Heartbeat Health

Registered Cardiac Nurse-CST

Posted on:

October 28, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Heartbeat Health is the leading virtual-first cardiovascular care company in the country, providing patients with convenient, high-quality heart care through a combination of telemedicine, diagnostics, and virtual care programs. By leveraging real-time data and AI-powered insights, Heartbeat Health empowers providers and patients with personalized treatment plans, reducing hospitalizations and improving long-term heart health outcomes. Heartbeat Health is redefining how cardiovascular care is delivered in the digital age, led by our medical group of cardiologists, advanced practitioners, nurses, and care coordinators.

We are seeking a skilled and compassionate Registered Nurse located within the Central Time Zone to provide remote consultation and expertise in the field of cardiology.

Must hold a current and unrestricted Registered Nurse (RN) license (Compact). At least 3+ years of experience in cardiology . Experience in telemedicine is a bonus. Excellent communication and interpersonal skills, especially in a virtual environment. Team-player is a must. Ability to effectively educate patients and collaborate with a multidisciplinary healthcare team, including cardiologists and advanced practitioners. Ability to work independently and make clinical decisions under appropriate supervision Proficiency in using telehealth platforms and electronic health records Commitment to patient-centered care and empathy for patients with chronic cardiology conditions Compassion and empathy when working with patients and their families, especially when delivering challenging diagnoses or managing chronic cardiac conditions.

Education and Counseling: This role is a remote, patient-facing role. As part of our RN team, you will provide education about a patient’s diagnosis, test results and treatment plan. Collaboration: Collaborate closely with cardiologists, PCPs and other healthcare professionals to ensure comprehensive and coordinated care for patients. Discuss complex cases and participate in multidisciplinary care teams. Utilize clinical decision making to escalate concerns to the care team. Documentation: Maintain accurate and detailed patient records, including patient interactions, medical histories, assessments, treatment plans, progress notes, and discharge summaries within scope of practice. Ensure compliance with legal and ethical standards. Follow-Up Care: Schedule and conduct follow-up virtual visits to monitor patients' progress and address any concerns or questions. Patient Advocacy: Serve as an advocate for patients' needs and preferences, ensuring that they receive appropriate care and support throughout their healthcare journey. Compliance: Adhere to legal and ethical guidelines, including patient confidentiality and telemedicine regulations, while providing virtual care. Prioritization & Triage: Efficiently triage incoming patient requests and manage patient panel by prioritizing patients based on need and client SLAs. Continuing Education: Pursue ongoing education and professional development in the field of cardiology to stay updated on the latest advancements and maintain relevant certifications. Quality Assurance: Participate in quality assurance programs to monitor and improve the quality of cardiology care provided within the organization.

Healthmap Solutions

Remote RN Care Navigator

Posted on:

October 28, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

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

Active, unrestricted Compact RN license required Bachelor's degree required CCM preferred Three (3) years of experience in case management preferred Experience in a dialysis center or transplant center preferred Experience with Medicare and Medicaid preferred Skills: Advocate and energize a culture of collaboration, positivity, and motivation Strategic thinking and planning Deliver effective communication – verbal and written Succeed in a challenging environment with changing priorities Travel No Travel #LI-Remote

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

Cherokee Federal

Registered Nurse Case Manager

Posted on:

October 28, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Oklahoma

Cherokee Nation Integrated Health (CNIH) is a part of Cherokee Federal – the division of tribally owned federal contracting companies owned by Cherokee Nation Businesses. As a trusted partner for more than 60 federal clients, Cherokee Federal LLCs are focused on building a brighter future, solving complex challenges, and serving the government’s mission with compassion and heart. To learn more about CNIH, visit cherokee-federal.com. #CherokeeFederal #LI #LI-REMOTE

A government contract requires that this position be restricted to U.S. citizens or legal permanent residents. You must provide documentation that you are a U.S. citizen or legal permanent resident to qualify. The Registered Nurse – Case Manager provides clinical, administrative, and organizational expertise to manage continuity of care for patients supported through the Virtual Medical Center (VMC). This includes comprehensive assessments, development of individualized care plans, coordination with multidisciplinary teams, patient education, and advocacy to ensure high-quality, cost-effective outcomes. The RN Case Manager facilitates communication among patients, families, healthcare providers, and community resources, while integrating case management and utilization management strategies. Compensation & Benefits: Estimated Starting Salary Range for Registered Nurse – Case Manager: Commensurate with experience. Pay commensurate with experience. Full time benefits include Medical, Dental, Vision, 401K, and other possible benefits as provided. Benefits are subject to change with or without notice.

Bachelor of Science in Nursing (BSN) from an accredited institution. Minimum of 1 year of nursing experience post-graduation; experience in case management preferred. One of the following: CCM, CDMS, CRRN, COHN/COHN-S, ACCC, CRC, RN-NCM, or CMC. Basic Life Support (BLS) required. Current, active, unrestricted license to practice as a Registered Nurse. Must fulfill credentialing requirements and maintain appropriate clinical privileges. Must pass pre-employment qualifications of Cherokee Federal

Conduct comprehensive patient assessments and develop, implement, and monitor individualized care plans. Provide patient education on healthcare options, benefits, and community resources to support informed decision-making. Coordinate care with multidisciplinary teams to ensure continuity, safety, and optimal outcomes. Recommend hospitalization or follow-up care and complete Active Duty Profiles, Medical Evaluation Boards (MEBs), and other military-required evaluations. Maintain accurate patient records and documentation in accordance with SOPs; update charts within 72 hours or by COB for high-acuity patients. Identify and resolve issues related to healthcare access, utilization, and quality improvement. Participate in case management program development, quality assurance, and continuous improvement initiatives. Performs other job-related duties as assigned

Acentra Health, LLC

Clinical Reviewer (Remote - SCA - 25 Hrs/Wk)

Posted on:

October 28, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

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

The purpose of this position is to utilize clinical expertise during beneficiary interaction and determine appropriateness for advocacy intervention in conjunction with contract requirements, critical thinking and utilize decision-making skills to assist with communicating determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA and other regulatory standards.

Required Qualifications: Active unrestricted LPN, RN or, Social Worker or other applicable State and/or Compact State clinical license Minimum three years of clinical experience in an acute or med-surgical environment Strong clinical assessment and critical thinking skills required Medical record abstracting skills required Excellent written and verbal communication skills Must be proficient in Microsoft Office and Internet/web navigation Preferred Qualifications: Bachelor’s Degree from an accredited college or university in a related field Some knowledge of Case Management, UR and/or Prior Authorization or related experience Experience in a behavioral health setting Bilingual

Assures accuracy and timeliness of all applicable review type cases within contract requirements Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns Functions as providers’ liaison and contact/resource person for provider customer service issues and problem resolution Performs all applicable review types as workload indicates Fosters positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process Attends training and scheduled meetings and for maintenance and use of current/updated information for review Cross trains and perform duties of other contracts to provide a flexible workforce to meet client/customer needs Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

Acentra Health, LLC

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

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

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

Acentra Health is looking for a Clinical, Supervisor - RN - Full-time (Remote U.S.) to join our growing team. Job Summary: As the Clinical Supervisor – RN – Full-time (Remote U.S.), this individual plays a pivotal role in overseeing and managing the Utilization Management (UM) activities within the organization. With a strong clinical foundation and leadership acumen, the Clinical Supervisor ensures that UM processes are executed efficiently, consistently, and in alignment with regulatory and contractual standards. A key focus of the role is to uphold excellence in clinical programs, fostering continuous improvement and innovation in care management practices. Additionally, the Clinical Supervisor is instrumental in cultivating and maintaining strong relationships with customers and stakeholders, ensuring that service delivery meets or exceeds expectations and contractual obligations. The Clinical Supervisor will also have oversight of direct reports. The Clinical Supervisor and direct reports are expected to work Monday through Friday, with participation in a rotating schedule that includes weekends and holidays.

Required Qualifications/Experience: Active, unrestricted Registered Nurse (RN) license in the state of Indiana or a valid compact state license. Associate degree or equivalent experience directly applicable to clinical practice. 5+ years of experience as a practicing RN. 5+ years of supervisory experience in a healthcare setting with a minimum of 2+ years in Utilization Management. 2+ years of experience applying InterQual and/or MCG clinical criteria in utilization review processes. Preferred Qualifications/Experience: Bachelor's degree preferred. Strong verbal and written communication skills, with the ability to convey complex information clearly and professionally. Demonstrated customer-centric approach with a focus on achieving results and fostering positive relationships with internal and external stakeholders. Excellent organizational and time management skills, with the ability to prioritize multiple tasks effectively. Proven ability to work both independently and collaboratively within a team environment. Proficiency in Microsoft Office Suite and other relevant software applications essential to the role. Ability to provide technical guidance and leadership support to management and clinical teams.

Lead and oversee all Utilization Management (UM) activities including prior authorization and retrospective reviews, ensuring accuracy, consistency, and timely completion. Conduct utilization reviews as needed to support workload demands and program requirements. Monitor daily work queues and adjust staffing schedules to align with departmental demands. Evaluate productivity and performance metrics of nurse reviewers to maintain high standards of efficiency and quality. Identify onboarding and ongoing learning needs for Clinical Reviewers; collaborate with leadership to design and implement effective development plans. Actively participate in leadership meetings, committees, and cross-functional workgroups to promote shared decision-making and continuous improvement. Oversee quality assurance activities such as audits, Quality Improvement Plans (QIPs), database management, and Inter-Rater Reliability (IRR) support. Identify areas for process and clinical improvements; develop and execute action plans to enhance outcomes. Serve as a liaison to customers and providers, ensuring timely resolution of issues and promoting service excellence. Stay current with clinical best practices and UM protocols, act as the primary resource for nurse reviewers regarding clinical review inquiries. Support departmental and organizational goals by performing additional duties as assigned. Read, understand, and adhere to all corporate policies, including policies related to HIPAA and its Privacy and Security Rules. The above list of responsibilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary.

Acentra Health, LLC

Manager of Clinical Review (Remote)

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Virginia

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

Acentra Health is looking for a Manager of Clinical Review to join our growing team. Job Summary: The Manager of Clinical Review is responsible for overseeing the clinical operations of the organization, ensuring that the highest quality of care is provided to patients while meeting compliance and regulatory requirements.

Required Qualifications: Active unrestricted RN license required. Minimum three years of clinical management experience required. Strong knowledge of regulatory standards and healthcare laws. Preferred Qualifications: Bachelor's degree in nursing or healthcare administration preferred. Excellent leadership and interpersonal skills. Ability to manage multiple priorities effectively. Strong communication and problem-solving abilities.

Monitor quality of care and compliance with policies and regulations. Coordinate with healthcare professionals to ensure seamless care delivery. Provide training and support to clinical staff to enhance their skills and performance. Evaluate staff performance and provide feedback. Manage budgets and resources effectively to optimize clinical operations. Participate in strategic planning for clinical services. Conduct regular staff meetings to discuss operational issues and improvements. Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

ProgenyHealth LLC

Nurse Case Manager - NICU (must reside & be licensed in SC)

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

South Carolina

ProgenyHealth is a leading provider of care management solutions for premature and medically complex newborns positively impacting maternal and infant health outcomes across America. Our program builds a network of support for an uninterrupted continuum of care from prenatal health, through any resultant NICU stay, and all the way to one full year of life. Our team of neonatologists, pediatricians, and NICU nurses provide continuity of care in collaboration with providers from hospital to caregivers at home and throughout the first year of life. We help overcome systemic barriers to support healthier pregnancies and healthier starts to life for all moms and babies, one family at a time.

Must reside and be licensed in South Carolina. Assesses the physical, functional, psychological, environmental, educational, and financial needs of members referred to the Case Management program. Completes needs assessments for all members in CM and develops care plans individualized to the needs of each member as per ProgenyHealth policies and procedures. Assigns risk stratification based on complexity of medical and social needs and determines ongoing frequency of calls to continually assess plan of care. Monitors the care plan to ensure effective, appropriate provision of services and adequacy of benefits. Interfaces with providers to assist with care coordination activities, which can include appointments, transportation, DME, etc. Provides education to members regarding condition, treatment plan, benefits, services, and how to access needed care. Monitors ongoing progress towards goal achievement and reassess changes in health status throughout continuum of care. Provides referrals to appropriate community resources; facilitates access and communication when multiple services are involved; monitors activities to ensure that services are actually being delivered and meeting the needs of the member. Participates in interdisciplinary and client rounds with pertinent health care team members to identify, clarify, and/or prevent risk, quality, or plan of care variances. Qualifications: Registered Nurse (RN) with a current, unrestricted license is required (SC license and residency required for this position). College degree is preferred. Experience in a Case Management role is preferred. Previous experience in a maternity management program preferred. Three (3) or more years of clinical experience in a Level III or above NICU is required. CCM certification required within the timeframe specified by company policy. Experience with data entry into a database or EHR required. Must be computer literate. Excellent communication skills and organizational ability are required. Must be self-motivated and willing to learn multiple tasks. · ·Must be well organized and able to prioritize tasks. Must demonstrate accuracy in spelling and documentation. Demonstrated strength in working independently as well as collaboratively within a team. Must have excellent interpersonal skills, telephone etiquette, and maintain positive communication at all times. Must have commitment to excellence in customer service.

The Case Manager will focus on empowering the members’ family to support optimal wellness while advocating for the necessary medical services across the health care continuum. The Case Manager works in a telephonic managed care setting combining strong clinical knowledge and critical thinking to facilitate a plan of care that will ensure quality medical care for the high-risk member population serviced by ProgenyHealth Inc. based on the CMSA national standards for case management practice.

Sedgwick

Nurse Allocator- RN Medicare Compliance

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Tennessee

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

Nurse Allocator- RN Medicare Compliance Prior Medicare-set-aside (MSA) experience highly desired for this position. PRIMARY PURPOSE OF THE ROLE: To perform provider outreach, specialized document review, and analysis and interpretation of interventions for the preparation of Medicare Set-Aside allocations. ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. Apply your nursing or rehabilitation knowledge and experience to assist in the management of complex medical conditions, treatment planning and recovery from illness or injury. Work in the best of both worlds - a rewarding career making an impact on the health and lives of others, and a remote work environment. Enjoy flexibility and autonomy in your daily work, your location, and your career path while advocating for the most effective and efficient medical treatment for injured employees in a non-traditional setting. Enable our Caring counts® mission supporting injured employees from some of the world’s best brands and organizations. Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. Celebrate your career achievements and each other through professional development opportunities, continuing education credits, team building initiatives and more. Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs.

