multiple systems Ability to effectively communicate telephonically and in written form 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 handwritten and computer-generated documents as well as a PC monitor Ability to synthesize large volumes of medical records & facilitate multi-point care coordination Must meet productivity & quality expectations Ability to organize and prioritize daily work independently and effectively Additional Competencies: Strategic thinking Customer focus Business knowledge Problem solving Collaboration – partnership Decision making skills Communication skills

Through the use of clinical tools, telephonic interviews, and clinical information/data, completes assessments that will take into account information from various sources to address all conditions including biopsychosocial, co-morbid and multiple diagnoses that impact recovery and return to work Leverages critical thinking, extensive clinical knowledge, experience, and skills in a collaborative process to develop a comprehensive strategy for the injured worker to become medically stable and/or return to work Independently identifies complex situations where communication with internal and/or external partners is needed to reach a full understanding of the factors involved with the assessment of the mechanism of injury, causality, and ability to return to work Application, Interpretation and Compliance with clinical criteria and guidelines, applicable policies and procedures, regulatory standards, and jurisdictional guidelines to determine eligibility and integration with available internal/external resources and programs Using holistic approach to focus on medical and ability management activities resulting in accurate and timely treatment and return to work Consults with supervisor and others to address and problem solve barriers to meeting goals and objectives, participate in roundtables and claim meetings with claim partners to focus and benefit overall claim management

Managed Staffing, Inc.

Case Management Nurse

Posted on:

May 21, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Illinois

Job Title: RN Case Manager Location: Illinois (Remote) Description: Must have RN License.

Minimum 3-5 years clinical practical experience preference: (diabetes, CHF, CKD, postacute care, hospice, palliative care, cardiac) with Medicare members. Minimum 2-3 years CM, discharge planning and/or home health care coordination experience

Maximus

Sr Coordinator - Clinical Ops, LPN (remote)

Posted on:

May 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Virginia

Maximus is currently hiring for a Sr Coordinator - LPN to join our QIC DME team. The Sr Coordinator - LPN is responsible for medical reviews and applying Medicare coverage criteria following project guidelines. -This is a remote opportunity. *Position is contingent upon contract award*

Minimum Requirements: Current Licensed Practical Nurse (LPN) license valid in the state of practice is required High School Degree or equivalent required Minimum 2 years of clinical experience required Please note: For this position Maximus will provide equipment to use. Home Office Requirements: Internet speed of 20mbps or higher required / 50 Mpbs for shared internet connectivity (you can test this by going to www.speedtest.net) Minimum 5mpbs upload speed Connectivity to the internet via either Wi-Fi or Category 5 or 6 ethernet patch cable to the home router Private work area and adequate power source Must currently and permanently reside in the Continental US

Responsible for reviewing documentation and/or assessments and applying clinical criteria to complete determinations, approvals or recommendations. Determine need for and obtain any additional information required to complete actions. Determine when escalation or consultation is required with supervisor, physician or related medical or related clinical discipline. Complete reports or documentation in accordance with contract requirements. Performs other related duties as assigned. Provides clinical review on Medicare Appeals reviewing clinical data and application of Medicare Law for QIC Part B Reviews cases to determine and summarize the facts of each case and assesses issues involved in the case. Render reconsideration determinations on Medicare appeals. Will utilize search engines tools to research issues using federal or law, federal regulations, and relevant CMS policies. Write the rationale rendering a determination in a clearly written letter is sent to all appropriate parties as required by the specific client contract. Ensures all data collected in a case file is accurate and enters and maintains data to related appeal computer tracking system. Performs other duties as assigned by management

Yoh, A Day & Zimmermann Company

RN Care Coordinators

Posted on:

May 20, 2025

Job Type:

Contract

Role Type:

Behavioral Health

License:

RN

State License:

Pennsylvania

At Yoh, we focus on helping you precisely navigate and fulfill your talent demands. Are you securing the right talent pipelines? Seeking the truth about your talent needs and processes? Start leveraging our deep industry expertise today. Yoh covers your diverse talent and specialized resource needs in the areas of IT, Fintech, Cloud Computing & Migration, Cybersecurity, Product Engineering, Healthcare, Life Sciences, and Interactive, Media & Entertainment. You can be confident that we have the right subject-matter experts for you. You need it - Yoh has it!

RN Care Coordinator needed for a remote contract opportunity with Yoh’s client located in Philadelphia, PA. This Care Coordinator will join the Behavioral Health Care Management team. *This is a REMOTE position, however, all eligible candidates MUST reside in the Tri-state area. Schedule: M-F 8am-5pm Duration: 3 months with possible extension or direct placement Pay: $31-38/hr DOE

What You Need to Bring to the Table: RN, LSW, LCSW, LPC or LMFT licensure valid in PA, NJ, or DE Residency in the tri-state area 3+ years of Behavioral Health clinical experience in a hospital or other health care setting. Behavioral Health utilization management and Medical management/precertification experience is preferred.

Applies critical thinking and judgement skills based on advanced medical knowledge to cases utilizing specified resources and guidelines to make case determination. Utilizes resources such as; InterQual, American Society of Addiction Medicine criteria (ASAM), Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan. Utilizes the behavioral health criteria of InterQual, ASAM and/or Medical Policy to establish the need for inpatient, continued stay and length of stay, procedures and ancillary services. Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services. Reviews treatment plans/plan of care with provider for requested services/procedures, inpatient admissions or continued stay, clarifying behavioral health information with provider if needed. Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation determination. Performs early identification of members to evaluate discharge planning needs. Collaborates with case management staff or physician to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting. Reports potential utilization issues or trends to designated manager and recommendations for improvement. Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated to include delays in care. Appropriately refers cases to Case and Disease Management. Ensures request is covered within the member’s benefit plan. Ensures utilization decisions are compliant with state, federal and accreditation regulations. Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests. Ensures that all key functions are documented in accordance with Care Management Coordination Policy. Maintains the integrity of the system information by timely, accurate data entry. Performs additional duties assigned.

