Galileo

Population Health Registered Nurse

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

Compact / Multi-State

Galileo is a team-based medical practice working to improve the quality and affordability of health care for all. Operating across 50 states, Galileo offers high-touch, data-driven, multi-specialty, longitudinal care to diverse and complex patients—on the phone, in the home, and everywhere in between. Regional and national health plans, employers, and Fortune 500 organizations trust Galileo as the leading solution to improve population health. Founded by Dr. Tom X. Lee, the healthcare pioneer behind One Medical and Epocrates, Galileo is a team of leading innovators from healthcare, technology, and human-centered design. Our mission is to apply that talent and scientific thinking to transform society by solving our largest, toughest healthcare problems, while at the same time bringing patient and provider closer.

Are you a Registered Nurse who thrives on connecting with patients and making a real difference in their health outcomes? Do you want to leave behind rigid, cookie-cutter systems and join a dynamic, patient-centered organization that values your creativity and clinical expertise? If you are passionate about improving patient outcomes and enjoy making meaningful connections, we want you to be part of our team at Galileo! At Galileo, we’re transforming healthcare by delivering personalized, comprehensive care to those who need it most—underserved patients and patients with complex medical needs. Our focus is on patient engagement and outcomes, and we’re looking for someone just like you to join our growing team of healthcare heroes. This is a remote, full-time position at 40 hours/week. We're currently hiring for a schedule of Monday-Friday from 10am-6:30pm ET, with one weekend per month.

About You: You’re a “people person”. You love to connect with others and have an innate ability to build rapport and quickly engage with new patients. Your curious nature and creativity comes through in conversations with others. You’re looking for a new environment where your natural ability can shine and you’re given the ability to thrive. We look for passionate Registered Nurses who are invested in solving complex problems that impact millions of lives and are excited about fixing what’s broken to improve care quality and health outcomes for everyone. We believe in a culture that fosters teamwork, excellence, and sound decision-making—one that is based on mutual respect and trust. We would love to hear from you if you have the following or equivalent experience: 2+ years of experience in case management in insurance organizations or VBC health care startups OR as a primary care RN with population health experience Engaging with Medicare and Medicaid populations with complex chronic conditions Nurse Licensure Compact (NLC) required Active RN license(s) in NY, NV, MI, MN, OR, CA, MA, CT and/or IL a plus Ability to leverage your motivational interviewing skills to encourage patients to make behavioral changes Excellent written and verbal communication skills Familiarity with Population Health and HEDIS quality gaps in care preferred Well versed with operating in an Mac iOS and Google Suite technology environment Physical Requirements: Employee must be able to meet the following requirements with or without a reasonable accommodation: This is primarily a sedentary position. Physical requirements may include lifting up to 10 pounds, manual dexterity, near/far visual acuity, keyboarding, the ability to hear, understand, and distinguish speech, sitting, standing, walking, and screen usage 8 or more hours per day.

Telephonic outreach, including cold calls, to patients for post discharge assessments of clinical symptoms, barriers to medication adherence, safety concerns, social needs Educate and coordinate preventative health screenings Perform chronic disease management and medication adherence education Navigate conversations with patients seeking insight on Galileo’s care model Facilitate the coordination of care between health care services, including hospital/ED care, pharmacies and community providers to improve patient outcomes Develop an understanding of various health plan contracts / goals, Galileo markets, and needs of various patient populations Be accountable to performance targets as an individual contributor Collaborate internally with Engagement and Population Health leadership to improve population outcomes

Rasmussen University

Online Adjunct Instructor - Adult-Gerontology Primary Care Nurse Practitioner Practicum II and Clinical

Posted on:

April 26, 2026

Job Type:

Part-Time

Role Type:

Primary Care

License:

NP/APP

State License:

Minnesota

This course and practicum experience provide an opportunity for students to apply newly acquired knowledge and skills as they participate in the evaluation, treatment, and management of patients seeking primary care services. Although practicum experiences may include a variety of adult patients, there is a focus on caring for adolescent, young adult, and adult patients. Students apply the knowledge of advanced assessment and diagnostic reasoning to formulate treatment plans for primary care patients within the ages of adolescence through adult. Emphasis is placed on the identification of signs and symptoms of disorders, selecting treatments and pharmacological interventions, inclusive of health promotion, health restoration and maintenance, and evidence-based practice in primary care settings.