EDUCATION AND LICENSING: Bachelor's degree from an accredited college or university preferred. Active unrestricted RN license issued in a state or territory of the United States required. TAKING CARE OF YOU BY: Thrives when allowed flexibility & autonomy. Wants dynamic company culture. Passionate about creativity. Craves culture of support, both giving and receiving. Thrives when everyone is working towards same vision/goals. Strong team and customer service orientation. Seeks clear role expectations. Wants to e valued as a collective "we". ​We offer a diverse and comprehensive benefits including medical, dental vision, 401K, PTO and more beginning your first day.

Contacts providers and attorneys to obtain clarification of documentation needed to support the preparation of Medicare Set-Aside allocations. Creates customized correspondence for any applicable providers that will provide the clarity needed to proceed with the preparation of the Medicare Set-Aside. Executes outreach activities with providers for each case via telephone, email, and fax, adhering to best practice guidelines. Reviews and analyzes completed documentation from providers to ensure accuracy, completeness, adherence to quality assurance standards. Determine the outcome of involvement to include efficacy of response, financial, and client satisfaction. Maintains accurate record of management including costs savings. Articulates and effectively documents clear and concise information.

OSIS

Healthcare Quality Consultant (Remote)

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

Are you passionate about transforming healthcare through data-driven quality improvement? Do you thrive in a collaborative, tech-forward environment? OSIS is seeking a dynamic Quality Consultant to join our team remotely and support Federally Qualified Health Centers (FQHCs) and Participating Health Centers (PHCs) in achieving excellence in care delivery.

This is a remote role with occasional travel. To Succeed, you'll need: Reliable cable or fiber internet Minimum download speed: 20 Mbps Minimum upload speed: 5 Mbps Required Qualifications: Bachelor’s degree in healthcare or 5+ years clinical experience (RN, LPN, MA) Strong understanding of healthcare technology and data reporting systems Ability to apply data insights to drive change Preferred Qualifications: NextGen or CEHRT certification Experience with UDS, FQHCs, CMS/State PI programs Familiarity with HEDIS measures and CPT Category II Codes Certifications (Required or Willing to Obtain): NextGen Certified Professional (NCP) or CEHRT certification within 6 months NCQA PCMH Certified Content Expert within 1 year

Guiding Members/PHCs through Patient Centered Medical Home (PCMH) transformation and Promoting Interoperability (PI) initiatives Supporting Uniform Data Set (UDS) reporting and other performance goals Delivering training and technical assistance on clinical workflows and CEHRT optimization Collaborating across teams to resolve escalated issues and improve EHR usage Presenting at conferences and contributing to national healthcare improvement efforts

Alignment Healthcare

Telephonic RN Case Manager – Special Needs Plan (California RN License Required)

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Telehealth

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.

Location: Fully Remote (Must be licensed in California) (HIPAA compliant work space) Schedule: Monday–Friday, 8:00 AM – 5:00 PM PT Language: Bilingual candidates strongly preferred (Spanish and Vietnamese) Join the Team That’s Redefining Healthcare! Are you a compassionate Registered Nurse with a passion for improving the lives of seniors and complex care patients? Join Alignment Health as a Telephonic RN Case Manager for our Special Needs Plan (SNP) members — all from the comfort of your home! This is a fully remote, phone-based position where you'll play a vital role in helping members navigate their care journeys, close gaps in care, and overcome barriers to better health. (HIPAA compliant work space)

Must-Haves: Active, unrestricted RN license in California (Non-Compact) Minimum 2 years of clinical nursing experience At least 1 year of case management experience Proficiency with Microsoft Office (Word, Excel, Outlook) Nice-to-Haves: Bilingual (Spanish, Korean, Mandarin, etc.) Previous health plan or IPA experience Bachelor's Degree in Nursing (BSN) Licensure Requirement Upon Hire: Must be willing to obtain RN licensure in Nevada, Arizona, North Carolina, and Texas (company reimburses costs) Work Environment Fully remote — work from anywhere in the U.S., but must work Pacific Time hours All communication is conducted via phone, email and Teams. Company-provided equipment and IT support included

Provide telephonic case management to medically complex and chronically ill members Conduct comprehensive health assessments and create individualized care plans Coordinate care with internal and external partners, including physicians and specialists Educate members and caregivers on disease management and preventive care Monitor member progress and advocate for timely, appropriate interventions Identify and help resolve service or access issues impacting care quality

Alignment Healthcare

Telephonic RN Case Manager – Special Needs Plan (California RN License Required) (Bilingual preferred)

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Telehealth

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.

Location: Fully Remote (Must be licensed in California) (HIPAA compliant work space) Schedule: Monday–Friday, 8:00 AM – 5:00 PM PT Language: Bilingual candidates strongly preferred (Spanish and Vietnamese) Join the Team That’s Redefining Healthcare! Are you a compassionate Registered Nurse with a passion for improving the lives of seniors and complex care patients? Join Alignment Health as a Telephonic RN Case Manager for our Special Needs Plan (SNP) members — all from the comfort of your home! This is a fully remote, phone-based position where you'll play a vital role in helping members navigate their care journeys, close gaps in care, and overcome barriers to better health. (HIPAA compliant work space)

Must-Haves: Active, unrestricted RN license in California (Non-Compact) Minimum 2 years of clinical nursing experience At least 1 year of case management experience Proficiency with Microsoft Office (Word, Excel, Outlook) Nice-to-Haves: Bilingual (Spanish, Korean, Mandarin, etc.) Previous health plan or IPA experience Bachelor's Degree in Nursing (BSN) Licensure Requirement Upon Hire: Must be willing to obtain RN licensure in Nevada, Arizona, North Carolina, and Texas (company reimburses costs) Work Environment: Fully remote — work from anywhere in the U.S., but must work Pacific Time hours All communication is conducted via phone, email and Teams. Company-provided equipment and IT support included

Provide telephonic case management to medically complex and chronically ill members Conduct comprehensive health assessments and create individualized care plans Coordinate care with internal and external partners, including physicians and specialists Educate members and caregivers on disease management and preventive care Monitor member progress and advocate for timely, appropriate interventions Identify and help resolve service or access issues impacting care quality

SOUTH COLLEGE

Nursing Adjunct Faculty Online

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

RN

State License:

Compact / Multi-State

South College - We are one of the nation’s fastest growing institutions of higher learning … come grow your career with us. In order to fully meet our Mission to our students, we require a diverse combination of perspectives, backgrounds, life experiences, and ideas from our faculty and staff and will provide them with an equitable and inclusive work environment -where respect and open interchange of ideas are at the heart of that culture. Almost 20,000 Students 10 Campuses Competency Based Education Online Nursing Clinical Instructor

South College - Online Campus is conducting a search for the position of adjunct clinical instructor to teach in the School of Nursing.

Education: Prefer a master’s degree in nursing. Licensure: Unrestricted license to practice as a Registered Nurse in Tennessee or one of the eNLC compact states. Experience: Prefer experience in secondary instruction.

Maintain professional standards of practice in teaching in the clinical settings. Collaborate with course faculty and works closely with clinical coordinator. Facilitate effective learning and critical thinking/reasoning during clinical while fostering a positive learning environment. Establishes and maintains a positive working relationship with clinical agencies. Monitors student progress with evaluations and grades care plans as assigned. Provides positive and constructive feedback if needed.

Welby Health Inc

Care Manager (Michigan Licensed)

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Michigan

Welby Health is a San Diego-based healthcare organization committed to transforming the way complex conditions are managed. Our mission is to advance patient outcomes by integrating efficient care coordination, data-driven insights, and enhanced communication across the care continuum. Through a technology-enabled, clinically grounded service model, we partner with physicians and health systems to deliver scalable solutions that improve quality of care, increase practice efficiency, and empower patients to live healthier lives.

Care Manager (Michigan Licensed) The Care Manager is a licensed nurse responsible for providing ongoing remote care management to patients enrolled in Welby Health’s remote physiological monitoring program. In this position, you will leverage Welby Health’s platform to monitor vitals, develop individualized care plans, and deliver education and coaching that improve adherence and patient outcomes. As a Care Manager at Welby Health, you will collaborate closely with physicians and cross-functional teams to ensure timely interventions, seamless care coordination, and an excellent patient experience. Furthermore, you will represent Welby Health’s innovative healthcare model to patients and their families, helping them understand how our solutions support long-term health management while empowering them to take an active role in their care.

Required Qualifications: Active and valid registered nurse (RN), licensed vocational nurse (LVN), or licensed practical nurse (LPN) license Bachelor’s degree in nursing or a closely related healthcare field Exceptional written and verbal communication skills Ability to work independently in a remote, technology-enabled environment Strong organizational skills with attention to detail and follow-through Preferred Qualifications: Experience in case management, chronic care management, and/or telehealth Bilingual or multilingual proficiency Familiarity with remote physiological monitoring, electronic medical record (EMR) or electronic health record (EHR) systems, and patient engagement tools

Monitor and interpret patient vitals, assessments, and alerts within Welby Health’s platform Provide timely, evidence-based guidance and escalate clinically significant findings Document patient interactions accurately and completely in accordance with internal protocols and regulatory standards Develop, implement, and adjust individualized care plans that address both clinical and social needs Coordinate with physicians, specialists, and community resources to close gaps in care Serve as a liaison between patients and providers to improve engagement and adherence Deliver patient education and coaching via telephone and secure messaging Empower patients to manage chronic conditions and build sustainable health habits Identify barriers to care and address them through practical, patient-centered solutions

MedRisk LLC

Clinical Nurse Review

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

We’re a group of talented, driven professionals who strive every day to improve the lives of our clients, our providers and the ultimate stakeholders – the injured workers. We offer an exciting workplace environment plus competitive salaries and benefits. What makes us stand out? It’s the people, the culture we foster and the opportunity to learn and to grow.

The Clinical Bill Review Nurse is responsible for reviewing medical bills and associated documentation to ensure accuracy, medical necessity, and compliance with workers’ compensation guidelines. This role supports payment integrity by identifying inappropriate charges, ensuring adherence to jurisdictional fee schedules, and applying clinical expertise to support fair and accurate reimbursement.

Active, unrestricted RN license (required) Minimum of 3 years of clinical experience; experience in workers’ compensation or medical bill review strongly preferred Familiarity with state-specific workers’ compensation regulations and treatment guidelines Strong analytical, communication, and documentation skills Experience with bill review platforms (e.g., Strataware, Medata, Mitchell) is a plus

Conduct clinical reviews of medical bills to assess medical necessity, appropriateness of care, and alignment with workers’ compensation treatment guidelines. Identify billing discrepancies such as unbundling, upcoding, duplicate charges, and non-compensable services. Apply jurisdiction-specific fee schedules, utilization review (UR) protocols, and treatment guidelines (e.g., ODG, MTUS). Collaborate with bill review analysts, adjusters, and medical providers to clarify clinical information and resolve billing issues. Document clinical rationale for recommended payment reductions or denials in accordance with regulatory and client requirements. Maintain current knowledge of workers’ compensation regulations, medical coding (ICD, CPT, HCPCS), and clinical best practices. Support quality assurance and continuous improvement initiatives within the bill review process.

Sage Clinical RCM, LLC

Certified Clinical Documentation Integrity (CDI) Specialist – RN or FMG

Posted on:

October 27, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Florida

We are seeking 5 experienced and certified Clinical Documentation Integrity (CDI) Specialists to support an urgent, high-impact project. This is a remote, full-time contract role suited for Registered Nurses (RNs) or Foreign Medical Graduates (FMGs) who hold CDI certifications and have a proven background in inpatient clinical documentation review. Job Details Job Type: Full-time Contract Schedule: 8-hour shift, Monday to Friday Work Location: Remote

Active CDI certification (e.g., CCDS, CDIP) Licensed Registered Nurse (RN) or Foreign Medical Graduate (FMG) background required Minimum of 3+ years of inpatient CDI experience Strong understanding of ICD-10, MS-DRGs, clinical indicators, and coding guidelines Excellent communication skills, with the ability to work effectively with providers and interdisciplinary teams Comfortable working independently in a fast-paced, remote environment

Conduct thorough reviews of inpatient medical records to ensure accurate, complete, and compliant documentation. Collaborate with physicians and care teams to clarify clinical documentation and support accurate coding. Identify opportunities to improve documentation that impacts reimbursement, risk adjustment, and quality reporting. Apply CDI best practices to ensure alignment with regulatory and compliance standards. Meet established productivity and accuracy metrics within project deadlines.

Imagine360

Supervisor, Utilization Management

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

Imagine360 understands We developed a self-funded health plan solution that’s fixing today’s one-size-fits-none PPO insurance problems with powerful, customized solutions. We take a different approach: putting control back in your hands and providing access to higher-quality care. For you, your employees and their families. With deep savings. And unwavering support. Imagine that.

Imagine360 is seeking a Supervisor, Utilization Management to join the team! The Supervisor, Utilization Management is responsible for utilizing their nursing education, clinical, and professional experiences to provide supervision to the Utilization Management Nurses and associated programs and processes, as directed by the Senior Manager, Patient Review and Intake Services. Position Location: 100% remote

Required Experience/Education: A nursing degree or diploma from an accredited college, university, or school of nursing Bachelor's degree in nursing preferred but not required. 3 years' experience in a clinical role with responsibilities for direct patient care. Experience in Utilization Review Services, Case Management, or transferable clinical experience and skills. Experience mentoring or managing a team of clinical or non-clinical staff. Experience working in a utilization review role. Experience working in a URAC accredited program preferred. Knowledge and ICD and CPT codes. Skills and Abilities: Ability to work independently in a home office environment. Computer skills which include proficiency in Microsoft Outlook, Word, Excel, and PowerPoint, as well as navigation utilizing the internet. Ability to resolve problems independently and demonstrate ability to multi-task. Strong verbal and written communication skills. Strong presentation skills. Ability to demonstrate a commitment to building new skills and fostering a positive work environment. License and Certifications: An active, current, and unrestricted Compact Registered Nurse License. Must maintain CEUs as required by applicable State Board(s) of Nursing and required certifications.