Virta Health

Manager, Nurse Coach

Posted on:

May 20, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

Virta Health is on a mission to transform type 2 diabetes and weight-loss care. Current treatment approaches aren’t working—over half of US adults have either type 2 diabetes or prediabetes, and obesity rates are at an all-time high. Virta is changing this by helping people reverse their metabolic condition through innovations in technology, personalized nutrition, and virtual care delivery reinvented from the ground up. We have raised over $350 million from top-tier investors, and partner with the largest health plans, employers, and government organizations to help their employees and members restore their health and take back their lives. Join us on our mission to reverse diabetes and obesity in one billion people.

To achieve that mission, Virta is looking for an experienced leader to help build and manage this team of registers nurses as a player-coach. Calling out two key requirements of the role: You must hold an active RN license in a Nursing Compact state. In your application you must demonstrate that as a manager, you have helped your direct reports improve their skills and develop their careers, hired quality and counseled people out, and built team cohesion and rapport.

Minimum of 2 experience working with diabetes patients in a clinical setting Interest and knowledge of diabetes care, diabetes prevention, and low carbohydrate nutrition. 3+ years experience managing nurses ideally in an corporate, tele-health, or in a clinical diabetes setting. Active RN license with at least one year of clinical experience working with patients with type 2 diabetes. CDE licensure preferred but not required Active RN license in, and resident of, a Nursing Licensure Compact state Telehealth or start up experience preferred Associate or Bachelor's RN Nursing degree from an accredited school or university Eligible for licensure in every U.S. state. Interest and aptitude for working with a growth stage, tech-enabled healthcare organization Occasional (2-3x/yr) travel to team and company events. An outstanding bedside manner: patients trust you and feel supported and empowered by your presence on the phone/video and your communication. Team player: You work well with others, put your team first, and contribute toward the betterment of the Virta clinical team. On Our Values-Driven Culture: Virta’s company values drive our culture, so you’ll excel if: You put people first and take care of yourself, your peers, and our patients equally. You take initiative and complete tasks conscientiously while empowering others to do the same. You value positive impact over busy work. You can check your ego and recognize that everyone has something to bring to the table. You take risks and iterate rapidly. You promote transparency, trust, and empowerment through open access of information. You prioritize data and science over seniority and dogma.

Build and manage a team of 10-15 outstanding full time nurses coaches, including managing QA/QI, supervision, scheduling, and working with our administrative team to manage licensure of team members. Be a player coach: spend approximately half your time seeing patients and half your time managing the team. Management activities will include, but are not limited to: Daily Schedule hygiene for assigned nursing team to enhance applicant throughput. Monitoring and assigning provider support requests and initiatives. Providing updates to clinical intake workflow Delivery of just in time feedback as needed Weekly POD meeting with team Working with the Head of Nursing and Clinical leads on developing and implementing quality initiatives. Commitment to providing care of the highest quality that delivers an exceptional experience for the patient

CorVel Corporation

Clinical Review Auditor

Posted on:

May 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

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

The Diagnostic Related Groups (DRG) Clinical Auditor will be responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding and clinically supported as defined by review methodologies specific to the type of review. This involves completing medical records review, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. Experience using ICD-10-CM & PCS coding guidelines, the ability to understand modern pharmacology, disease management and clinical intervention procedures. The ideal DRG Clinical Auditor candidate will have strong oral and written communication skills, clinical knowledge of disease process, and knowledge of medical necessity rules. This is a remote position.

KNOWLEDGE & SKILLS: Proficient in Medicare, CMS guidelines and ICD-10 coding guidelines Effective and professional communication skills, both verbal and written Ability to think and work independently, while working in an overall team environment Ability to work in a fast-paced environment Proficient in Microsoft Office Suite EDUCATION & EXPERIENCE: Current LVN or RN license in the state of employment. Current license must be maintained during employment CCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCS Experience in the OR, ICU, or ER as an RN highly preferred Extreme attention to detail Must possess critical thinking skills

The Clinical Auditor will review medical records to determine accuracy of billing through verification of coding and supporting clinical documentation Conducting audits to ensure accurate reimbursement and identifying potential savings Demonstrated knowledge of ICD-10-CM codes, PCS and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid The ability to work independently with minimal supervision and demonstrate initiative Able to communicate clearly and accurately Clearly understands and comply with all internal and external policies Working knowledge of HIPAA Privacy and Security Rules Ability to multi-task and assist with team coverage and provide support when needed Ability to build relationships both internally and externally Assists Quality Control team and medical director with Appeals, Rebuttals, etc. Demonstrated proficiency in basic computer skills and typing, i.e., Microsoft Windows, Outlook, Word, PowerPoint, Internet Explorer, etc. Notify manager/leadership of any issues or concerns in a timely manner Additional duties as assigned by leadership

CorVel Corporation

CA Medical Case Manager I

Posted on:

May 20, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

CorVel, a certified Great Place to Work® Company, is a national provider of industry-leading risk management solutions for the workers’ compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 3500 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

CorVel Corporation is hiring a caring, self-motivated, energetic and independent registered nurse to fill a Medical Case Manager position in Folsom, CA. Work from home, and on the road. Monday – Friday, regular business hours. As a Medical Case Manager you will make a meaningful difference in the lives of injured workers and their families. Your responsibilities include working closely with injured workers to facilitate their recovery. You will work collaboratively with the patient, their family, medical providers, members of our team, and others. This is a heavy local travel role responsible for working with a caseload of workers compensation injured workers within a defined jurisdiction.