Reporting Relationships: Adjunct Faculty will report to an Academic Dean Responsibilities: Competency-Based Education (CBE) allows students to master content and skills within a course or program at their own pace and prioritizes the demonstration of student learning over time. Students are able to show what they know when they know it. CBE courses are broken into multiple modules that are self-paced. Each module has an assessment at the end of it that allows students to demonstrate their mastery of the material. CBE Combined Instructional/Assessment Adjunct Faculty model consists of one faculty member facilitating and grading student assignment submissions. Faculty are responsible for running a number of live sessions during the week based on student need. These live sessions will cover a variety of topics including help with submissions, open office hours, content delivery, and general success strategies. Grading is facilitated through the use of detailed rubrics and feedback.

Experience and Qualifications: Teaching experience preferred. (Minimum of 3 years’ experience in the field of study) Self-motivated, flexible, and able to work in a team environment with minimal supervision Strong interpersonal skills to interact with students, leadership, and peers. Excellent written communication and strong verbal communication skills in the English language. Online adjuncts will need regular access to a computer with the following system requirements Windows XP or greater Microsoft Office 2010 An internet connection Education, certifications and Licensures: Doctorate in Nursing Must hold active Minnesota RN License and certified AGNP 2-3 years experience as an AGNP Rasmussen University follows the requirements set by the Department of Education, accrediting agencies, and the states in which the campuses operate. Must be able to provide professional licenses/certifications required for specialized schools (Health Sciences, Nursing) before teaching. License must be active and unencumbered Must be able to provide official transcripts for each degree earned from an accredited institution before teaching. Location: This position is remote but not available to CO residents

The essential function of the position include, but are not limited to the following tasks, duties, and responsibilities consistent with the function. The employee is expected to perform all other duties as requested, directed, and/or assigned. Adjunct faculty will be assigned up to 3 work units per academic quarter. Teaching Effectiveness: Professionalism, Use of Technology, and Content Expertise Dynamic, Active Classroom Use of effective teaching strategies and multiple teaching techniques; teaching and modeling appropriate level learning skills and creating an environment conducive to learning Creating high levels of student engagement through activities, community building, and student-centered learning including the use of live classroom tools to hold synchronous learning sessions with students Clarity, relevance, and connection of class session objectives to course performance objectives Organized classroom and efficient use of class time Subject Matter Expertise Demonstrate mastery and ability to articulate and relate to students Play an integral role in the development and implementation of curriculum and assessment for their area of expertise Student and University Support and Professionalism: Faculty are responsible for creating a classroom presence in support of students in collaboration with their Dean Student support and outreach that supports the success of students is accomplished through faculty availability to students in all courses through synchronous or asynchronous communication and meetings to help students achieve the learning objectives for their course(s) Faculty Meetings and other responsibilities: Faculty will attend events, programmatic meetings, and committee work as agreed upon and/or designated by the Dean Appropriate behavior, language, professional communication, demeanor and dress will be exhibited at all times Professional Development Faculty must complete a minimum of six (6) Rasmussen Educational Units (REUs) annually or two (2) REUs per quarter for each quarter you teach (whichever is less) between the combined areas of Teaching Development and Development in Discipline on an annual basis as described in the faculty handbook

American Senior Communities

Community Nurse Liaison LPN

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Indiana

Compassion, Accountability, Relationships and Excellence are the core values for American Senior Communities. These words not only form an acronym for C.A.R.E., but they are also our guiding principles and create the framework for all our relationships with customers, team members and community at large. American Senior Communities has proudly served our customers since the year 2000, with a long history of excellent outcomes. Team members within each of our 100+ American Senior Communities take great pride in our Hoosier hospitality roots, and it is ingrained in everything we do. As leaders in senior care, we are not just doing a job, but following a calling.