Collaborate with Senior Manager, Patient Review & Intake Services or Manager, Utilization Management to: Manage team responsible for completing utilization management programs, processes, and tasks. Edit, maintain, and implement policies & procedures that meet applicable regulatory, accreditation, and business needs. Implement orientation curriculum and ongoing training and educational needs. Coordinate and supervise daily employee activities through supervision of the UM team. Maintain daily case assignment statistics and reporting for metrics. Manage and coordinate daily & weekly staffing needs and schedules based on the business. Review and manage approvals and communications for PTO requests by employees, as directed by the Manager or Senior Manager. Conduct performance evaluations and performance improvement plans for team. Conduct monthly 1:1 coaching sessions with UM Nurses, BR Nurses, and Lead Nurses. Lead bi-monthly UM Nurse and Benefit Review Nurse meetings. Lead the interviewing and hiring processes as needed. Research member complaints and issue resolutions. Lead projects and employee discussions that promote improvement in the delivery of services within the department. Collaborate with Quality Management programs by assisting in the quality assurance review and chart audit processes for UM employees. Perform monthly call and chart audits for the UM Nurses, BR Nurses, and Lead Nurses. Review QA results to develop educational opportunities for the UM employees and completes performance improvement plans for scores <90% per policies and procedures. Review policies and procedures as required and recommends changes to the Manager and Senior Manager. Collect, analyze, and report data of quality improvement projects and other data related to utilization services and benefit review services. Assist Supervisor, MIS with triaging of cases and monitoring call que as needed. Escalate high priority, high risk cases or staffing issues appropriately to Manager or Senior Manager. Perform UM tasks as staffing levels dictate. Communicate effectively with members, employees, healthcare providers, vendors, peers, and customers. Act as role model within a team setting to provide mentoring, coaching, and positive outcomes for employees, peers, and overall operations. Attend team and department meetings, trainings, and other job specific events as required. Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and department and company policies and procedures. Complete HIPAA training and trainings assigned by quality team monthly/annually; follow PHI guidelines. Complete duties in accordance with scope of licensure and certifications held or requested. Other duties as assigned by the Manager or Senior Manager.

Imagine360

Utilization Management RN

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Pennsylvania

Imagine360 understands We developed a self-funded health plan solution that’s fixing today’s one-size-fits-none PPO insurance problems with powerful, customized solutions. We take a different approach: putting control back in your hands and providing access to higher-quality care. For you, your employees and their families. With deep savings. And unwavering support. Imagine that.

Imagine360 is seeking a Utilization Management, RN to join the team! The RN Utilization Management Nurse is responsible for providing utilization review/notifications and education for individuals under the group health plans administered by imagine360 by utilizing nursing education, clinical, and professional experience. The Registered Nurse will practice within the scope of practice while performing assessments, coordination, planning, monitoring and evaluation. Position Location: 100% remote

Required Experience/Education: Nursing Degree from an accredited college or university and an active, current, and unrestricted Registered Nurse License in eNLC compact state Bachelors degree preferred 1+ year in Utilization Management and/or Case Management experience Experience in utilization review services preferred. Experience and knowledge of CPT and ICD coding preferred. Skills and Abilities: Ability to read and interpret documents such as HIPAA compliance, safety rules, operating and maintenance instructions, and policy and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively to members and employees. Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages. Ability to apply concepts of basic mathematics and fundamental accounting principles. Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems and exercise sound judgment involving several concrete variables in standardized situations. To perform this job successfully, an individual must have basic knowledge and skills using Microsoft Office Word, Internet software, and Database software. License and Certifications: Current, active, and unrestricted compact Registered Nurse license. Must maintain CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization. Current Certified Case Manager (CCM) Certificate preferred; if Certification is not current, employee must pursue and achieve CCM Certification within three years of employment.

Perform all tasks in accordance with Department of Labor, HIPAA, ERISA and Care 360 department Policy and Procedures. Complete HIPAA and URAC training annually. Identify, collect, process and manage data to complete reviews for Medical Necessity per imagine 360 approved clinical guidelines. Accurate utilization and documentation in appropriate software including time slips in CaseTrakker to complete and document the review process per Care 360 Policy and Procedure. Provide oversight to non-clinical staff members regarding interpretation of clinical data. Consult with Care 360 Physician Advisor or peer reviewer per policy and procedures. Assess and review current treatment history to identify appropriate referrals to Case Management Program or other Care 360 Services. Communicates professionally and effectively as needed with members, physicians, other healthcare professionals, peers, Supervisor of UM to complete the utilization process per Care 360 Policy and Procedures. Utilize clinical knowledge, expertise and imagine 360 approved educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment. Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite. Participate in the Quality Management program of the organization by completing the Quality Assurance review process and other procedures per policy and procedure. Work regular scheduled hours and be available for additional coverage outside of normal working hours as needed. Evaluating clinical data. Assessment and evaluation of the acquired clinical data to assess for appropriateness of treatment plan based upon imagine 360 clinical guidelines. Coordination of treatment plans, interventions and outcomes measurement. Rationale for the effects of medication and treatments. Provide patient education and educational resources. Accurately report: Administration of medication and treatments Client response Contact with other health care team members Respect the client's right to privacy by protecting confidential information. Promote and participate in education and counseling to a participant based on health needs. Clarify any treatment that is believed to be inaccurate, non-effacious, or contraindicated by consulting with appropriate practitioner. Other duties as assigned.

Imagine360

Bilingual Disease Management Care Coach

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

RN

State License:

Compact / Multi-State

Imagine360 understands We developed a self-funded health plan solution that’s fixing today’s one-size-fits-none PPO insurance problems with powerful, customized solutions. We take a different approach: putting control back in your hands and providing access to higher-quality care. For you, your employees and their families. With deep savings. And unwavering support. Imagine that.

Imagine360 is seeking a Bilingual Disease Management Care Coach to join the team!  The Care Coach is responsible for providing telephonic coaching and educational resources to people with chronic health conditions. Coaching topics include medication compliance, nutrition, physical activity, and care coordination. Responsibilities include assessment, coordination, planning, monitoring, and evaluation. Position Location: 100% remote

Required Experience/Education: Nursing Degree from an accredited college or university. 2+ years of experience in direct participant coaching. Skills and Abilities: Must have intermediate knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software License and Certifications: Active and unrestricted Compact Registered Nurse License required

Provide telephonic coaching, and information and referral services to program participants managing various chronic health conditions with clinical oversight assistance Assess participant needs using scripted assessments Communicate, as needed, with service delivery partners, physicians, and other health professionals to provide care coordination Review pertinent medical history, current diagnosis, and pharmaceutical data via information database system with clinical oversight Assist participant in forming realistic goals related to overall health Determine and provide relevant community and/or healthcare resources that help support participant's goals Promote wellness and provide education regarding preventative care measures Effectively assess, coach and graduate clients from care, resulting in appropriately managed caseloads Document participant activities and coaching/counseling sessions in established format in the case tracking software In addition to performing standard Care Coach roles, Registered Nurses are involved in clinical decision-making and patient education. The scope of practice for nursing work includes, but is not limited to: Rationale for the effects of medications and treatments Implement measures to promote a safe environment for clients and others Accurately report: Administration of medication and treatments Client response Contact with other health care team members The client's status including signs and symptoms Nursing care (education) rendered Respect the client's right to privacy by protecting confidential information Promote and participate in education and counseling to a participant based on health needs Clarify any treatment that is believed to be inaccurate, non-effacious, or contraindicated by consulting with appropriate practitioner Know, recognize, and maintain professional boundaries of the nurse-client relationship

Imagine360

Benefit Review RN

Posted on:

October 27, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Imagine360 understands We developed a self-funded health plan solution that’s fixing today’s one-size-fits-none PPO insurance problems with powerful, customized solutions. We take a different approach: putting control back in your hands and providing access to higher-quality care. For you, your employees and their families. With deep savings. And unwavering support. Imagine that.

Imagine360 is seeking a Benefit Review RN to join the team!  The Benefit Review Nurse RN is responsible for providing benefit review/ utilization review and processing the independent physician review request for individuals under the group health plans administered by Imagine360 Administrators. You will utilize your nursing education, clinical and professional experience while participating in assessments, coordination, planning, monitoring, evaluation and determining outcomes of our members. Position Location: 100% remote

Required Experience/Education: Graduate of Accredited School of Nursing, College, or University 1+ years of Utilization Management experience Experience and knowledge of CPT and ICD Coding Skills and Abilities: Basic proficiency in MS Office including Outlook, Word, and Excel License and Certifications: Active and unrestricted Compact Registered Nurse License or Active and unrestricted Nursing License

Identify, collect, process, and organize data to complete the Benefit Reviews by utilization of Imagine360 Administrators approved clinical guidelines and following department policies and procedures. Works with the case management support employees to facilitate completion of the Benefit Review process. Staffs medically complex cases with the Supervisor/Manager, Case Management. Accurate utilization and documentation in the appropriate software including time slips in CaseTrakker to complete and document the nurse benefit review process. Identify and refer cases for Physician Advisor review. Facilitates the Independent Physician review process. Reviews high dollar pharmacy reports to identify appropriate referrals to Case Management or other Medical Management Services. Assess and review current treatment history to identify appropriate referrals to Case Management Program or other Medical Management Services. Communicates professionally and effectively with physicians, other healthcare professionals, peers, customers, member(s), and Supervisor/Manager of Case Management to complete the utilization process. Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite. Maintains current license and obtains additional license as required in order to perform the job functions. Adhere to internal Medical Management Policy and Procedures, Department of Labor, ERISA, and HIPAA regulations. Perform all tasks in accordance with HIPAA/PHI guidelines. Complete HIPAA training annually. Perform other duties and projects, as assigned. In addition to performing standard duties, the RN is involved in clinical decision making and patient education. The scope of practice for nursing work includes, but is not limited to: Evaluating clinical data. Assessment and evaluation of the acquired clinical data to assess for appropriateness of treatment plan based upon Imagine360's clinical guidelines. Coordination of treatment plans, interventions, and outcomes measurement. Rationale for the effects of medication and treatments. Provide patient education and educational resources. Accurate reporting. Administration of medication and treatments. Contact with other health care team members. Respect the client's right to privacy by protecting confidential information. Promote and participate in education and counseling to a participant based on health needs. Clarify any treatment that is believed to be inaccurate, non-effacious, or contraindicated by consulting with appropriate practitioner. The RN will have knowledge and practices the Core components of Case Management that include: Case Management Concepts Case Management Principle & Strategies Psychosocial & support systems HealthCare Management & delivery Healthcare Reimbursement Vocational concepts & Strategies.

Blue Cross Blue Shield of Minnesota

Health Plan Quality Assurance Specialist - RN

Posted on:

October 26, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Minnesota

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us.

This position is accountable for performing a wide variety of services related to quality investigations. The associate works as a member of the care management clinical audit team to ensure compliant, effective and efficient investigations of quality issues impacting the health and service of Blue Cross and Blue Plus members. This work contributes directly to adherence with regulatory and accreditation requirements including the organizations Quality Improvement Program. This position collaborates with multiple stakeholders at many levels across the company, as well as with external entities, providing coordination and support as required.

5+ years of related professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered. Registered nurse with current MN license or licensed behavioral health clinician without restrictions or pending restrictions. Detail orientation, with the ability to compare clinical practices against current standard of care/best practices, evaluating compliance, recommending improvement strategies, and producing accurate documentation. Demonstrated ability to work independently and make decisions as needed, must possess a proven track record of achievement. Organized and able to manage several priorities against challenging deadlines. Ability to develop strong cross-functional and collaborative relationships with internal and external partners, including the ability to work with a wide variety of people and personalities. Must project a strong professional image when representing Blue Cross externally. Must be self-motivated, able to take initiative, and work independently with minimal oversight to meet timelines, including strong follow-through skills and a solutions-oriented attitude. Experience in using Microsoft Excel, Word and Access as well as demonstrated ability to learn/adapt to computer-based tracking tools. Knowledge of medical terminology. High school diploma (or equivalency) and legal authorization to work in the U.S. Preferred Skills and Experience: Health Care Administration or Health Plan experience including experience in complaint/grievance processes and requirements. Medical Coding education and/or experience. CPHQ certification or equivalent healthcare quality or compliance certification. Current experience with Electronic Medical Records navigation, specifically EPIC.

Perform the initial triage and review of quality issues referred to the Quality Improvement Department, including confirmation of clinical issue needing investigation and categorization for tracking. Perform Quality of Care and Quality of Service reviews which includes summarizing medical records and determining if complaint is substantiated. Draft questions for practitioners and clinic staff to answer related to the investigation. Organize and manage documentation, policies and procedures, job aids, manuals, file system, reporting and outcome measurement related to the quality investigations, including connections with other departments (contracting, credentialing, medical management, etc.). Draft and implement corrective action plans for providers and practitioners when needed, including tracking and follow-up (case audits, etc.). Develop and manage regular standardized reporting to meet regulatory, accreditation, contractual and other requirements; including spreadsheets, databases and other systems as needed; including summarizing cases and analysis; creating presentations and facilitating Director-Level Quality Committee reports. Ensure compliance with regulatory and accreditation standards, including HIPAA, NCQA and Department of Labor regulations. Ad Hoc collaboration with MDH internal stakeholders during external audits. Special projects as assigned.

PharmD Live

Spanish Speaking LPN – Tennessee

Posted on:

October 26, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Tennessee

Job Title: Spanish & English speaking LPN – Tennessee Location: Fully Remote Schedule: Flexible – create your own hours Requirement: Must hold an active Tennessee RN or LPN license Position Overview: We are looking for a bilingual Care Coordinator (RN/LPN) fluent in Spanish and English to play a key role in managing patients enrolled in Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) programs. This role emphasizes patient engagement, data review, and coordination of care to reduce preventable complications and hospitalizations.