KNOWLEDGE & SKILLS: Effective communication and multi-tasking skills in a high-volume, fast-paced, team-oriented environment. Experience as a RN, Medical Case Manager is ideal, or a clinical background in orthopedics, neurology, or rehabilitation is preferred. Ability to meet with the patient, their physicians, other healthcare providers, attorneys, and advisors/clients and coworkers. A cost containment background, such as utilization review or managed care is helpful. Strong interpersonal, time management and organizational skills. Computer proficiency and technical aptitude with the ability to utilize MS Office including Excel spreadsheets. Ability to work both independently and within a team environment. EDUCATION & EXPERIENCE: Graduate of accredited school of nursing. Current RN Licensure in state of operation. Certification as a CCM, CIRS, or other Case Management certifications are preferred. A valid driver’s license, reliable transportation, and ability to travel to assigned locations is required.

Provides Medical Case Management to individuals through in person and telephonic communications with the patient, physician, other health care providers, employer and others. Utilizes their medical and nursing knowledge to discuss the current treatment plan with the physician and discuss alternate treatment plans. Evaluates patient’s treatment plan for appropriateness, medical necessity, and cost effectiveness. Provides assessment, planning, implementation and evaluation of patient’s progress. Attends doctors, other providers, home and in some cases, attorney’s visits. Attends hospital and/or long-term facility discharge planning conferences, et cetera for the purpose of determining appropriateness of care and developing an effective long-term care strategy. Initial home visit for initial evaluation. Implements care such as negotiation the delivery of durable medical equipment and nursing services. This role requires regular travel, dependent on the injured worker’s injuries and needs. The employee must be available for local travel up to approximately 60% of the work week/month This role may require overnight travel.

CorVel Corporation

Legal Nurse Consultant I

Posted on:

May 20, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

Georgia

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

The Legal Nurse Consultant reviews medical records and billing, applying nursing expertise to prepare a concise medical treatment analysis, opining medical treatment relatedness to an injury. This a part time position.

KNOWLEDGE & SKILLS: Effective multi-tasking skills in a high-volume, fast-paced, team-oriented environment Ability to interface with claims staff, attorneys, physicians and their representatives, and advisors/clients and coworkers. Excellent written and verbal communication skills Ability to meet designated deadlines Computer proficiency and technical aptitude with the ability to utilize Microsoft Office including Word and Excel spreadsheets Strong interpersonal, time management and organizational skills Ability to work both independently and within a team environment EDUCATION/EXPERIENCE: Graduate of accredited school of nursing, BSN desirable Current RN Licensure in state of operation Legal Nurse Consultant certification required 3 or more years’ of recent experience in similar role preferred Certification as a MSCC or CNLCP preferred Strong clinical background in orthopedics, neurology, or rehabilitation preferred Strong cost containment background, such as utilization review or managed care helpful

Communicate with customers clarifying specific requirements of case Assess, review and summarize medical records and bills in a clear, concise manner Prepare a timeline or other summary of documentation for medical records Perform evidenced based medical research Ability to apply nursing knowledge to prepare a summary, conclusion, and recommendations of medical record review and research Required to prepare concise, organized written reports within a specified timeframe Educate and advise attorneys and clients regarding relevant medical issues Required to read extensively May require serving as an expert witness in the court system Minimum Productivity Standard is 95% Requires regular and consistent attendance Complies with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP). Additional duties as required

Optum

Discharge Care Management Nurse RN Remote in Central or Eastern Time Zone

Posted on:

May 20, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

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

As a Discharge Care Manager (Central or Eastern Region) at UnitedHealth Group, you will be responsible for implementing day-to-day telephonic case management interventions for identified high risk members. This means you will be tasked with assessing and interpreting member needs and identifying solutions that will help our members live healthier lives. This is an inspiring job at a truly inspired organization. The Discharge Care Manager (DCM) will coordinate and document the discharge plan in collaboration with other key clinical care team members. The DCM will also follow the member while in the acute inpatient setting. If you are located in Central or Eastern Time Zone, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Bachelor of Science in Nursing Current, unrestricted Compact RN license in the State of residence and either hold or be willing to obtain MI State RN Licensure 5+ years of recent experience in the inpatient acute setting 2+ years of experience of discharge planning Experience working with multiple health insurance products (Medicaid, Medicare, Commercial) within the insurance industry, including regulatory and compliance requirements Proficient in typing skills and software applications that includes, but is not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Microsoft Outlook Designated work space and access to install secure high speed internet via cable/DSL in your home Permanent residence within the U.S. Central or Eastern Standard Time zone Preferred Qualifications: Case Management Certification InterQual/MCG Guidelines or other nationally recognized practice guidelines Demonstrated ability to assist with focusing activities toward a strategic direction as well as develop tactical plans, drive performance, and achieve targets Proven problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action Proven excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others

Evaluation of member discharge needs including delays in care and readmission prevention plan Collaboration with providers and members to coordinate care post discharge Participate in rounds with the Medical Director to discuss cases as needed Identification of internal or community-based program support or resources Coordination with the facility Discharge Planner to ensure post hospital services are arranged prior to the member being discharged Assist with coordination of difficult cases needing placement in an alternate level of care facility Documentation of discharge activities as outlined in standard operating procedures and data entry strategies Participate in team meetings, education discussions and related activities Works collaboratively with team members in a matrix environment to ensure an end-to-end positive experience for members, providers and care teams

w3r Consulting

Case Management/Utilization Review RN

Posted on:

May 20, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Michigan

Job Title: Registered Nurse - Review Analyst Location: Remote – Must reside in Michigan Contract Duration: 10 Months Position Summary: Seeking a Michigan-based Registered Nurse (RN) for a fully remote, 10-month contract role reviewing clinical documentation for Medicare Advantage members.