American Senior Communities is now hiring a Community Nurse Liaison (LPN) Hours: Monday – Friday 4p – 8p and Weekends 9a – 6p Remote position but must live within reasonable driving distance to Indianapolis.

Minimum of three years of clinical experience in acute care or long-term care setting. Must be able to work weekends and evenings. Current LPN License

The Clinical Nurse Liaison provides patient evaluations, while collaborating with hospital personnel to determine patient’s clinical needs and appropriateness for admission to skilled nursing facility. This position works closely with our communities and healthcare partners. This position will also be checking benefits and payor sources.

Highmark

Complex Case Manager RN - (Remote)

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

An independent licensee of the Blue Cross Blue Shield Association, Highmark Inc., together with its Blue-branded affiliates, collectively comprise the fifth largest overall Blue Cross Blue Shield-affiliated organization in the country with approximately 7.1 million members in Pennsylvania, Delaware, West Virginia and western and northeastern New York. The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield; CPA/SEPA: Highmark Inc. d/b/a Highmark Blue Shield; Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield; West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield; Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield; Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield. All references to “Highmark” are to Highmark Inc. and/or to one or more of its affiliated Blue companies. We're proudly part of Highmark Health.

This job has primary ownership and oversight over a specified panel of members that range in health status/severity and clinical needs. The incumbent assesses health management needs of the assigned member panel and utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent will be supported by a multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent will manage an active case load of members in his/her panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but is not limited to developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial and functional) for the specified panel of members.

Required: High School Diploma/GED Substitutions None Preferred Bachelor's Degree in Nursing EXPERIENCE Required 7 years of any combination of clinical, case management and/or disease/condition management experience, provider operations and / or health insurance experience Preferred Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT) Experience working with the healthcare needs of diverse populations Understanding of the importance of cultural competency in addressing targeted populations LICENSES AND CERTIFICATIONS Required Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) or WV or DE or NY is required. Other RN license(s), if applicable, must be obtained within the first 6 months of employment. Preferred Certification in Case Management SKILLS Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion Broad knowledge of disease processes Understanding of healthcare costs and the broader healthcare service delivery system Proficiency in MS Excel and strong analytic skills with ability to interpret, evaluate and act on clinical and financial data, including analysis of statistical data Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization Ability to work in a high performing team environment that requires flexibility Demonstrated ability to handle multiple priorities in a fast paced environment. Excellent organizational, time management and project management skills Self-directed; self-starter, ability to work successfully with indirect supervision and moderate autonomy LANGUAGE REQUIREMENT (Other Than English) None TRAVEL REQUIREMENT 0% - 25% PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS Position Type Office-Based Teaches/Trains others regularly Rarely Travels regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (Sales employees) Does Not Apply Physical Work Site Required No Lifting up to 10 pounds Rarely Lifting 10 to 25 pounds Rarely Lifting 25 to 50 pounds Rarely

Maintain oversight over specified panel of members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support. For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment. Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved. Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards. Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization. Other duties as assigned or requested.

Guidehealth

RN Case Manager - Remote

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. As a growing and innovative organization, we operate with a high degree of agility. Employees are expected to adapt to evolving business needs, step in to support cross-functional initiatives, and contribute beyond traditional role boundaries when needed. This collaborative and flexible mindset is essential to our success. We encourage cross-training, ongoing development, and a commitment to learning across all areas of the business—ensuring we continue to grow and you continue to thrive as a high-performing, mission-driven team.

As an RN Case Manager, you will partner with clinical teams to provide complex case management and strengthen the connection between the patient, the primary care physician/medical practice staff, and the patient’s care team. The Registered Nurse (RN) Case Manager is responsible for a specific patient population experiencing complex medical conditions, socio-economic, and/or mental health co-morbidities. The RN Case Manager will optimize the patient’s health status through assessment, planning, implementation, coordination, monitoring, and evaluation of the options and services available to the patient. The RN Case Manager collaborates with their assigned Healthguides to achieve optimal quality, clinical, and financial outcomes. This is primarily a remote position that will require travel as needed (10%-15%) to clinical sites in the Atlanta, GA area.