Active Tennessee RN or LPN license. Fully bilingual in Spanish and English (oral and written). 2+ years of experience in care coordination, telehealth, or chronic disease management. Strong skills in patient education, clinical judgment, and data interpretation. Proficient in EHR systems and comfortable with telehealth technology. Organized, compassionate, and able to thrive in a remote, HIPAA-compliant workspace.

Serve as the primary point of contact for patients enrolled in RPM and CCM programs. Review transmitted patient health data daily, identify red flags, and escalate issues to the clinical team. Provide culturally competent health education in Spanish and English, empowering patients to manage chronic conditions effectively. Partner with physicians, pharmacists, and interdisciplinary teams to optimize patient outcomes. Coordinate follow-ups, specialist referrals, and care transitions. Document interactions thoroughly in the EHR, ensuring accuracy and compliance with CMS regulations. Support program enrollment and assist with patient onboarding for RPM devices.

EmblemHealth

Care Manager, Complex & Disease Management - Multiple Openings/REMOTE

Posted on:

October 26, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

New York

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.

Provide care management, as part of a multi-disciplinary care team, that includes care coordination, performing telephonic or face-to-face assessments of members’ health care needs, identifying gaps in care and needed support, administering/coordinating implementation of interventions. Support and enable members to manage their physical, environmental and psycho-social concerns, understand and appropriately utilize their health plan benefits and remain safe and independent in their home or current living environment in collaboration with health care providers. Provide Care Management services to identified high risk members within the community, including but not limited to Physician Practices, Retail Centers/Neighborhood Care Centers, and members’ homes. Coordinate and provide care that is safe, timely, effective, efficient and member-centered to support population health, transitions of care, and complex care management initiatives. Engage with the most complex members of the health plan with the goal of improving health care outcomes and appropriate and timely utilization of services across the continuum of care. Assist the entire Care Management interdisciplinary team in managing members with Care Management needs.

Bachelor’s degree RN required, with current active RN license CCM certification preferred Certification in utilization or care management preferred 4 – 6 years of clinical experience Organization/prioritization ability; and the ability to effectively manage a caseload of highly complex members Support an integrated care model tapping into appropriate resources both internally and external to the organization Experience in case management/care coordination, managed care, and/or utilization management Strong communication skills (verbal, written, presentation, interpersonal) Trained in the use of Motivational Interviewing techniques Experience working in medical facility or practice and/or with electronic medical records Computer proficiency: MS Office (Word, Excel, Powerpoint, Outlook); mobile technology (wireless phone/laptop, etc.) System user experience in a highly automated environment Bilingual ability (verbal, written) Strong cross-group collaboration, teamwork, problem solving, and decision-making skills Ability to work a flexible schedule (evenings, weekends and holidays) to meet member and/or caregiver and departmental scheduling needs

Assess and evaluate the needs of our most complex members, acting as the clinical coordinator collaborating with members, caregivers, providers, multi-disciplinary team, and health care and community resources through a variety of assessments to identify areas of (medical, financial, environmental, health insurance benefit, psycho-social, caregiving) concerns and potential gaps in care utilizing the most appropriate resources to support members’ needs. Identify appropriate goals, strategies and interventions that may include referrals, health education, activation of community-based resources, life planning, or program/agency referrals based on areas of concern. Develop, communicate and evaluate medical management strategies and interventions including potential for alternative solutions to ensure high quality, cost effective continuum of care with the member, caregiver, provider(s) and multidisciplinary team. Include member and family as appropriate. Engage actively with the member PCP / designee. Engage with the member in support of their treatment team to identify and establish attainable goals that positively impact clinical, financial, and quality of life outcomes for member. Work collaboratively with all stake holders to ensure knowledge of the action plan, including participation in telephonic and face-to-face case conferences when appropriate. Assess the needs of members and align them with the appropriate member of the care team (wellness team, registered dietitian, social worker, community health workers). Act as the member’s advocate and liaison by completing or facilitating interventions with providers and/or private, non-profit, and governmental agencies. Ensure that all Care Management processes and reporting are compliant with all applicable federal and state regulations, and NCQA and company standards. Participate in delegation collaboration activities, as required. Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making care management recommendations. Enter and maintain documentation in the Electronic Medical Records System (EMR), meeting defined timeframes and performance standards. Maintain an understanding of Care Management principles, program objectives and design, implementation, management, monitoring, and reporting. Actively participate on assigned committees. Attend and complete all department-mandated training as well as satisfy educational in-service requirements. Perform other related projects and duties as assigned. Provide ongoing monitoring, evaluation, support and guidance to the coordination of the member's health care. Develop, implement and coordinate plan of care and facilitate members’ goals. Coordinate interdisciplinary team tasks and activities, with the goal of maintaining team performance and high morale.

EmblemHealth

Clinical Reviewer, Grievance & Appeals (Remote)

Posted on:

October 26, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

New York

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.

Perform clinical and administrative reviews within the Grievance and Appeals department, ensuring accurate administration of benefits, execution of clinical policy, timely access to appropriate levels of care and provision of payment for services that have already been rendered. Support the corporate and departmental goals and objectives.

Bachelor’s Degree, preferably a BSN CPC preferred Active, unrestricted LPN or RN license 4 – 6+ years of relevant, professional, clinical experience Managed care experience Knowledge of Medicare, Medicaid and Commercial Product Lines Knowledge of ICD-10 and CPT codes Strong organizing and analytical skills; detail oriented, with ability to identify and resolve/escalate problems as needed Ability to successfully manage multiple competing priorities and to meet deadlines Proficiency with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) Strong communication skills (verbal, written, presentation, interpersonal)

Prepare and present clinical summations/recommendations to the Medical Director or Pharmacist, or Independent Review Organization in accordance with state and federal regulations, NCQA requirements, and internal policy for final case determination in accordance with regulation and department policy. Research evidence-based guidelines, medical protocols, member benefit packages, provider networks, and on-line resources to review and investigate member and provider requests; determine appropriate utilization of benefits and/or claim adjudication. Consider quality initiatives and regulatory requirements as part of all case assessments. Under the direction of the leadership, is responsible for the execution of efficient departmental processes designed to manage utilization within the benefit plan. Responsible for the review of grievance and appeal cases referred for clinical and administrative pre-service, concurrent, and post-service appeal determinations; expedited and standard. Act as a clinical coordinator collaborating with members, providers, and facilities to evaluate member needs within the appropriate clinical setting, and as a clinical resource to the non-clinical Appeals staff. Enter and maintain documentation in the appropriate workflow tools meeting defined timeframes and performance standards (decision, notification, and effectuation). Communicate authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, NCQA and business standards. Effectively communicate verbally and in writing all decisions in an understandable, effective, timely and professional manner. Maintain an understanding of utilization management/grievance and appeals program objectives and design, implementation, management, monitoring, and reporting. Track and trend outcomes, analyzes data, and report on these to the Supervisor/Manager as required. Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager; report any quality of care or services issues or serious adverse events identified through the appeals process to the appropriate staff for investigation and processing. Assist with processing Department of Insurance Complaints related to medical necessity determinations; review and decide if a denied service or claim should be reversed or consult with the Medical Director in the decision-making process. Regular attendance is an essential function of the job. Perform other duties as assigned or required.

Preferred Healthcare LLC

Wound Care Nurse RN LPN

Posted on:

October 26, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Georgia

At Preferred Healthcare, we simplify wound care by bringing skilled, compassionate services directly to patients' homes. You'll be joining a mission-driven team committed to healing with heart.

Wound Care Nurse (LPN / RN) Location: East Atlanta | In-Home Patient Visits | Full-Time Preferred Healthcare is expanding our high-touch, home-based wound care services and is seeking Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) who are committed to compassionate care, clinical excellence, and collaboration. In this vital role, you will provide direct wound care in patients' homes, supporting our mission to deliver accessible, high-quality healing where patients are most comfortable. As a key member of the clinical team, you will work under the direction of our Practice Manager to ensure patients receive consistent, evidence-based, and personalized wound care. If you thrive in a dynamic, fast-paced environment and are ready to bring healing home, then this role is for you.

Education & Advocacy Educate patients and caregivers on wound care management, prevention, and recovery expectations to ensure optimal outcomes. Collaborate with internal teams to support patient education, compliance, and holistic wellness. Team Collaboration Partner closely with the Wound Care Quality Coordinator, Nurse Leadership, and Patient Support teams to ensure seamless delivery of care. Communicate clearly with providers and administrative staff to support coordination and continuity of care. Attend team huddles and contribute to continuous improvement conversations and training. Qualifications Education & Licensure: Active LPN or RN license in the state of Georgia (Required) Wound Care Certification (WCC, CWCN, or equivalent) – Preferred but not required Current BLS/CPR Certification Experience: More than 2 years of hands-on wound care or bedside nursing experience (home health, SNF, or hospital) Home health experience preferred but not required Familiarity with EHR documentation and mobile charting Skills: Strong assessment and clinical judgment in wound identification and treatment Compassionate bedside manner with strong communication and patient education skills Proficiency in Google Workspace and comfort with mobile health technology Ability to work independently in the field while staying connected to the support team Preferred Characteristics: Passionate about delivering care with dignity and empathy in patients' homes Comfortable navigating diverse patient environments and adapting care to meet needs Emotionally intelligent and collaborative—committed to teamwork, respect, and communication Organized, accountable, and detail-oriented

Clinical Care & Wound Management Deliver in-home, hands-on wound care to patients, including assessment, debridement (within scope), dressing changes, and infection prevention. Execute individualized wound care plans in collaboration with the clinical leadership team. Administer NasuWave UltraMIST therapy as prescribed, adhering to proper technique and infection control procedures. Nurses must be trained in or familiar with the UltraMIST process and be able to administer this non-contact, low-frequency ultrasound therapy safely and effectively. Monitor wound progression, identify complications, and escalate concerns appropriately. Maintain accurate and timely documentation in the EHR, following standard operating procedures and charting guidelines. Quality, Compliance & Best Practices Ensure all care and documentation meet internal quality standards and align with payer and audit expectations. Support ongoing wound care audits by maintaining thorough, well-documented visit notes and assisting in clinical reviews as needed. Follow established protocols, safety guidelines, and infection control measures.

Evolent Health

Clinical Reviewer, Nurse -9am -6pm PST

Posted on:

October 26, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Virginia

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. Your Future Evolves Here Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture.

The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are performed within the RN/LVN/LPN scope of practice, under Medical Director direction, using independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost effective care delivery.

Registered Nurse or Licensed Practical/Vocational Nurse with a current, unrestricted license. High School Diploma or equivalent required Minimum of three years of direct clinical patient care Minimum of one year of experience with medical management activities in a managed care environment Schedule: Monday–Friday, 9:00 AM–6:00 PM PST, with weekend and holiday rotation required. Finishing Touches (Preferred): Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual) UM Experience Strong interpersonal, oral and written communication skills. Possess basic computer skills Technical Requirements: We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Performs utilization review of outpatient procedures and ancillary services. Fulfills on call requirements for selected clients as scheduled. Determines medical necessity and appropriateness of services using clinical review criteria. Accurately documents all review determinations and contacts providers and members according to established timeframes. Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director. Appropriately identifies and refers quality issues to UM Leadership. Appropriately identifies potential cases for Care Management programs Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum. Performs accurate data entry. Communicates appropriate information to other staff members as necessary/required. Participates in continuing education initiatives. Collaborates with Claims, Quality Management and Provider Relations Departments as requested. Availability on some weekends and holidays may be required Performs other duties as assigned.

Medcor Inc

Bilingual Telephonic Triage Nurse - Remote (Midshift)

Posted on:

October 26, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Illinois

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

Medcor is looking to hire a full-time bilingual Spanish-speaking Registered Nurse for our remote 24/7 Occupational Health triage call center! The hours for this position include 8-hour or 10-hour shifts between the hours of 12pm and 2am CST. Job Type: Full-time - 40 hours per week Salary: $30 per hour with additional shift differential pay available for evenings, nights & weekends. By joining our nursing team, you will be helping thousands of employers better manage their workplace injuries and improve the quality of healthcare for their employees. Nurses who are successful in this position must be able to talk on the phone for long periods while typing and navigating through various software applications simultaneously. Our nurses must be able to visualize an injury while on the phone and clarify details about the injury while following our propriety algorithms to guide the triage of the injured worker. Training: Training for this role will last 5-6 weeks, with 2.5 weeks of classroom instruction and 2.5 weeks of precepting. These first 5-6 weeks of training are held Monday through Friday, from 8a-4p CST. The training schedule is non-negotiable, and all training must be successfully completed within the 6-week time frame. Following training, you will transition to your permanent schedule between the hours of 12p and 2a CST with an every-other-weekend requirement and holiday rotation. Changes to the permanent schedule are not allowed within the first 12 months of employment.

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

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

TriStar Centennial Medical Center

Clinical Appeals Specialist Medicare RN or LPN

Posted on:

October 25, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

TriStar Health is the region's largest, most comprehensive healthcare provider with locations in Tennessee and Southern Kentucky. As a family of hospitals all with the same mission, vision and values, we pride ourselves on delivering patient-focused care in the communities where you live and work. We lead the industry in developing and implementing patient safety initiatives to deliver the highest quality care.

This Work from Home position requires that you live and will perform the duties of the position; within 60 miles of an HCA Healthcare Hospital (Our hospitals are located in the following states: FL, GA, ID, KS, KY, MO, NV, NH, NC, SC, TN, TX, UT, VA). Do you want to join an organization that invests in you as a Clinical Appeals Specialist Medicare RN or LPN? At Parallon, you come first. HCA Healthcare has committed up to $300 million in programs to support our incredible team members over the course of three years. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Clinical Appeals Specialist Medicare RN or LPN like you to be a part of our team. Job Summary and Qualifications: Seeking a Clinical Appeals Specialist Medicare RN or LPN , who is responsible for handling appeals requiring clinical input or interpretation. We are an amazing team that works hard to support each other and are seeking a phenomenal addition like you. We want you to apply today!

Currently licensed as an LPN or RN in the state(s) of practice and/or has an active compact license, in accordance with law and regulation. High School diploma or GED required; Associate’s Degree preferred. 1 year of Case Manager, Insurance utilization and/or hospital experience preferred. Relevant education may substitute experience requirement. InterQual knowledge required.