Top Required Skills: Strong clinical background with experience in utilization review Attention to detail; ability to manage multiple case reviews Advanced computer skills; 45–50 WPM typing, Microsoft Office proficiency Additional Qualifications: Certification in Case Management or Utilization Review (preferred) Experience with SNF, LTAC, or Home Health care reviews Excellent time management and communication skills Education & License: Active RN license in Michigan (Required) Associate’s degree or higher in Nursing

The role involves evaluating post-acute care records to support utilization management decisions.

Maximus

Clinical Reviewer, RN/LPN (Remote in TN)

Posted on:

May 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Tennessee

We partner with the State of Tennessee to perform Preadmission Screening and Resident Review (PASRR) for individuals who are applying to, or residing in, Medicaid-certified nursing homes. The primary goal of this federally mandated assessment is to determine whether the nursing home is the appropriate placement for individuals with mental illness, intellectual disabilities or developmental disabilities. PASRR also works as a critical function to help match individuals with the care and services they need. Why 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. Paid Time Off Package - Enjoy PTO, 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

Maximus is seeking a dedicated Clinical Review RN or LPN to join our team! In this role, you’ll perform document-based and telephonic reviews to evaluate medical necessity and screen for serious mental illness or intellectual disabilities. Your assessments will help determine the appropriate level of care, including eligibility for short- or long-term nursing facility placement. This is a remote role that follows Central Time Zone business hours.

Required Skills/Abilities: Preferred knowledge may include community support programs, long-term care assessment and level of care in medical, behavioral health or related programs Knowledge and understanding of medical and/or behavioral health diagnoses and prescribed medications Ability to collect data, define problems, establish facts, and draw valid conclusions Minimum Requirements: Education and licensure requirements are based on program contract requirements and are outlined in job posting High School Degree or equivalent required- Minimum 1 year of clinical experience required Current and valid Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the state of Tennessee. Minimum of two (2) years of experience working with individuals diagnosed with mental health conditions and/or intellectual disabilities, with a primary focus on behavioral health. At least two (2) years of medical experience with demonstrated knowledge of rehabilitation potential based on factors such as diagnosis, age, disease progression, and chronicity. A minimum of one (1) year of experience in Long-Term Care (LTC) or hospital settings. Strong clinical assessment, critical thinking, and documentation skills. Preferred: Candidates who reside in Tennessee. 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.

The HT Group

Quality Assurance Clinician (RN) - Remote

Posted on:

May 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

The HT Group has partnered with a major insurance client based in Austin, TX to hire a Remote licensed Registered Nurse (RN) who will support clinical quality and compliance initiatives through detailed review of long-term care documentation. The Quality Assurance Clinician ensures adherence to regulatory standards, consistency in clinical assessments, and best practices in care review procedures. This remote role also contributes to process improvements, training evaluations, and collaborative quality initiatives, serving as a clinical subject matter expert. This is a Direct-Hire role. Only Registered Nurse (RN) candidates will be considered.

Active Registered Nurse (RN) license (required) Experience in clinical quality review, compliance, or healthcare documentation oversight Strong understanding of healthcare regulations and long-term care standards Excellent analytical, communication, and problem-solving skills Ability to work independently and collaboratively in a remote environment

Conduct clinical and documentation reviews to assess accuracy, consistency, and compliance Identify trends, training needs, and opportunities for operational improvements Support development and updates of internal procedures and best practices Collaborate on quality initiatives and participate in cross-functional projects Provide guidance on clinical standards and regulatory alignment

Cosán Group

LPN Care Navigator MST/PST

Posted on:

May 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

Cosán Group, founded in 2015, is a leader in preventative care services, combining technology and a patient-centric model to support at-risk older adults. We’re on a mission to deliver excellence in chronic and behavioral health management that promotes aging in place. As a Care Coordinator, you’ll help patients close gaps in care, connect to essential resources, and improve health outcomes—all while working in a supportive hybrid environment designed for growth and purpose.

Licensed Practical Nurse Care Navigator (Remote – US) **This is a remote/telecommute position. Candidates must reside in the United States to be considered.** Job Title: Licensed Practical Nurse Care Navigator Salary Range: $19.00 – $23.00 per hour Location: Applicants must reside in the Mountain or Pacific Time Zone, as this role supports patients within those regions. Full-Time Opportunities Available Are you a clinically trained LPN or LVN looking to make a meaningful impact in a non-traditional healthcare setting? At Cosán Group, we’re reimagining how nurses support aging populations through remote care coordination. This role is perfect for someone who is passionate about empowering patients, addressing barriers to care, and combating social isolation—without the usual bedside routines.

What We’re Looking For: A team player who thrives on communication, empathy, and patient-centered advocacy. A quick learner comfortable with adapting to new technology and evolving priorities. A motivated healthcare professional who enjoys meaningful patient relationships. Medical specialties: gastroenterology, geriatrics, home health, internal medicine, primary care, and urology. Required Qualifications: Active Licensed Practical Nurse or Licensed Vocational Nurse license: Must have multi-state compact license. Willing to obtain company-paid state-specific license if needed. Must reside in the U.S. Minimum 2 years’ clinical experience. Experience working with EMR systems. Familiarity with chronic condition management and individualized care planning. Intermediate to advanced computer skills, with the ability to navigate multiple systems. Telephonic and virtual communication skills to effectively engage with patients and providers. Preferred Qualifications: 2-5 years’ clinical experience. Bilingual in Spanish and English. Prior experience with CMS CCM/PCM guidelines. Previous experience in adult in-home, in-facility, or remote chronic condition care coordination. Experience with complex care management principles. Work Environment & Requirements: 100% Remote with a Monday–Friday schedule—no weekends or late nights. Work hours: MST or PST Company-provided equipment (laptop, monitor, headset, etc.) High-speed broadband internet and private home workspace required Candidates must complete a company-provided internet speed test to confirm a minimum of 50 Mbps download / 5 Mbps upload. Private workspace for compliance with HIPAA privacy laws.