Licensed Registered Nurse in good standing in the State of Georgia with a compact license. 3+ years of RN Case Management experience in an outpatient setting. Bachelor of Science in Nursing, preferred. Certification in Case Management, preferred. Strong problem-solving skills to diagnose, troubleshoot, and resolve barriers to patient care, workflows, and care plan progression. Ability to analyze complex healthcare challenges and implement effective solutions while maintaining compliance within a high-regulation healthcare environment. Ability to manage multiple priorities, meet deadlines, and work independently in a fast-paced environment, ensuring timely and efficient case management. Exceptional written, visual, and verbal communication skills. Ability to participate in virtual meetings with clear verbal communication, engaging effectively with healthcare teams, patients, and stakeholders. Exceptional conversational skills and the ability to precisely document patient interviews, leveraging software in real time. Strong interpersonal skills with a focus on empathy, patience, professionalism, and respect in all patient, team, and client interactions. Demonstrated competency and ability to independently navigate technology using multiple platforms, computer screens, and other technical components (i.e., Electronic Medical Records, care management analytics databases, phone dialing system, Microsoft Office). Ability to meet accreditation and quality standards, including but not limited to NCQA and HEDIS. Observance of patient confidentiality through the use of the provided headset during all conversations in a private home office without distraction. Compliance with all Guidehealth policies and procedures. What we'd love for you to have: BSN and Case Management certification preferred.

Conducting in-depth telephonic assessments to understand each patient’s medical, psychosocial, and social needs. Reviewing and updating medical histories—including medications, chronic conditions, and preventive care. Developing individualized care plans and guiding patients through their treatment goals and care options. Providing empathetic, evidence-based education on chronic disease management and preventive health. Monitoring progress by phone, adjusting care plans, and ensuring patients stay connected to their providers. Completing Medicare Annual Wellness Visits (AWVs) via telehealth under physician supervision. Partnering with Healthguides who support non-clinical needs such as scheduling, transportation, food assistance, and SDOH resources. Performing proactive outreach and timely follow-ups to maintain continuity of care and patient engagement. Advocating for patients, helping them access the right resources at the right time. Documenting clearly and accurately in the EHR and care-management systems during and after calls. Supporting quality outcomes (HEDIS, NCQA) by coordinating preventive services and managing chronic conditions. Participating in virtual meetings, ongoing education, and clinical training to stay current with care standards. Using multiple communication methods (phone, text, patient portals, email, AI-supported tools) to reach high-risk patients. Collaborating in AI-driven outreach programs that help connect with vulnerable populations. Protecting patient privacy in a secure, private home workspace. Performing additional responsibilities as needed to support patients and the care team.

Henry Ford Health

Registered Nurse-Access Care-UMC-Remote work-36 Hours-Afternoons - Detroit

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Michigan

Serving communities across Michigan and beyond, Henry Ford Health is committed to partnering with patients & members along their entire health journey. Henry Ford Health provides a full continuum of services – from primary and preventative care, to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care & other healthcare retail. It is one of the nation’s leading academic medical centers, recognized for clinical excellence in cancer care, cardiology and cardiovascular surgery, neurology and neurosurgery, orthopedics and sports medicine, and multi-organ transplants. Consistently ranked among the top five NIH-funded institutions in Michigan, Henry Ford Health engages in thousands of research projects annually. Equally committed to educating the next generation of health professionals, Henry Ford Health trains more than 4,000 medical students, residents and fellows every year across 50+ accredited programs. With more than 50,000 valued team members, Henry Ford Health is also among Michigan’s largest and most diverse employers. President and CEO Bob Riney leads the health system and serves a growing number of customers across more than 550 sites across Michigan. That includes: 13 acute care hospitals; 3 behavioral health facilities including two world-class addiction treatment centers; a state-of-the-art orthopedics and sports medicine facility; multiple cancer care destinations including the Brigitte Harris Cancer Pavilion, Henry Ford Health’s premier location in Detroit; & more options than ever for primary care for patients and families across the region.