Review medical records and other documentation to compose RAC appeal letter with concise medical summary based on support from the medical record and prepare RAC appeal package accordingly. Demonstrate ability to interpret CMS policy requirements. Strong ability to research evidence-based practices. Identify problem claims and appeals and escalate as appropriate. Update the RRT and any other systems (Artiva, SSD Web Tools) to identify actions taken on the account.

BlueCross BlueShield of South Carolina

RN Concierge Care Manager – Case Management

Posted on:

October 25, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Provides care management services to more than 2 million members in South Carolina and nationally. Administers complex, high-touch concierge case management for members identified into specialized programs such as high-risk maternity, NICU, ESRD, Cancer, Palliative Care or Behavioral Health. Identifies risks and provides outreach services to facilitate the coordination of healthcare services and gap closure. Provides individualized care plans to ensure cost-effectiveness, overall care satisfaction, and improved quality of life. Position Purpose: We are currently hiring for an RN Concierge Care Manager – Case Management to join BlueCross BlueShield of South Carolina. In this role as an RN Concierge Care Manager – Case Management, you will provide care management services to more than 2 million members in South Carolina and nationally, administer complex, high-touch concierge case management for members identified into specialized programs such as high-risk maternity, NICU, ESRD, Cancer, Palliative Care or Behavioral Health, identify risks and provides outreach services to facilitate the coordination of healthcare services and gap closure, and provide individualized care plans to ensure cost-effectiveness, overall care satisfaction, and improved quality of life. Location: This position is full-time (40 hours/week) Monday-Friday from 8:00am-5:00pm EST and will be fully remote.

Required Education: Associate’s degree in nursing OR Graduate of Accredited School of Nursing OR master’s degree in social work, Psychology, or Counseling. Required Work Experience: 5 years' case management experience as an RN OR 2 years’ case manager experience as an RN in a health insurance environment. Required Skills and Abilities: Working knowledge of word processing software. Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or creative thinking skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools: Microsoft Office Required Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire; OR active, compact, multistate, unrestricted RN license as defined by the Nurse Licensure Compact (NLC); OR active licensure as a social worker, psychologist, or counselor in state of hire. Nationally recognized Case Management certification to be obtained within 2 years of hire as a Case Manager. We Prefer That You Have the Following: Preferred Education: Bachelor's degree in health-related field (Nursing, Healthcare Administration, Pharmacy, Sciences, Applied Health) Preferred Work Experience: 5 years’ experience in case management in a sub-specialty area (i.e. ICU, Palliative Care, Hospice, or Home Health) Preferred Skills and Abilities: Strong communication and customer services skills. Excellent analytical skills to problem solve and remedy issues immediately. Ability to work in an autonomous environment or leadership capacity. Preferred Software and Tools: Working knowledge of Microsoft Word, PowerPoint, Excel, or other spreadsheet/database software; TMCS, LiveOps, MDDS, and BlueVue. Preferred Licenses and Certificates: Case manager certification, clinical certification in specialty area. Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS) certification.

Directs day-to-day, high-touch member management to include implementation of program goals, coordination of treatment plans and benefit coordination for high-risk patient populations and/or those with complex conditions. Coordinates clinical services with external sources to include: providers, vendors, facilities, social workers/case managers and/or community services. Participates in team training and continuing medical education. Prepares for external audits and quality assurance efforts.

Cadence Health

PRN Remote Nurse Practitioner

Posted on:

October 25, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

In the U.S., 60% of adults – more than 133 million people – live with at least one chronic condition. These patients need frequent, proactive support to stay healthy, yet our care system isn’t built for that level of attention. With rising clinician shortages, strained infrastructure, and reactive care models, patients too often end up in the ER or the hospital when those outcomes could have been prevented. At Cadence, we’re building a better system. Our mission is to deliver proactive care to one million seniors by 2030. Our technology and clinical care team extend the reach of primary care providers and support patients every day at home. In partnership with leading health systems, Cadence consistently monitors tens of thousands of patients to improve outcomes, reduce costs, and help patients live longer, healthier lives.

The Cadence Health team seeks a remote-based PRN Nurse Practitioner to serve as the point person to help patients navigate their remote care journey. Our Nurse Practitioners are responsible for appropriately triaging patients based on vitals, and managing treatment plans and medications in collaboration with the patient’s physician/provider. The role of PRN staff is to provide relief when regularly scheduled staff take time off for scheduled vacation, sick leave, or CME.

LICENSURE REQUIREMENTS: Active Compact Multi-State RN license is required Seven active Nurse Practitioner (NP) licenses including TX, and six or more of the following states: AL, AR, CT, FL, IL, IN, KY, MI, MS, NC, NY, OK, PA, TN, VA, VT, WI SCHEDULE REQUIREMENTS: Minimum requirement of 4 shifts per month (as needed), with priority given to night shifts. Night shifts must be accepted when available. Coverage of 2 holidays per year. 5+ years experience treating patients with chronic diseases (T2D, Hypertension, CHF) either in an outpatient or inpatient setting at a high-performing medical center. Active multi-state compact RN license. ANCC or AANP certification required. Master’s Degree as a Nurse Practitioner with the willingness to expand state licensure as Cadence adds new markets and partners. Experience managing CHF with GDMT. To ensure that our clinicians have the necessary tools for a successful remote work environment, home office setups must have consistently stable Wi-Fi with strong upload and download speeds. A Wi-Fi speed test is required before participating in the interview process to verify that these standards are met. Ability to thrive in an environment founded on trust, autonomy, and direct communication & feedback. Love of owning problems end-to-end. Independent thinker/operator. Passion for the patient/customer experience and systematically improving healthcare with digital innovation. Experience working in a CHF bridge clinic or T2D clinic (preferred). Experience working with remote patient monitoring technology (preferred). Experience working in a startup environment (preferred).

Oversee the monitoring of patient vitals, symptoms, and labs in collaboration with our team of RNs and MDs. Manage the patient's treatment plan and medications – with an emphasis on initiating and titrating guideline-directed medical therapy (GDMT) for Heart Failure and other appropriate guidelines for T2D and Hypertension. Respond to patient escalations identified via RPM – i.e. abnormal vitals, symptoms, and labs. Lead regular virtual check-ins with patients to review labs and GDMT optimization and adherence. Our programs support both primary care offices as well as cardiology offices. Ensuring every healthcare interaction with Cadence is an exceptional experience that prioritizes the well-being of the patient and aligns with the goals of the health system. Support internal growth efforts to help Cadence scale exceptional care delivery to patients with CHF and other chronic conditions including hypertension, and Type 2 diabetes. Be instrumental in shaping the culture of one of the fastest-growing teams at Cadence.

Vantive

Clinical Educator, Renal - Remote

Posted on:

October 25, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Vantive is a vital organ therapy company on a mission to extend lives and expand possibilities for patients and care teams everywhere. For 70 years, our team has driven meaningful innovations in kidney care. As we build on our legacy, we are deepening our commitment to elevating the dialysis experience through digital solutions and advanced services, while looking beyond kidney care and investing in transforming vital organ therapies. Greater flexibility and efficiency in therapy administration for care teams, and longer, fuller lives for patients— that is what Vantive aspires to deliver. We believe Vantive will not only build our leadership in the kidney care space, it will also offer meaningful work to those who join us. At Vantive, you will become part of a community of people who are focused, courageous and don’t settle for the mediocre. Each of us is driven to help improve patients’ lives worldwide. Join us in advancing our mission to extend lives and expand possibilities.

In this customer / client facing role, you’ll have the opportunity to utilize your dialysis nursing experience to provide implementation, education, and training on Vantive Renal product portfolio. Ideal candidate will reside in: New Mexico, Colorado, Georgia, Virginia, North Carolina

Active RN compact license required. Associate degree or higher, BSN preferred. Heavy Travel (75%-90%) Minimum of five years’ clinical experience required, in a HD/ PD Chronic setting, Acute (Med/Surg, Critical Care) in a dialysis environment. Hemodialysis and Peritoneal Dialysis experience required. Strong, demonstrated expertise in education, product and therapy knowledge. Must live within one hour of major international airport. Must have valid driver’s license and acceptable driver record. Must be able to push dialysis machine and lift PD equipment, from one location to another, and be able to lift up to 25 – 40 Lbs. in solutions and accessories. Must be able to fly for extended timeframes and the possibility of driving for extended distances. Require the ability to travel with appropriate tools and/or resources to perform responsibilities (i.e., laptop computer, projector, iPad, etc.)

Provide training education for facilities in Hemodialysis, and Peritoneal Dialysis. Requires extensive travel (90%). Promote product demonstrations during education sessions and document product leads on the current CRM. Document and provide written solutions to recurring problems for client use incorporating use of corporate label approval policies. Develops and uses collaborative relationships to facilitate the accomplishment of business goals with both inter (sales) and external customers. Provide therapy, technical and operation consultation to hemodialysis and peritoneal dialysis contract services such as chronic, hospitals and long-term care facilities, utilizing Vantive Healthcare equipment during pre and post-Implementation phases for renal product lines. Conduct on-site customer training. Continuously increase and sharpen therapy and technical knowledge as well as presentation skills. Responsible for being able to conduct scientific / technical presentations and discussions on renal therapy. Works in a consultative manner with customers and in collaboration with other renal business team members. Prioritize accounts based on need and return on investment. Prepare weekly calendar updates. Effectively meets or exceeds customer needs builds productive customer relationships; takes responsibility for customer satisfaction and loyalty. Account Management – Collaborate with the sales team and Renal Clinical Education Coordinator to prioritize account education. Coordinate and manage resources to provide necessary customer service. Track and analyze progress. Manage budget and expenses, adhere to company policies, and communicate effectively with corporate and field personnel. Maintain a positive, proactive approach to problem solving. Keeps current with developments and trends in Extracorporeal Therapies. Assist sales and marketing management with special requests by acting as a member of a task force. Provide sales marketing management with field updates and competitive information. Participate in sales meetings. Assumes responsibility for turning in all required written reports on a timely basis.

Family Allergy & Asthma

Part Time Triage Nurse - Remote

Posted on:

October 25, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Founded in 1979 by Drs. Stephen J. Pollard and James L. Sublett, Family Allergy & Asthma is a group of board-certified allergy and asthma specialists with offices in Arkansas, Florida, Illinois, Indiana, Kentucky, Missouri, Ohio, Pennsylvania, and Tennessee. We recognize that patients come to us because of the limitations placed on them due to their allergic or asthmatic conditions. It is our goal to remove these limitations, to the greatest possible extent, and to give patients their lives back.

Job Title: Part Time Triage Nurse - Remote Employment Classification: Non-exempt, Hourly Status: Part Time - 20 Hours Position Summary The Triage Nurse is responsible for demonstrating knowledge and application of job duties within scope of practice and functions under the direction of their manager(s) and/or Director(s); respectfully interacts with all levels of staff; provides direct assistance during assigned duty hours; participates in department activities; promotes independence; adherence to the attendance policy; encourages socialization; advocates for the quality of life of our patients while maintaining compliance with all applicable laws, regulatory and organizational standards; supports the company’s core values

Abilities, Knowledge, and Skills Effective communication skills to include: Ability to fluently speak and read English Ability to read and interpret documents such as safety rules, handbooks, policies, patient care plans and procedure manuals Ability to communicate effectively, verbally and written, with all levels of staff and patients Education, Prior Work Experience, Special Skill And Knowledge Requirements Diploma in Nursing- LPN/RN with an active and unrestricted KY Nursing License, or an eNLC multistate nursing license 1 to 2 years nursing experience in an office setting, preferred Previous allergy/asthma experience preferred CPR certification required Valid Driver’s License required Active CPR Certification Acceptable results on Office of Inspector General, State Medicaid Exclusions, Abuse Registry Checks, Background Screenings, Drug Screen, and Sanction Checks Ability to travel to satellite offices as needed Must be at least 18 years of age Physical Demands and Work Environment 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 physical demands. While performing the duties of this job, the employee is regularly required to use hands to handle, or feel objects, tools, or controls; reach with hands and arms; and talk or hear. The employee frequently is required to stand, walk, stoop, kneel, crouch, reach, push, pull, bend and sit. On average, triage staff may be sitting 80% of their shift. The employee must occasionally lift and/or move up to 30 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus. Specific communication abilities required by this job include the ability to talk and hear in order to converse with others, discern, convey, express oneself, and exchange information. Work Environment The work environment characteristics described here are representative of those an employee may encounter while performing the essential functions of this job. The noise level in the work environment is usually moderate; lighting is in the standard range. The employee is subject to infectious waste, potential exposure to allergens in concentrated forms, diseases, and conditions.

Works with providers, nurses, and patients to resolve questions concerning medications, health education, and medical advice within skill level and scope of practice Works with providers and nurses to assess the urgency of patient problems Assists the patient by acquiring the appropriate appointment, as needed Records and maintains complete and accurate records of patient and physician communications regarding medical care according to the standard medical record documentation requirements Retrieves messages from phone and electronic submissions in a timely manner and responds to patient needs according to medical priority Documents all incoming calls according to established department routine Responds appropriately within skill level and documented departmental policies, and when appropriate, seeks provider advice when responding to patients medical care Follows through in a timely manner on patients requests Submits electronically/faxes new prescriptions and refill prescriptions according to physician orders Records all prescription/refill information in the medical record according to established department routine Serves as a resource to clinic staff regarding medical information, patient assessment, and nursing management of illness Acquire pre-certs/prior authorizations for patient needs Provide test results Other tasks as delegated

MPF Federal

Call Center Nurse (RN-BSN) - Remote - Nov Dec 2025

Posted on:

October 25, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Ready to Bring Your Acute Care Skills Home? Join Our Remote RN Team Supporting Our Military Communities! Are you a seasoned ER or Med-Surg nurse looking for a meaningful, mission-driven role that lets you care for others without the scrubs and long drives to the hospital? MPF Federal is hiring Remote Telehealth Triage Nurses (RNs) to join our 24/7 Nurse Advice Line—supporting veterans and their families—all from the comfort of your home. This isn’t just a job; it’s your chance to use your clinical expertise, empathy, and critical thinking skills to guide patients through their toughest moments—all while achieving better work-life balance. Pay & Perks $35.00/hr base rate Evening, night, and weekend differentials may apply 100% Remote – Work From Home Most schedules include Saturday and Sunday and do not rotate Shifts Available (Share Your Schedule Preference!) Day Shifts Evening Shifts Night Shifts Training Approximately 6 Weeks Paid Training | Monday–Friday, 8:00 AM – 4:30 PM Start Date: December 1, 2025 - You will be required to also work BOTH Christmas and New Years.