Engage in monthly telephonic patient interactions to build relationships and support care goals. Deliver services under Chronic Care Management (CCM), Behavioral Health Integration (BHI), Principal Care .Management (PCM), and Remote Physiological Monitoring (RPM). Create individualized care plans and manage coordination via our proprietary software. Communicate with patients, caregivers, and providers to resolve needs and promote care alignment. Document all interactions and escalate clinical concerns as necessary. Meet performance metrics and follow best practices for documentation, compliance, and workflow. Participate in a collaborative culture with a mission-first mindset.

Cosán Group

LPN Care Navigator EST/CST

Posted on:

May 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

Cosán Group, founded in 2015, is a leader in preventative care services, combining technology and a patient-centric model to support at-risk older adults. We’re on a mission to deliver excellence in chronic and behavioral health management that promotes aging in place. As a Care Coordinator, you’ll help patients close gaps in care, connect to essential resources, and improve health outcomes—all while working in a supportive hybrid environment designed for growth and purpose.

Licensed Practical Nurse Care Navigator (Remote – US) **This is a remote/telecommute position. Candidates must reside in the United States to be considered.** Job Title: Licensed Practical Nurse Care Navigator Salary Range: $19.00 – $23.00 per hour Location: Applicants must reside in the Eastern or Central Time Zone, as this role supports patients within those regions. Full-Time Opportunities Available Are you a clinically trained LPN or LVN looking to make a meaningful impact in a non-traditional healthcare setting? At Cosán Group, we’re reimagining how nurses support aging populations through remote care coordination. This role is perfect for someone who is passionate about empowering patients, addressing barriers to care, and combating social isolation—without the usual bedside routines.

What We’re Looking For: A team player who thrives on communication, empathy, and patient-centered advocacy. A quick learner comfortable with adapting to new technology and evolving priorities. A motivated healthcare professional who enjoys meaningful patient relationships. Medical specialties: gastroenterology, geriatrics, home health, internal medicine, primary care, and urology. Required Qualifications: Active Licensed Practical Nurse or Licensed Vocational Nurse license: Must have multi-state compact license. Willing to obtain company-paid state-specific license if needed. Must reside in the U.S. Minimum 2 years’ clinical experience. Experience working with EMR systems. Familiarity with chronic condition management and individualized care planning. Intermediate to advanced computer skills, with the ability to navigate multiple systems. Telephonic and virtual communication skills to effectively engage with patients and providers. Preferred Qualifications: 2-5 years’ clinical experience. Bilingual in Spanish and English. Prior experience with CMS CCM/PCM guidelines. Previous experience in adult in-home, in-facility, or remote chronic condition care coordination. Experience with complex care management principles. Work Environment & Requirements: 100% Remote with a Monday–Friday schedule—no weekends or late nights. Work hours: EST or CST Company-provided equipment (laptop, monitor, headset, etc.) High-speed broadband internet and private home workspace required Candidates must complete a company-provided internet speed test to confirm a minimum of 50 Mbps download / 5 Mbps upload. Private workspace for compliance with HIPAA privacy laws.

Engage in monthly telephonic patient interactions to build relationships and support care goals. Deliver services under Chronic Care Management (CCM), Behavioral Health Integration (BHI), Principal Care .Management (PCM), and Remote Physiological Monitoring (RPM). Create individualized care plans and manage coordination via our proprietary software. Communicate with patients, caregivers, and providers to resolve needs and promote care alignment. Document all interactions and escalate clinical concerns as necessary. Meet performance metrics and follow best practices for documentation, compliance, and workflow. Participate in a collaborative culture with a mission-first mindset.

Cosán Group

Bilingual Medical Assistant Patient CCM Care Coordinator

Posted on:

May 20, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Compact / Multi-State

At Cosán Group, we’re redefining healthcare by making patient interactions more accessible and impactful. Unlike traditional healthcare roles, we offer a Monday through Friday schedule—no weekends, no late nights—allowing you to enjoy a healthy work-life balance. Our team provides virtual care coordination services to patients nationwide, helping them navigate their healthcare journey with confidence and support.

Bilingual Care Coordinator (Remote-US) **This is a remote/telecommute position. Candidates must reside in the United States to be considered. Job Title: Bilingual Care Coordinator Salary Range: $18.00 - $20.00 Non-exempt hourly role. Full-Time Opportunities Available Are you passionate about making a real difference in patients’ lives? Join our team as a Care Coordinator and help bridge gaps in healthcare through virtual support. This is a fully remote role where you’ll provide personalized care management and advocacy for patients from the comfort of your home.

What We’re Looking For: A compassionate, patient-focused professional with excellent active listening and problem-solving skills. Ability to work independently while thriving in a team-based, fast-paced environment. Comfortable adapting to new processes and technology-driven healthcare solutions. Medical specialties: gastroenterology, geriatrics, home health, internal medicine, primary care, and urology. Required Qualifications: Bilingual (Spanish/English)– Must be fluent in both written and spoken communication. One of the following certifications/licenses: Certified Medical Assistant (CMA) Nationally Certified Pharmacy Technician (CPhT) Licensed Practical Nurse (LPN) with a multi-state compact license 2+ years of experience in care coordination, chronic care management, or clinical healthcare roles. Strong understanding of healthcare terminology, chronic conditions, and patient-centered care principles. Experience working with EMR systems. Intermediate to advanced computer skills, with the ability to navigate multiple systems. Telephonic and virtual communication skills to effectively engage with patients and providers. Preferred Qualifications: Experience with CMS CCM/PCM guidelines and care management principles. Previous experience in adult in-home, in-facility, or remote chronic conditions care management. Knowledge of complex care management and patient advocacy strategies.