Position: 36 hours per week Shift: Afternoons 12 Hour Shifts Every other weekend and Holiday Rotations Benefits: Full time benefit package MUST be within driving distance of Elijah McCoy building in downtown Detroit for purposes of ongoing training and if internet is down at remote location

Education/Experience Required: Bachelor's degree in nursing. Three (3) years of clinical experience. Experience facilitating InterQual reviews, admission process preferred. Experience with systems that support patient flow, admission, and transfer preferred. Ability to prioritize, meet deadlines and produce detailed and accurate work. Excellent clinical knowledge and assessment skills to evaluate and prioritize care issues. Ability to assess and handle highly sensitive and confidential matters with considerable discretion and independent judgment. Demonstrated positive work ethic and strong sense of teamwork/problem solving with co-workers. Understanding of Henry Ford Health policies and procedures preferred. Certifications/Licensures Required: Licensed as a Registered Nurse in the State of Michigan

Within the System Capacity Command Center (SC3) at Henry Ford Health, the Access Management Nurse operates under minimal supervision, to review and screen recommended admission cases at Henry Ford Health System Emergency Departments (ED). Utilizes clinical and regulatory knowledge and skills to reduce financial risk and exposure due to inappropriate admissions. Collaborates with ED physicians, attending physicians, and third-party payers regarding initial screening reviews. Facilitates throughput in the most cost-effective manner, through continuous assessments, problem identification, and education.

Tuesday Health

Licensed Practical Nurse (Boston)

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Massachusetts

Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. We deliver goal-centered care focused on alleviating physical symptoms and emotional stress for individuals and their caregivers. Our interdisciplinary care teams reduce avoidable hospitalizations and improve quality of life wherever individuals call home. Through our leading-edge care model, Tuesday Health is shaping the future of community-based palliative care nationwide.

The Complex Care Navigator LPN plays a key role in delivering coordinated, compassionate care for members with serious illnesses. Working closely with nurse practitioners and registered nurses, the LPN administers clinical assessments and screenings throughout the care journey. They prioritize member needs based on assessment results and collaborate with the interdisciplinary team to develop and execute individualized care plans. The LPN ensures seamless communication, participates in care rounds, and leverages Tuesday Health’s electronic tools to optimize the member experience. Trust-building, empathy, and consistent member engagement are essential to the role, enabling a truly person-centered approach to care.

Active and unrestricted licensed practical nurse license in the State of Massachusetts without any board action Experience in clinical/medical setting preferred Experience in a multi-disciplinary care model working across network providers, health plan care management support, and employed clinicians Strong communication and organization skills Ability to multitask and work under pressure without sacrificing a positive member experience Ability to know when to escalate and potentially act professionally in an emergent situation Strong technical skills to navigate different documentation systems and tools; as well as ability to learn new systems as the company grows and evolves Strong written skills Ability to drive during daytime, nighttime, or inclement weather Valid driver's license with safe driving record State minimum automobile insurance coverage Comfort with change and ambiguity; you understand that rapid changes to the business, strategy, organization, and priorities will come with rapid evolution of our business

Administer multiple assessments and screening tools within the clinical model at different times throughout the care timeline with the support of nurse practitioners and registered nurses Prioritize needs based on assessment results and task interdisciplinary care team Be accountable for care plan development within the multidisciplinary care team Participate in internal and joint rounds to ensure the member experience is optimal and coordinated Learn the Tuesday Health electronic systems, tools, technology, to deliver a coordinated approach to ensure the members have a unique experience Build a strong, trusting relationship with every member, where listening and empathy are the foundation of every interaction Serve as the quarterback of the multidisciplinary team transforming care for members with serious illness

Molina Healthcare

(RN) Care Review Clinician- Utilization Review

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

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.

This role 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. EMERGENCY DEPARTMENT SUPPORT UNIT This is a remote role supporting our California Health Plan. The role is remote, but candidates must have an active and valid CALIFORNIA RN license and must be willing to work the Pacific Time Zone shift hours as posted. 3-12 SHIFT 7:00 AM - 08:30PM PACIFIC HOURS, schedule will rotate Must commit to working every other weekend and 4 Molina recognized holidays per year. This role will be on a provider-facing phone queue for the entirety of the shift, excluding breaks and lunches.