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

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

MPF Federal

FULL TIME - Remote Telehealth Nurse (RN-BSN)

Posted on:

October 25, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Please note, for this position you will be required to also work BOTH Christmas and New Years during training and other holidays throughout the year as scheduled. Ready to Bring Your Acute Care Skills Home? Join Our Remote RN Team Supporting Our Military Communities! Are you a seasoned ER or Med-Surg nurse looking for a meaningful, mission-driven role that lets you care for others without the scrubs and long drives to the hospital? MPF Federal is hiring Remote Telehealth Triage Nurses (RNs) to join our 24/7 Nurse Advice Line—supporting veterans and their families—all from the comfort of your home. This isn’t just a job; it’s your chance to use your clinical expertise, empathy, and critical thinking skills to guide patients through their toughest moments—all while achieving better work-life balance. Pay & Perks $35.00/hr base rate Evening, night, and weekend differentials may apply 100% Remote – Work From Home Most schedules include Saturday and Sunday and do not rotate Shifts Available (Share Your Schedule Preference!) = means day off; R means Thursday; and Y means Saturday SMTWR==11:00-19:30(11:00am-7:30pm)8 HR SMTWR==11:00-19:30(11:00am-7:30pm)8 HR =MTW==Y11:00-21:30(11:00am-9:30pm)10 HR SM==R=Y11:00-21:30(11:00am-9:30pm)10 HR =MTW==Y11:00-21:30(11:00am-9:30pm)10 HR SMTW==Y15:30-0:00(3:30pm-12:00am)8 HR S====FY7:00-19:30(7:00am-7:30pm)12 HR ==TWRFY15:30-0:00(3:30pm-12:00am)8 HR S==WRFY15:30-0:00(3:30pm-12:00am)8 HR Schedules are not flexible and include all holidays. Training Approximately 6 Weeks Paid Training | Monday–Friday, 8:00 AM – 4:30 PM Start Date: December 1, 2025 You will be required to also work BOTH Christmas and New Years during training and other holidays throughout the year as scheduled.

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

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

Elevance Health

OB Nurse Case Mgr SR

Posted on:

October 25, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

OB Nurse Case Manager Sr Location: Washington, DC. This role requires associates to be in-office 4 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of remote work, promoting a dynamic and adaptable workplace. Alternate locations may be considered. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law The OB Nurse Case Manager Sr will be responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planning.

Minimum Requirements: Requires BA/BS in a health related field and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. Preferred Skills, Capabilities and Experiences: Experience with OB preferred. Certification as a Case Manager is preferred.

Ensures member access to services appropriate to their health needs. Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Coordinates internal and external resources to meet identified needs. Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. Negotiates rates of reimbursement, as applicable. Assists in problem solving with providers, claims or service issues. Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups. May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff. Participates in department audit activities.

Axis Community Health

TELEPHONE TRIAGE REGISTERED NURSE

Posted on:

October 23, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

California

Axis Community Health, a nonprofit established in 1972, provides comprehensive healthcare services to over 15,000 individuals across all age groups in the Tri-Valley area. The mission of Axis Community Health is to provide quality, affordable, accessible and compassionate health care services that promote the well-being of all members of the community. Our mission is rooted in delivering high-quality patient care, encompassing primary healthcare, mental health support, and dental services. We are committed to ensuring access to essential healthcare services for every member of our community, irrespective of financial status, living situation, or insurance coverage.

The Telephone Triage Registered Nurse serves as a primary clinical point of contact for patients, managing inbound calls and patient messages related to medical concerns. This role involves assessing symptoms, addressing chronic disease management needs, and providing evidence-based guidance using standardized triage protocols and critical thinking skills. The nurse evaluates the urgency of each situation and directs patients to the appropriate level of care, ensuring timely and effective medical support.

Graduate of an accredited nursing program. Associate Degree in Nursing (ADN) is required, Bachelor of Science in Nursing (BSN) is preferred. Minimum of 2-3 years of clinical nursing experience, preferably in outpatient, ambulatory care, or emergency setting preferred. Experience with telephone triage protocols is highly desired. Holds a current and unrestricted Registered Nurse (RN) license in the state of California. Ability to meet requirements of CPR, First Aid and other mandated programs. Possess critical thinking skills and the ability to work effectively and independently in a fast-paced setting. Possess strong clinical assessment, problem-solving, and decision-making skills to manage complex patient situations and make appropriate care recommendations. Demonstrate exceptional verbal communication and active listening skills, conveying empathy and reassurance to patients over the phone. Maintain calm, professional demeanor during stressful and urgent situations while exhibiting compassion and cultural sensitivity. Ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, and policies that are necessary for providing quality care. Be comfortable and proficient with Electronic Health Record (EHR) and telehealth technology. Strong employee relations and interpersonal skills. Excellent writing, business communication, editing, and proofreading skills. Ability to interact effectively and in a supportive manner with persons of all backgrounds. Proactive, self-motivated and able to work independently in a fast-paced environment as well as on a team with the ability to exercise sound independent judgment. Ability to maintain a high level of confidentiality and a professional demeanor and must positively represent the organization at all times. Ability to establish and maintain positive and professional working relationships. Ability to organize and set priorities and be able to adjust priorities quickly as circumstances dictate. Must be able to be at work regularly and on time. Must be a dynamic self-starter with demonstrated ability to work independently or in a group setting. A can-do attitude with attention to detail. Ability to type a minimum of 35 WPM with minimal errors. Must have good computer skills using Microsoft Office and the ability to use Axis departmental systems. Must be able to use office equipment (i.e. copier, fax, etc.). Available to work a part-time schedule with a minimum of 32 hours per week, with the potential for increased hours in the future.

Manages incoming calls and conducts telephonic or virtual health assessments to evaluate a patient’s symptoms and medical history determining the severity and urgency of their condition. Uses established, evidence-based guidelines, protocols and clinical judgment to provide appropriate medical advice and make decisions on next steps for a patient’s care. Provide appropriate patients dispositions to emergency/higher level of care or clinic provider appointments. Identifies and responds effectively to critical and emergency situations, escalating high-risk cases to clinical leadership or emergency services as appropriate. Obtains appropriate input and direction from provider as needed to determine best clinical course of action and recommendations for specific patient health care needs. Document symptoms, complaints, nursing assessments, advice provided, and patient or caller responses accurately and thoroughly. Adhere to established policies, procedures, and protocols to ensure consistency, departmental effectiveness, and improved patient health outcomes and access to appropriate care. Offers clear and concise medical education and self-care instructions for managing minor ailments or chronic conditions, and provides guidance on medications and follow-up care. Collaborates with providers and other members of the health care team to schedule appointments, coordinate referrals, manage prescription refills and close gaps in care. Provides RN coverage for nursing services as per the Title 22 CC Section 75028 Protects patients by adhering to infection control policies and protocols. Maintains accurate, timely and thorough documentation of all patient interactions, assessments and recommendations in the electronic health record. Maintains patient privacy and protects operations by complying fully with HIPAA regulations. Maintains a cooperative relationship among health care teams by communicating information, responding to requests, building rapport, participating in team problem-solving methods. Ensures that services are provided in a manner that is appropriate to patient needs and in full compliance with established medical protocols and legal and programmatic requirements. Assists with additional clinical duties as needed or assigned, such as managing clinical Inbox messages. Participate in staff meetings, and attend other meetings and training events as assigned. May be required to perform other related duties, responsibilities, and special projects as assigned.

Elevance Health

Nurse Case Mgr II (US)

Posted on:

October 23, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

Nurse Case Manager II Hours: 9am-5:30pm EST with 2 -3 evening shifts a month 11:30am-8pm EST Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Nurse Case Manager II is responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planning

Minimum Requirements: Requires BA/BS in a health related field and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. Preferred Skills, Capabilities and Experiences: Certification as a Case Manager is preferred. BS in a health or human services related field preferred. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $76,944- $120,912 Locations: Illinois, New York

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

Elevance Health

Nurse Care Mgr I (contract)

Posted on:

October 23, 2025

Job Type:

Contract

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

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

Anticipated Start Date: 11/10/2025 Additional Details: Monday through Friday, 8am-5pm PST Nevada Nursing license (Will Reimburse)

Requires a HS diploma or equivalent and a minimum of 3 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current, active valid unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. Home health/discharge planning experience preferred. AS or BS in nursing preferred. Certification as a Case Manager is preferred. For URAC accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows for an independent assessment to be conducted within their scope of practice. Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred or any combination of education and experience, which would provide an equivalent background, Multi-state licensure is required if this individual is providing services in multiple states. Certification as a Case Manager or a BS in a health or human services related field also preferred.

Responsible for collaborating with healthcare providers and/or consumer to drive personalized health management and improve health outcomes for optimal consumers. Performs care management activities within the scope of licensure for members with complex and chronic care needs. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions and extensions of stay, outpatient services, out of network services, and appropriateness of treatment setting and level of care. Partners with physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance. Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge. Conducts clinical assessment to develop goals that address individual needs in order to develop and implement a care plan. Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

Allina Health System

RN Triage

Posted on:

October 23, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Minnesota

Allina Health is a not-for-profit health system that cares for individuals, families and communities throughout Minnesota and western Wisconsin. If you value putting patients first, consider a career at Allina Health. Our mission is to provide exceptional care as we prevent illness, restore health and provide comfort to all who entrust us with their care. This includes you and your loved ones. We are committed to providing whole person care, investing in your well-being, and enriching your career.

Key Position Details: Fully remote position, including orientation, occasional onsite requirements. Employee is required to live within 60 min. of Apple Valley, MN. 0.70 FTE (56 hours per two-week schedule) 8 hour Day shifts Every 3rd weekend rotation and holiday rotation required Cross trained to process medication refills Job Description: Nursing is the diagnosis and treatment of human response to actual or potential health problems. This includes establishing an intentional therapeutic relationship between a registered nurse and a patient and family. As a leader and the integrator of care, the professional nurse has the responsibility, authority, and accountability for planning, coordinating and evaluating the patient’s care needs. Provides patient care support for centralized nursing program, outpatient and home care services. This includes Triage services, Anti-coagulation, and refill. Individuals in this role will work in an outpatient clinic setting.

Required Qualifications: Associate's or Vocational degree in nursing Minimum 3 years RN experience Preferred Qualifications: Experience in triage, anticoagulation, or remote nursing support Licenses/Certifications Licensed Registered Nurse-MN Board of Nursing required Licensed Registered Nurse-WI Dept of Safety & Professional Services required by completion of orientation Physical Demands Sedentary: Lifting weight up to 10 lbs. occasionally, negligible weight frequently

Assessment. Collects, prioritizes and synthesizes comprehensive data pertinent to the patient's health or situation. Collects and prioritizes data in a systematic and ongoing process that involves the patient, family, other health care providers and environment as appropriate. Integrates data relevant to the situation to identify needs, patterns and variances. Uses appropriate evidence based assessment techniques and instruments in data collection. Diagnosis. Analyzes assessment data to determine nursing diagnoses. Interprets assessment information to identify each patient's needs relative to age, developmental stage and culture. Formulates, revises and resolves nursing diagnoses that reflect the current patient status. Validates and communicates nursing diagnoses with the patient, family and other health care team members. Documents nursing diagnoses in compliance with the patient care guidelines. Outcomes Identification. Identifies expected outcomes individualized to the patient. Establishes, in the collaboration with the family, patient, realistic and measurable patient expected outcomes based on nursing diagnoses, patients present and potential capabilities, goals, available resources and plan for continuity of care. Planning. Develops a plan that prescribes interventions to attain expected outcomes. Develops an individualized plan considering patient characteristics or the situation as appropriate in conjunction with the patient, family and others. Establishes a plan that provides for continuity of care. Incorporates evidence based nursing practice takes into consideration current statutes, rules and regulations when developing the plan of care. Implementation. Implements the identified plan. Implements interventions in a safe, timely, appropriate manner. Utilizes evidence-based interventions and treatments specific to the diagnoses as appropriate. Coordinates implementation of the plan of care if appropriate Documents interventions according to documentation guidelines. Evaluation. Evaluates the patient’s progress towards attainment of the outcome. Evaluates the patient’s/family’s understanding of and response to the plan of care. Utilizes systematic and ongoing assessment data to revise diagnoses, outcomes and the plan of care. Involves the patient, family, and health care team members in the evaluation process when appropriate. Documents revisions in diagnoses, outcomes and the plan of care according to documentation guidelines. Quality of Practice. Systematically enhances the quality and effectiveness of nursing practice. Participates in quality improvement activities related to nursing practice. Incorporates available QI data to improve nursing practice and outcome. Education. Attains knowledge and competency that reflects current nursing practice. Participates in educational activities related to nursing practice. Acquires and applies the knowledge gained from educational experiences to current nursing practice. Professional Practice Evaluation. Evaluates one’s own nursing practice in relation to professional practice standards and regulatory guidelines. Engages in self-evaluation of practice on a regular basis, identifying strengths and goals for professional development. Obtains informal feedback regarding one’s own practice from patients, peers, professional colleagues, and others. Collegiality. Contributes to the professional development of peers, colleagues, and others. Shares knowledge and skills in practice settings. Provides immediate and ongoing positive and constructive feedback to colleagues regarding their performance. Contributes to a supportive and healthy work environment. Collaboration. Collaborates with patient, family, and others in the conduct of nursing practice. Partners with others to effect change and generate positive outcomes through knowledge of the patient or situation. Ethics. Acts in an ethical manner. Maintains a therapeutic and professional patient-nurse relationship with appropriate professional role boundaries. Serves as a patient advocate assisting patients in developing skills for self-advocacy Uses available resources to help formulate ethical decisions. Research. Integrates research findings in practice. Utilizes the best evidence, including research findings, to guide practice decisions. Resource Utilization. Incorporates factors related to safety, effectiveness, cost, and impact on practice in planning and delivering patient care. Utilizes resources related to standards of care in a safe, effective and ethical manner. Manages resources to assure they will be accessible to other in the future. Leadership. Provides leadership in the professional practice setting and the profession. Functions as a professional role model. Promotes a positive work environment. Participates in shared decision-making. Environmental Health. Practices in an environmentally safe and healthy manner. Attains knowledge of environmental health concepts, such as implementation of environmental health strategies. Promotes a practice environment that reduces environmental health risks for workers and healthcare consumers. Communicates environmental health risks and exposure reduction strategies to healthcare consumers, families, colleagues and communities. Charge Nurse (only when acting in this role). Demonstrates ability to coordinate and direct unit operation so the patient and family needs are met and resources are efficiently utilized in a safe manner. Promotes an environment that encourages individual growth, nurtures professional practice and fosters teamwork. Collaborates effectively with unit staff, leadership and other disciplines. Preceptor (only when acting in this role). Demonstrates ability to identify the orientee's learning needs and plans appropriate learning experiences. Demonstrates ability to implement an individualized orientation plan for the orientee. Demonstrates ability to validate clinical competence of orientee. Facilitates development of organizational and prioritization skills of orientee. Demonstrates ability to evaluate interpersonal sills of orientee. Serves as a professional role model. Facilitated socialization of orientee into the organization and work group. Other duties as assigned.