Build rapport with patients through monthly telephonic outreach and care coordination services. Assist patients with Chronic Care Management (CCM), Behavioral Health Integration (BHI), Principal Care Management (PCM), and Remote Physiological Monitoring (RPM). Advocate for patients by identifying barriers to care, addressing concerns, and connecting them to essential healthcare resources. Develop and implement individualized care plans to improve patient outcomes. Collaborate with healthcare providers, caregivers, and clinical teams to ensure a seamless care experience. Maintain accurate documentation in EMR systems.

Cosán Group

Bilingual LPN Care Navigator

Posted on:

May 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

Cosán Group, founded in 2015, is a leader in preventative care services, combining technology and a patient-centric model to support at-risk older adults. We’re on a mission to deliver excellence in chronic and behavioral health management that promotes aging in place. As a Care Coordinator, you’ll help patients close gaps in care, connect to essential resources, and improve health outcomes—all while working in a supportive hybrid environment designed for growth and purpose.

Bilingual Licensed Practical Nurse Care Navigator (Remote – EST) **This is a remote/telecommute position. Candidates must reside in the United States to be considered. Job Title: Licensed Practical Nurse Care Navigator Salary Range: $19.00 – $23.00 per hour Location: Applicants must reside in the Eastern Time Zone, as this role supports patients within that region. Full-Time Opportunities Available Are you a clinically trained LPN or LVN looking to make a meaningful impact in a non-traditional healthcare setting? At Cosán Group, we’re reimagining how nurses support aging populations through remote care coordination. This role is perfect for someone who is passionate about empowering patients, addressing barriers to care, and combating social isolation—without the usual bedside routines.

What We’re Looking For: A team player who thrives on communication, empathy, and patient-centered advocacy. A quick learner comfortable with adapting to new technology and evolving priorities. A motivated healthcare professional who enjoys meaningful patient relationships. Medical specialties: gastroenterology, geriatrics, home health, internal medicine, primary care, and urology. Required Qualifications: Bilingual (Spanish/English)– Must be fluent in both written and spoken communication. Active Licensed Practical Nurse or Licensed Vocational Nurse license: Multi-state compact license. Company-paid compact license if needed. Must reside in the U.S. and EST Time Zone. Minimum 2 years’ clinical experience. Experience working with EMR systems. Familiarity with chronic condition management and individualized care planning. Intermediate to advanced computer skills, with the ability to navigate multiple systems. Telephonic and virtual communication skills to effectively engage with patients and providers. Preferred Qualifications: 2-5 years’ clinical experience. Bilingual in Spanish and English. Prior experience with CMS CCM/PCM guidelines. Previous experience in adult in-home, in-facility, or remote chronic condition care coordination. Experience with complex care management principles.

Engage in monthly telephonic patient interactions to build relationships and support care goals. Deliver services under Chronic Care Management (CCM), Behavioral Health Integration (BHI), Principal Care .Management (PCM), and Remote Physiological Monitoring (RPM). Create individualized care plans and manage coordination via our proprietary software. Communicate with patients, caregivers, and providers to resolve needs and promote care alignment. Document all interactions and escalate clinical concerns as necessary. Meet performance metrics and follow best practices for documentation, compliance, and workflow. Participate in a collaborative culture with a mission-first mindset.

IntellaTriage

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

Posted on:

May 20, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

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

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

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

UnitedHealth Group

Oncology RN Case Manager - Remote in Nebraska

Posted on:

May 19, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

We’re making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that’s driving the health care industry forward. As a Telephonic Oncology Case Manager RN, you’ll support our Oncology member population with education, advocacy, and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Apply today. Core hours are 8:00am – 4:30pm Monday-Friday in your time zone. One late night per week to be worked until 7:00pm in your time zone. If you live in the state of Nebraska, you will have the flexibility to work remotely* as you take on some tough challenges.

This position will require active and unrestricted Nursing licensure in multiple US States. Selected candidate must be willing and able to obtain and maintain multiple state licensure (Application fees and filing costs paid for by UHG). You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: Current, unrestricted RN license Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses 3+ years of recent Oncology experience in a Hospital setting, Acute Care, Direct Care experience or experience as an Oncology Telephonic Case Manager for an insurance company Recent Chemotherapy administration experience Computer proficiency, to include solid data entry skills and the ability to navigate a Windows environment Access to high speed internet from home (Broadband Cable, DSL or Fiber) Dedicated workspace for home office set up Preferred Qualifications: BSN OCN Certification Chemo Administration Certification Certified Case Manager (CCM) Background in managed care Case or disease management experience Experience / exposure with discharge planning

Making outbound calls to assess patient’s current health status Identifying gaps or barriers in treatment plans Interacting with Medical Directors on challenging cases Providing patient education to assist with self – management Coordinating care for members Encouraging members to make healthy lifestyle changes Documenting and tracking findings Educating members on disease processes Encouraging members to make healthy lifestyle changes Making post – discharge calls to ensure that discharged member receive the necessary services and resources Utilization management through evaluating appropriateness and efficiency of requested health care services, procedures, and cancer treatments under the provisions of the applicable health benefits plan

Care Advantage, Inc.