Allina Health System

RN Centralized Nursing Services Refill

Posted on:

October 23, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Minnesota

Allina Health is a not-for-profit health system that cares for individuals, families and communities throughout Minnesota and western Wisconsin. If you value putting patients first, consider a career at Allina Health. Our mission is to provide exceptional care as we prevent illness, restore health and provide comfort to all who entrust us with their care. This includes you and your loved ones. We are committed to providing whole person care, investing in your well-being, and enriching your career.

Key Position Details: Fully remote position, including orientation with occasional onsite requirements. Employee is required to live within 60 min. of Apple Valley, MN. 0.90 FTE (72 hours per two-week schedule) 8 hour Day/Evening shifts Every 3rd weekend rotation and holiday rotation required Will cross train to Nurse Triage Job Description: Nursing is the diagnosis and treatment of human response to actual or potential health problems. This includes establishing an intentional therapeutic relationship between a registered nurse and a patient and family. As a leader and the integrator of care, the professional nurse has the responsibility, authority, and accountability for planning, coordinating and evaluating the patient’s care needs. Provides patient care support for centralized nursing program, outpatient and home care services. This includes Triage services, Anti-coagulation, and refill. Individuals in this role will work in an outpatient clinic setting.

Required Qualifications: Associate's or Vocational degree in nursing Minimum 3 years RN experience Preferred Qualifications: Experience in triage, anticoagulation, or remote nursing support Licenses/Certifications: Licensed Registered Nurse-MN Board of Nursing required Licensed Registered Nurse-WI Dept of Safety & Professional Services required by completion of orientation

Assessment: Collects, prioritizes and synthesizes comprehensive data pertinent to the patient's health or situation. Collects and prioritizes data in a systematic and ongoing process that involves the patient, family, other health care providers and environment as appropriate. Integrates data relevant to the situation to identify needs, patterns and variances. Uses appropriate evidence based assessment techniques and instruments in data collection. Diagnosis. Analyzes assessment data to determine nursing diagnoses. Interprets assessment information to identify each patient's needs relative to age, developmental stage and culture. Formulates, revises and resolves nursing diagnoses that reflect the current patient status. Validates and communicates nursing diagnoses with the patient, family and other health care team members. Documents nursing diagnoses in compliance with the patient care guidelines. Outcomes Identification. Identifies expected outcomes individualized to the patient. Establishes, in the collaboration with the family, patient, realistic and measurable patient expected outcomes based on nursing diagnoses, patients present and potential capabilities, goals, available resources and plan for continuity of care. Planning. Develops a plan that prescribes interventions to attain expected outcomes. Develops an individualized plan considering patient characteristics or the situation as appropriate in conjunction with the patient, family and others. Establishes a plan that provides for continuity of care. Incorporates evidence based nursing practice takes into consideration current statutes, rules and regulations when developing the plan of care. Implementation. Implements the identified plan. Implements interventions in a safe, timely, appropriate manner. Utilizes evidence-based interventions and treatments specific to the diagnoses as appropriate. Coordinates implementation of the plan of care if appropriate Documents interventions according to documentation guidelines. Evaluation. Evaluates the patient’s progress towards attainment of the outcome. Evaluates the patient’s/family’s understanding of and response to the plan of care. Utilizes systematic and ongoing assessment data to revise diagnoses, outcomes and the plan of care. Involves the patient, family, and health care team members in the evaluation process when appropriate. Documents revisions in diagnoses, outcomes and the plan of care according to documentation guidelines. Quality of Practice. Systematically enhances the quality and effectiveness of nursing practice. Participates in quality improvement activities related to nursing practice. Incorporates available QI data to improve nursing practice and outcome. Education. Attains knowledge and competency that reflects current nursing practice. Participates in educational activities related to nursing practice. Acquires and applies the knowledge gained from educational experiences to current nursing practice. Professional Practice Evaluation. Evaluates one’s own nursing practice in relation to professional practice standards and regulatory guidelines. Engages in self-evaluation of practice on a regular basis, identifying strengths and goals for professional development. Obtains informal feedback regarding one’s own practice from patients, peers, professional colleagues, and others. Collegiality. Contributes to the professional development of peers, colleagues, and others. Shares knowledge and skills in practice settings. Provides immediate and ongoing positive and constructive feedback to colleagues regarding their performance. Contributes to a supportive and healthy work environment. Collaboration. Collaborates with patient, family, and others in the conduct of nursing practice. Partners with others to effect change and generate positive outcomes through knowledge of the patient or situation. Ethics. Acts in an ethical manner. Maintains a therapeutic and professional patient-nurse relationship with appropriate professional role boundaries. Serves as a patient advocate assisting patients in developing skills for self-advocacy Uses available resources to help formulate ethical decisions. Research. Integrates research findings in practice. Utilizes the best evidence, including research findings, to guide practice decisions. Resource Utilization. Incorporates factors related to safety, effectiveness, cost, and impact on practice in planning and delivering patient care. Utilizes resources related to standards of care in a safe, effective and ethical manner. Manages resources to assure they will be accessible to other in the future. Leadership. Provides leadership in the professional practice setting and the profession. Functions as a professional role model. Promotes a positive work environment. Participates in shared decision-making. Environmental Health. Practices in an environmentally safe and healthy manner. Attains knowledge of environmental health concepts, such as implementation of environmental health strategies. Promotes a practice environment that reduces environmental health risks for workers and healthcare consumers. Communicates environmental health risks and exposure reduction strategies to healthcare consumers, families, colleagues and communities. Charge Nurse (only when acting in this role). Demonstrates ability to coordinate and direct unit operation so the patient and family needs are met and resources are efficiently utilized in a safe manner. Promotes an environment that encourages individual growth, nurtures professional practice and fosters teamwork. Collaborates effectively with unit staff, leadership and other disciplines. Preceptor (only when acting in this role). Demonstrates ability to identify the orientee's learning needs and plans appropriate learning experiences. Demonstrates ability to implement an individualized orientation plan for the orientee. Demonstrates ability to validate clinical competence of orientee. Facilitates development of organizational and prioritization skills of orientee. Demonstrates ability to evaluate interpersonal sills of orientee. Serves as a professional role model. Facilitated socialization of orientee into the organization and work group. Other duties as assigned.

Elevance Health

Med Mgmt Nurse (US)

Posted on:

October 23, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

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

Medical Management Nurse Location: Washington, DC. This role requires associates to be in-office 4 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of remote work, promoting a dynamic and adaptable workplace. Alternate locations may be considered. The Medical Management Nurse will be responsible for review of the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of member’s clinical presentation to determine whether to approve requested service(s) as medically necessary. Works with healthcare providers to understand and assess a member’s clinical picture. Utilizes nursing judgment to determine whether treatment is medically necessary and provides consultation to Medical Director on cases that are unclear or do not satisfy relevant clinical criteria. Acts as a resource for Clinicians. May work on special projects and helps to craft, implement, and improve organizational policies.

Requires a minimum of associate’s degree in nursing. Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background. Current active, valid and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required. Multi-state licensure is required if this individual is providing services in multiple states.

Utilizes nursing judgment and reasoning to analyze members’ clinical information, interface with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity. Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources. Determines and assesses abnormalities by understanding complex clinical concepts/terms and assessing members’ aggregate symptoms and information. Assesses member clinical information and recognizes when a member may not be receiving appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis. Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate. May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience. Collaborates with case management nurses on discharge planning, ensuring patient has appropriate equipment, environment, and education needed to be safely discharged. Collaborates with and provides nursing consultation to Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear. Serves as a resource to lower-level nurses. May participate in intradepartmental teams, cross-functional teams, projects, initiatives and process improvement activities. Educates members about plan benefits and physicians and may assist with case management. Collaborates with leadership in enhancing training and orientation materials. May complete quality audits and assist management with developing associated corrective action plans. May assist leadership and other stakeholders on process improvement initiatives. May help to train lower-level clinician staff.

CVS Health

Behavioral Health Utilization Management Clinical Consultant - Work at Home - Oklahoma

Posted on:

October 23, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Oklahoma

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 at home Position-Must Reside in Oklahoma Position Summary: Behavioral Health Clinical Reviewer (LCSW, LCPC, RN) Licensed clinical professional with a passion for behavioral health and a strong background in psychiatric care. As a Behavioral Health Clinical Reviewer, your expertise will drive impactful decisions that improve lives. In this role, you’ll leverage your clinical skills to coordinate, document, and communicate all aspects of our utilization and benefit management programs. You’ll apply critical thinking and evidence-based guidelines to assess treatment plans, ensure appropriate levels of care, and promote quality healthcare outcomes.

Qualifications: Active licensure as LCSW, LCPC, or RN. Experience in a psychiatric or behavioral health setting required. Strong knowledge of clinical practice guidelines and utilization management. Required Qualifications : Unrestricted OK state independent Behavioral Health clinician license or a Registered Nurse (RN) with psychiatric specialty, certification, or Behavioral Health experience 3+ years clinical practice experience, e.g., psychiatric hospital, residential or behavioral health treatment setting. 1+ year Electronic Medical Record documentation experience Must have reliable High Speed internet access Schedule is Monday-Friday with flexibility to work outside of the standard schedule based on business needs, including occasional rotating weekend and holiday schedules. Preferred Qualifications: Managed care/utilization review experience preferred Experience in a behavioral health inpatient setting Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Education Master's Level of Education resulting in independent Behavioral Health licensure (LCSW, LPCC, LMFT, LPAT, LP) or a Registered Nurse (RN) with unrestricted state license with psychiatric specialty, certification, or experience.

Evaluate treatment plans using clinical judgment and evidence-based standards. Coordinate and monitor healthcare services to ensure optimal benefit utilization. Provide triage and crisis support for members in need. Facilitate effective discharge planning and care transitions. Collaborate with providers and internal teams to support integrated care. Identify at-risk members and connect them with appropriate resources. Promote quality and cost-effective care through clinical consultation and review.

CareHarmony

Remote - Triage Nurse - Nights - Licensed Practical Nurse - LPN - LVN

Posted on:

October 23, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Compact / Multi-State

CareHarmony works comprehensively with providers to deliver value-based care management initiatives for their patients. Our clinicians are driven by their passion for the level of care delivered; experts in assisting patients and caregivers navigate a sometimes-fractured healthcare system and consistently prioritize a high-quality standard so patients may better manage chronic illnesses and improve their Quality of Life.

Under the direction of the Lead Triage RN, the triage nurse will be responsible for providing exceptional patient care for all calls after business hours. This includes telephonic triage of complex patients, assisting with psychosocial needs and business initiatives.

Required Skills/Abilities: Compact/Multistate Licensure required (additional licensures are a plus) Innovative mindset, driven to change how patients manage their health Robust clinical knowledge Extensive experience in telephonic triage Ability to quickly determine appropriate level of care based off clinical assessment Ability to navigate multiple technological platforms Excellent attention to detail Excellent customer service skills Excellent organizational skills Excellent verbal and communication skills Excellent professional presence when dealing with colleagues, clients and patients Ability to function cohesively within a team Education and Experience: Graduate of accredited School of Nursing Nursing license must be active and in good standing A minimum of five (5) years of professional experience in nursing Experience in Triage required Remote Requirements: Must have active high-speed Wi-Fi Must have a home office or HIPAA-compliant workspace Physical Requirements: This position is sedentary and will require sitting for long periods of time This position will require the ability to speak clearly and listen attentively, often by telephone, for an extended period of time The position will require the ability to understand, process, and take thorough notes in real-time on telephone conversations

Conduct thorough telephonic assessments with proprietary tools Identify and address patient concerns Address acute clinical concerns with close collaboration with the patient’s providers. Provide telephonic education to patients Participate in Innovation team projects Ensure excellent quality of care provided during on-call and triage interactions Foster relationships within the team to ensure the CareHarmony culture is positive and supportive

CareHarmony

Remote - Lead Triage RN - Manager- Nights - Registered Nurse

Posted on:

October 23, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

CareHarmony works comprehensively with providers to deliver value-based care management initiatives for their patients. Our clinicians are driven by their passion for the level of care delivered; experts in assisting patients and caregivers navigate a sometimes-fractured healthcare system and consistently prioritize a high-quality standard so patients may better manage chronic illnesses and achieve success.

Under the direction of the Head of Clinical Innovation, the Lead Triage RN will be responsible for helping to develop best practices for telephonic triage of complex patients while acting as the content matter expert to assist with plan development and implementation for these patients. The Lead Triage RN will be part of the Innovation Team, helping develop education content, train staff and lead the team of triage and on call staff.