Value Based Care - Clinical Lead Registered Nurse - Home Healthcare - Remote

Posted on:

May 19, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Care Advantage Inc is seeking a Value Based Care Clinical Lead Registered Nurse to join our team and contribute to our mission of delivering exceptional homecare services throughout the Mis-Atlantic area (VA, MD, DE, DC). This position can be fully remote or hybrid. We are looking for an exceptionally motivated and passionate Value Based Care Clinical Lead Registered Nurse who has strong leadership, training and education skills. Are you an experienced Registered Nurse with leadership skills looking for a great Full-Time opportunity and to join a winning team? We offer a competitive wage and an excellent opportunity for growth and advancement. Position Overview: The Value Based Care (VBC) Clinical Lead is a member of the Care Advantage team under the direction and supervision of the Senior Vice President of Clinical Operations. The VBC Clinical Lead oversees VBC relationships and data along with all related services provided. They promote quality service, cooperation between all types of services provided and growth in directed areas. This position promotes and supports the Company's core values of Compassion, a positive Attitude, Respect and Excellence.

Current licensed Registered Nurse for covered region (Multi State Compact License preferred) Previous Value Based care experience in a home healthcare setting preferred BS in Nursing or health related field preferred. Minimum of 5 years nursing experience with Value Based Care experience preferred Possess leadership, management, and marketing skills. Proficiency in Microsoft PPT, Word, Excel, and Teams required

Collaborate with the Senior VP of Clinical Operations and the Chief of Staff to organize data on program performance Use tools to consistently stratify the population, ensuring members that require increased oversight are accurate, up to date, and getting the necessary attention Communicate with key members of the payer partnerships in preparation for rounding sessions and as needed Provide requested and approved reports, data, or details to partners as needed Assist with design and creation of educational information for patients and primary caregivers, both paid and unpaid Extend education to patients, family, and primary caregiving staff to promote positive outcomes Collaborate closely with clinical leadership internally and externally as it relates to patient situations and improving outcomes Create visibility across the organization of selected members and their individualized needs Ensure high touch methods are applied consistently and that all identified members have the level of attention determined necessary to reach and maintain desired outcomes Create and maintain VBC Clinical Rounding presentations Lead all VBC Clinical Rounding sessions and document discussions and outcomes Ensure responsible internal clinicians are prepared for all rounding sessions Serve as a back up for clinical vacancies as it relates to VBC report out during rounding and other presentations required Track trends and communicate concerns to direct leadership when necessary to ensure we remain on target Monitor and evaluate the quality and appropriateness of clinical services for VBC membership Review and update VBC workflows or assigned policies and procedures at least annually or as needed Communicate with patients, families, and involved parties as necessary to improve overall outcomes and help ensure high satisfaction of the care received Monitor and positively impact contractual performance measures, also helping to generate new ways to continually meet this objective Responsible for setting and achieving goals on a quarterly basis

Synergy Healthcare USA, LLC

Nurse Case Manager/Nurse Advocate- Wichita, KS (Remote)

Posted on:

May 19, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Kansas

SYNERGY HEALTHCARE: Nurse Case Manager/Nurse Advocate – WICHITA, KS (Remote) Job Summary: We are seeking an experienced Case Manager to join our growing team and serve as a Nurse Advocate for our new client and their employees. The ideal candidate will be located in the greater Wichita area, have a thorough understanding of the healthcare system, and will be responsible for providing guidance and support to members in navigating the complex healthcare landscape. As the dedicated Nurse Advocate, you will be responsible for resolving a myriad of issues for their members and allow you the flexibility to “think outside the box”. With your clinical experience and background, you will help members better understand their health status, and will play a pivotal role in promoting patient wellness, managing chronic conditions, and enhancing overall health outcomes through personalized coaching and education. This position requires a blend of clinical expertise, strong communication skills, and a passion for helping others achieve their health goals. While our client has a major presence in KS, this opportunity allows for remote work so can be fairly flexible on location. Minimal travel within the State or region for periodic client visits may be required. Most if not all work will be done virtually out of the convenience of your own home office. The key to your success will rely on your ability to cultivate trusted relationships with stakeholders, members, and their families. Our growing Synergy team is passionate about delivering an exceptional healthcare experience that is personal, data driven, and value based to help every person live their healthiest life.

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

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

TRIUNE Health Group

Nurse Case Manager - South Bend, IN

Posted on:

May 19, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Indiana

TRIUNE Health Group is a nationally recognized managed healthcare company with over 35 years of experience. As a mission-driven, second-generation family-owned business, we are dedicated to improving lives by reducing the impact of injuries, enhancing health and wellness, and lowering healthcare and workers' compensation costs. At TRIUNE, we believe that every team member is essential to our success. We foster a supportive and collaborative environment where employees are valued, empowered, and provided with the tools they need to thrive—both professionally and personally.

Why Join TRIUNE Health Group as a Nurse Case Manager? Be part of a well-established, family-owned company that prioritizes people over profits. Experience our culture of People Helping People, where every team member is treated with dignity and respect. Enjoy the stability, support, and resources needed to succeed while maintaining a healthy work-life balance. Perks & Benefits: Generous Time Off: 20 days of vacation plus 8.5 paid holidays Retirement Savings: 401(k) match to help you plan for the future Comprehensive Insurance: Medical, dental, and vision coverage Disability Coverage: Short-Term (STD) and Long-Term Disability (LTD) insurance Employee Support: Employee Assistance and Referral Program Work-from-Home Essentials: Home office equipment, including a laptop and desktop monitor Travel Perks: Mileage and travel reimbursement TRIUNE Health Group is an equal opportunity employer and a values-driven organization. Compensation is competitive and commensurate with experience. Summary of Position: The Nurse Case Manager coordinates resources and creates flexible, cost-effective options for catastrophically or chronically ill or injured individuals to facilitate quality, individualized, holistic treatment goals, including timely return to work when appropriate.

Job Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Skills and Abilities: Proven leadership skills. Excellent verbal and written communication skills, including the ability to interact effectively with patients, customers, and fellow employees via phone, email, in-person, and formal presentations. Methodical in accomplishing job-related goals. Strong analytical and organizational skills, including the ability to multitask with attention to detail. In-depth knowledge of multi-software packages, notably Microsoft Office Suite (Word, Excel, PowerPoint, Outlook) and the Internet. Maintain a friendly, professional attitude at all times. Exercise initiative and be solution-oriented, while keeping management up-to-date on current situations or opportunities. Dependability and adaptability. Education and Experience: Graduate of an accredited school of nursing. Current RN licensure in the state of operation. Fluency in English (speaking, reading, and writing). Three or more years of recent clinical experience, preferably in trauma, psychology, emergency, orthopedics, rehabilitation, occupational health, and neurology. CCM preferred. Certificates, Licenses, Registrations: While not mandatory, individuals with one or a combination of the following certifications are preferred: COHN, COHN-S, and CDMS. Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The base salary range/hourly rate listed is dependent on job-related, non-discriminatory factors such as experience, education, and skills. This position is also eligible for incentive compensation awards.

Provide medical case management to individuals through coordination with the patient, physicians, other health care providers, the employer, and the referral source. Utilize the steps of Case Management to provide assessment, planning, implementation, evaluation, and outcome of an individual’s progress. Evaluate individual treatment plans for appropriateness, medical necessity, and cost-effectiveness. Facilitate care, such as negotiating and coordinating the delivery of durable medical equipment and home health services, ensuring clear communication. Assess rehabilitation facilities for appropriateness of care, facilitate transportation, and coordinate architectural assessments of patients’ homes when required. Communicate medical information clearly and compassionately to patients and families. Stay current with medical terminology and the federal and state laws related to health care, Workers’ Compensation, ADA, HIPAA, FMLA, STD, LTD, SSDI, and SSA. Utilize technology (computer, cell phone, fax, and scanning machine) to prepare organized, timely reports while complying with safety rules and regulations in conjunction with HIPAA. Research medical and community resources for individuals with catastrophic or chronic diagnoses, such as but not limited to AIDS, cancer, spinal cord injuries, diabetes, head injuries, back injuries, hand injuries, and burns, ensuring accessibility for individuals. Possess a valid driver’s license with the ability to travel 90% of the time. Perform other duties as assigned.

Molina Healthcare

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

Posted on:

May 19, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Mississippi

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.

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

REQUIRED QUALIFICATIONS: Bachelor’s degree in Business, Healthcare, Nursing or related field or equivalent combination of education and relevant experience Min 3 years experience improving provider Quality performance through provider engagement, practice transformation, managed care quality improvement, or equivalent experience. Experience with various managed healthcare provider compensation methodologies including but not limited to: fee-for service, value-based care, and capitation Strong working knowledge of Quality metrics and risk adjustment practices across all business lines Demonstrates data analytic skills Operational knowledge and experience with PowerPoint, Excel, Visio Effective communication skills Strong leadership skills PREFERRED QUALIFICATIONS: Min 3 years experience improving Quality performance for Medicaid, Medicare, and/or ACA Marketplace programs

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

Strategic Staffing Solutions

RN Case Manager Compact License Required

Posted on:

May 19, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Strategic Staffing Solutions is currently looking for a RN Case Manager for a contract opportunity with one of our largest healthcare clients! Title: RN Case Manager – Compact License Duration: Contract (long term) Location(s): Remote (Compact States) *100% remote – must reside in a state that is part of the Nurse Compact (multi-state-licensure)* Must have diverse case management experience; hospice, hospital, home care, medical (acute care, ER, ICU, Med-surg, etc.). Case management experience Must have multi state compact license ROLE SUMMARY: The Care Manager RN leads the coordination of a multidisciplinary team to deliver a holistic, person centric care management program to a diverse health plan population with a variety of health and social needs. They serve as the single point of contact for members, caregivers, and providers using a variety of communication channels including phone calls, emails, text messages and the online messaging platform. The Care Manager RN uses the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the member’s health across the care continuum. They work in partnership with the member, providers of care and community resources to develop and implement the plan of care and achieve stated goals.

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

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

Strategic Staffing Solutions

RN Case Manager

Posted on:

May 19, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Michigan

Strategic Staffing Solutions is currently looking for a RN Case Manager for a contract opportunity with one of our largest clients located in Detroit! Title: RN Case Manager Duration: Contract (long term) Location: Detroit, MI (Remote) Must have diverse case management experience; hospice, hospital, home care, medical (acute care, ER, ICU, Med-surg, etc.) Current, active, and unrestricted Michigan Registered Nurse license required ROLE SUMMARY: The Care Manager RN leads the coordination of a multidisciplinary team to deliver a holistic, person centric care management program to a diverse health plan population with a variety of health and social needs. They serve as the single point of contact for members, caregivers, and providers using a variety of communication channels including phone calls, emails, text messages and the online messaging platform. The Care Manager RN uses the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the member’s health across the care continuum. They work in partnership with the member, providers of care and community resources to develop and implement the plan of care and achieve stated goals.

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

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

IntellaTriage

Remote Hospice Triage RN- FT 10p-5a + rotating Sat & Sun 11:30p-8a CST

Posted on:

May 19, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence Part- time schedule: Work a minimum 3 shifts weekly 10p-5a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 11:30p-5a CST

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

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

IntellaTriage

Remote Hospice Triage RN- FT 10p-5a + rotating Sat & Sun 11:30p-8a CST

Posted on:

May 19, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence Part- time schedule: Work a minimum 3 shifts weekly 10p-5a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 11:30p-5a CST

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

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

IntellaTriage

Remote Hospice Triage RN- 2 PT 4:30a-10a + rotating Sat & Sun 4:30a-10a CST

Posted on:

May 19, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence Part- time schedule: Work a minimum 2 shifts weekly 4:30a-10a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 4:30a-10a CST

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

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