Required Skills/Abilities: Compact/Multistate Licensure required (additional licensures are a plus) Innovative mindset, driven to change how patients manage their health Robust clinical knowledge Extensive experience in telephonic triage Ability to quickly determine appropriate level of care based off clinical assessment Ability to navigate multiple technological platforms Excellent attention to detail Excellent customer service skills Excellent organizational skills Excellent verbal and communication skills Excellent professional presence when dealing with colleagues, clients and patients. Ability to function cohesively within a team Education and Experience: Graduate of accredited School of Nursing Registered Nurse (RN) license must be active and in good standing A minimum of five (5) years of professional experience in nursing Experience in Triage required Experience in leadership preferred Experience developing programs and protocols preferred Remote Requirements: Must have active high-speed Wi-Fi Must have a home office or HIPAA-compliant workspace Physical Requirements: This position is sedentary and will require sitting for long periods of time This position will require the ability to speak clearly and listen attentively, often by telephone, for an extended period of time The position will require the ability to understand, process, and take thorough notes in real-time on telephone conversations

Conduct thorough telephonic assessments Identify and address patient concerns Address acute clinical concerns with close collaboration with the patient’s providers. Participate and support departmental quality improvement activities and projects Develop resources, training and materials for staff and patients Plan and conduct continuing education programs Assist in developing protocols and defining best practice in telephonic triage during and after business hours Participate in Innovation team projects Develop On-Call team Manage On-Call staff members Ensure excellent quality of care provided during on-call and triage interactions Foster relationships within the team to ensure the CareHarmony culture is positive and supportive

Pharmko

Remote Care Manager CCM/RPM/BHI

Posted on:

October 23, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

New York

CCM/RPM The ideal candidate works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic/hospital/specialty provider and staff, and community resources in a team We are seeking a bilingual and remote care manager to join our rapidly growing team at Preventel Health performing Chronic Care Management (CCM), Remote Patient Monitoring (RPM) and Behavioral Health Integration (BHI) by telephonically delivering health and wellness calls to assigned patients.

Licensed Practical Nurse required Must be Licensed in NY, CO, or FL Must have good customer service skills Bilingual (Spanish) Knowledgeable using Microsoft Office Reliable Computer with internet

Remotely providing basic patient coaching and care to improve patient outcomes Develop a care plan with the patient, family/caregiver(s) and provider Monitor patient outcomes, adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner and facilitate changes as needed Coaching and educating patients on improving their Chronic Conditions, preventive care and physician directives Telephone outreach to English and Spanish-speaking patients Facilitate CCM, RPM and BHI program enrollment Concise and accurate documentation Cultivate and support the primary care providers with timely communication, inquiry follow-up, and integration of information into the care plan regarding transitions-in-care and referral

Horizon Blue Cross Blue Shield of New Jersey

Mgr, RN Clinical Ops

Posted on:

October 23, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New Jersey

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

This position is responsible for providing leadership and oversight of the overall clinical and non-clinical operations. Assists Director in establishing, interpreting and implementing new and existing company policies and procedures. The manager is also responsible for the adherence and maintenance of the regulatory agency requirements for DOBI, NCQA, DOL, DMHAS and CMS for analyzing utilization, performance trends, and quality of health care to ensure timely and cost effective delivery ASO (Administrative Services Only) managed care accounts are a type of self-funded health plan where an employer, known as the "plan sponsor," hires a third-party administrator (TPA) or an insurance company to handle the administrative tasks of benefits and claims processing, but the employer remains responsible for paying the actual employee claims.

Education/Experience: High School Diploma/GED required. Bachelor degree in Nursing or health related field preferred or relevant experience in lieu of degree. Requires minimum of five (5) years’ experience in a healthcare-related field. Requires minimum of five (5) years broad clinical experience. Requires minimum of three (3) years direct supervisory experience or demonstrated supervisory experience leading teams in a matrix management environment. Prefers professional certification in a clinical specialty as appropriate to the business unit. Additional licensing, certifications, registrations: Active Unrestricted NJ LCSW, LSW, LMFT, LPC, or RN License required. Knowledge: Requires strong knowledge of functional tasks performed within department. Requires knowledge in the principles of risk management and quality assurance. Requires knowledge of NCQA standards. Requires knowledge of State Mandates and Regulations. Requires knowledge of regulatory bodies and their processes. Prefer knowledge of Plan products, applications, policies, procedures and systems. Skills and Abilities: Requires excellent organizational skills and ability to set priorities. Requires excellent oral and written communication skills. Requires excellent presentation skills. Requires comprehensive leadership and decision-making skills. Requires strong analytical, problem solving, and critical analysis skills to report findings in a complete, succinct and accurate manner. Must be proficient in the use of personal computers and supporting software in a Windows based environment including MS Office products (Word, Excel, PowerPoint) and Outlook; should be knowledgeable in the use of intranet and internet applications. Travel : Travel required to other Horizon offices, provider locations and/or for oversight of remotely located workforce members in accordance with Company needs.

Manages, analyzes and coordinates the daily activities of the unit to ensure departmental goals are met with regards to timeliness, accuracy and consistency of medical decisions. Manages and directs staff to ensure overall client satisfaction, appropriate level of service delivery, quality outcomes. Recognizes and identifies opportunities to improve the quality of Care/services and initiates steps and activities to advance outcomes. Subject matter expert for multiple blue list projects, mandate office projects, task forces/Regulatory Committees. Develops and implements policies, procedures, and ad hoc reports to meet regulatory guidelines. Maintains and monitors the departmental budget to ensure administrative costs are managed. Subject matter lead for IPRO, CMS, Burchfield, NCQA audits. Identifies and implements business process improvements to identify efficiencies and cost savings opportunities. Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects. Represents the Plan with CBU with external group customers and Regulatory affairs for external agencies. Represents the unit on corporate issues and/or in the event of Director's absence. Creates and champions an atmosphere within the team, which fosters open communication, increase employee engagement, teamwork, ownership, and a collaborative cross-departmental environment to implement, optimize and share continuous improvement processes. Determines departmental budget and conducts ongoing expense management. Manages, directs, and develops staff by providing feedback and coaching. Administers performance and salary reviews for staff. Ensures staff meets all regulatory requirements and comprehends and complies with best practice methodology, professional standards, and internal policies and procedures.

Horizon Blue Cross Blue Shield of New Jersey

RN II-Case Manager (REMOTE)

Posted on:

October 23, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

This position is responsible for performing RN duties for the Primary Nurse population using established guidelines to ensure appropriate level of care, as well as, planning for the transition to the continuum of care and developing a member centric plan of care. Primary Nurses will outreach to high risk members and will work to engage members in preventative care opportunities & screenings when possible. This position will perform duties and types of care management as assigned by management. Serves as a mentor/trainer to new RN's and other staff as needed. Positions involving ASO accounts may require some travel for on-site availability.

Education/Experience: High School Diploma/GED required. Bachelor degree preferred or relevant experience in lieu of degree. Requires a minimum of two (2) years clinical experience. Experience with both acute and chronic conditions preferred. Requires a minimum of three (3) years' experience in the health care delivery system/industry. Experience with health care payer experience strongly preferred. Additional licensing, certifications, registrations: Active Unrestricted RN License Required; NJ License required and/or Compact License. Requires a valid Driver's License and Insurance. Knowledge: Requires proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, and PowerPoint) and Microsoft Outlook. Prefers knowledge in the use of intranet and internet applications. Requires working knowledge of case/care/disease management principles. Requires working knowledge of operations of utilization, case and/or disease management processes. Requires working knowledge of principles of utilization management. Requires basic knowledge of health care contracts and benefit eligibility requirements. Requires knowledge of hospital structures and payment systems. Prefers understanding of fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. Skills and Abilities: Bi-lingual proficiency preferred. Adaptability/Flexibility. Analytical. Compassion. Information/Knowledge Sharing. Interpersonal & Client Relationship. Sound decision making. Active listening. Organization Planning/Priority Setting. Problem Solving/Critical Thinking. Team Player. Time Management. Written/Oral Communications. Travel: Travel primarily within State of NJ may be required. Occasional travel in the tri-state area may also be required.

Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure. Facilitates response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs. Develops, coordinates and assists in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness. Coordinates with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care including transitional care. Monitors member's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness. Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided. Encourages member participation and compliance in the case/disease management program efforts. Documents accurately and comprehensively based on the standards of practice and current organization policies. Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. Serves as mentor/trainer to new RN's and other staff as needed Presents clinical cases during audits conducted by external review organizations. Performs other duties as assigned by management.

Horizon Blue Cross Blue Shield of New Jersey

RN II-Case Manager (REMOTE)

Posted on:

October 23, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

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

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

Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. Coordinates and assists in implementation of plan for members. Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care. Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness. Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided. Encourages member participation and compliance in the case/disease management program efforts. Documents accurately and comprehensively based on the standards of practice and current organization policies. Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care. Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. Serves as mentor/trainer to new RN's and other staff as needed. Acts as subject matter expert for respective area for projects. May assume leadership type activities in team leads absence. Represent clinical teams within committee meetings Present reports required at committee meetings. Subject matter expert for user acceptance testing for medical management system. Addendum for Horizon Clinical Advocate Roles: Outreaches to members identified by Horizon as needing Clinical Advocate services. Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast-paced environment. Builds trusting relationships with members and their families utilizing Motivational Interviewing techniques. Becomes knowledgeable in ASO client employer -sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language. Advocates for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. Focuses on whole person approach, by eliminating “homework” or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well-being physical, mental, and emotional. Schedule: 8- or 10-hour workday Monday through Friday varying between 8am and 11pm.

Molina Healthcare

RN Care Manager Complex Perinatal Care Remote in New York

Posted on:

October 22, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

New York

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.

The Care Manager (RN) provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. This position will be supporting our Complex Perinatal Care Management program. The ideal candidate will bring expertise in maternal and perinatal health conditions such as high-risk pregnancy, gestational diabetes, hypertension, and postpartum complications. Skilled in closing HEDIS and preventive care gaps through proactive outreach and coordination with members and providers. Experience integrating medical and behavioral health needs in care planning. The candidate must have an understanding of clinical guidelines, social determinants of health, and health equity principles. Case management and managed care experience is highly preferred. Remote position based in New York A New York RN licensure is required Work schedule Monday - Friday 8:30 AM to 5:00 PM EST.

Required Qualifications: At least 2 years experience in health care, preferably in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Understanding of the electronic medical record (EMR) and Health Insurance Portability and Accountability Act (HIPAA). • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and self-motivation. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. Preferred Qualifications: Certified Case Manager (CCM). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Completes comprehensive assessments of members per regulated timelines and determines who may qualify for care management based on clinical judgment, changes in member health or psychosocial wellness and triggers identified in assessments. Develops and implements care coordination plan in collaboration with member, caregiver, physician and/or other appropriate health care professionals and member support network to address member needs and goals. Conducts telephonic, face-to-face or home visits as required. Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Maintains ongoing member caseload for regular outreach and management. Promotes integration of services for members including behavioral health, long-term services and supports (LTSS), and home and community resources to enhance continuity of care. Facilitates interdisciplinary care team (ICT) meetings and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns. May provide consultation, resources and recommendations to peers as needed. Care manager RNs may be assigned complex member cases and medication regimens. Care manager RNs may conduct medication reconciliation as needed. 25-40% estimated local travel may be required (based upon state/contractual requirements).

Molina Healthcare

RN Care Manager Complex Pediatric Care REMOTE based in New York

Posted on:

October 22, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

New York

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.

The Care Manager RN provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. This position will be supporting our Complex Pediatric Care Management program. The ideal candidate will bring expertise in pediatric conditions such as asthma, diabetes, and ADHD. Skilled in closing HEDIS and preventive care gaps through proactive outreach and coordination with members and providers. Experience integrating medical and behavioral health needs in care planning, along with an understanding of clinical guidelines, social determinants of health, and health equity principles is also beneficial. Case management and managed care experience is preferred. Remote position based in New York A New York RN licensure is required Work schedule Monday - Friday 8:30 AM to 5:00 PM EST.

Required Qualifications: At least 2 years experience in health care, preferably in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. Understanding of the electronic medical record (EMR) and Health Insurance Portability and Accountability Act (HIPAA). Demonstrated knowledge of community resources. Ability to operate proactively and demonstrate detail-oriented work. Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. Ability to work independently, with minimal supervision and self-motivation. Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. Ability to develop and maintain professional relationships. Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. Excellent problem-solving, and critical-thinking skills. Strong verbal and written communication skills. Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. Preferred Qualifications: Certified Case Manager (CCM). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Completes comprehensive assessments of members per regulated timelines and determines who may qualify for care management based on clinical judgment, changes in member health or psychosocial wellness and triggers identified in assessments. Develops and implements care coordination plan in collaboration with member, caregiver, physician and/or other appropriate health care professionals and member support network to address member needs and goals. Conducts telephonic, face-to-face or home visits as required. Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Maintains ongoing member caseload for regular outreach and management. Promotes integration of services for members including behavioral health, long-term services and supports (LTSS), and home and community resources to enhance continuity of care. Facilitates interdisciplinary care team (ICT) meetings and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns. May provide consultation, resources and recommendations to peers as needed. Care manager RNs may be assigned complex member cases and medication regimens. Care manager RNs may conduct medication reconciliation as needed. 25-40% estimated local travel may be required (based upon state/contractual requirements).

Molina Healthcare

RN Care Review Clinician Critical Care Remote in WA state

Posted on:

October 22, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

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

The Care Review Clinician (RN) provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. We are seeking a candidate with a WA state RN licensure and critical care experience, i.e. ER or ICU. Candidates with Utilization Management and med/surge experience are highly preferred. Exceptional time management skills are needed to be successful in this position. Further details to be discussed during our interview process. Remote position preferably in Washington State. Work schedule: Friday- Tuesday: 8:00am- 5:00pm PST. The schedule includes 1 holiday per year

Required Qualifications: At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Ability to prioritize and manage multiple deadlines. Excellent organizational, problem-solving and critical-thinking skills. Strong written and verbal communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications: Certified Professional in Healthcare Management (CPHM). Recent hospital experience in an intensive care unit (ICU) or emergency room.

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