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.

Molina Healthcare

Remote Medical Review Nurse (RN) - Must Work CST time zone

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

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.

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care.

Highlights of the skills and qualifications needed for the Medical Review Nurse: Registered Nurse with a compact/multi-state license Must be willing to work a schedule within the Central Time Zone, Monday - Friday Have at least 2 years of clinical experience as a nurse Have at least 1 year of experience in the following areas: utilization review, medical claims review, claims auditing, medical necessity review and/or coding experience Excellent skills working with Microsoft Office Suite Confidence in having multiple screens open and toggling between them to complete necessary forms and documentation REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. Preferred Qualifications: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience.

Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols.

CareOregon

Registered Nurse - Utilization Management I

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Oregon

CareOregon is a nonprofit, mission-driven health plan, focused on providing care to low-income Oregonians. The CareOregon family includes Columbia Pacific CCO, Jackson Care Connect, Housecall Providers and our work as part of Health Share of Oregon. We also support recruitment for the Oregon Health and Education Collaborative.

The Registered Nurse – Utilization Management I is responsible for supporting specific utilization management (UM) program functions within the Clinical Operations department. UM program functions include Benefit Management, Benefit Review, Appeals and Grievances and Health Related Services (HRS). Together they support the healthcare needs of members, determine the best medically appropriate services, and apply clinical-based criteria for decision-making while managing medical expenses. Estimated Hiring Range $100,350.00 - $122,650.00 Bonus Target Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

Experience and/or Education: Current unrestricted Oregon RN license Minimum 2 years RN experience [OR 1 year RN experience AND 3 years’ experience in healthcare setting role(s) such as billing, coding, medical assistant, etc.] Preferred: More than 1 year RN experience Healthcare utilization management experience in the functional focus area (Appeals and Grievance, Benefits Review or Benefit Management) Experience with Medicaid and/or Medicare utilization management Knowledge, Skills And Abilities Required Knowledge Knowledge of Medicaid health plan and Medicare benefits Knowledge of applicable DMAP rules and regulations Knowledge of ICD-10, CPT, and HCPCS codes Familiarity with the principles of utilization management Familiarity with healthcare documentation systems Skills And Abilities: General computer skills including use of Microsoft Office applications and internet search functions Ability to use review criteria in accordance with departmental policies Ability to adhere to HIPAA regulations e.g., maintaining confidentiality of protected health information Ability to interpret and apply complex policies and procedures Ability to review work for accuracy Ability to independently prioritize work Ability to use critical thinking and problem-solving skills Strong spoken and written communication skills Strong interpersonal and customer service skills Ability to work effectively with diverse individuals and groups Ability to learn, focus, understand, and evaluate information and determine appropriate actions Ability to accept direction and feedback, as well as tolerate and manage stress Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day Ability to hear and speak clearly for at least 3-6 hours/day Working Conditions: Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person Hazards: May include, but not limited to, physical and ergonomic hazards. Equipment: General office equipment Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used. Work Location: Work from home

Communicate with members and/or providers in a professional manner and in accordance with State and Federal requirements as needed to complete requests. Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards. Refer members to care coordination per policies and procedures. Maintain accurate and complete documentation. Collaborate with Medical Directors to determine medical necessity and appropriateness of care for benefits requested and/or rendered. Work with clinical support staff to ensure service requests, authorizations and/or grievances are managed in accordance with state and federal guidelines. Identify and refer potential quality of care issues for peer review. Ensure that authorization decisions are based on organizational policy and state and federal coverage rules. Gather and submit documents for third party case review; this includes all documentation and follow-up activities. Issue denial notices based on established unit protocols and state and/or federal requirements. Assist with periodic audits, general quality management and improvement activities, and other regulatory activities as needed. Foster collaboration with teams across the Clinical Operations department to ensure work and goals are met. Meet or exceed department production, timelines, and quality standards established for level I. May participate in departmental workgroups or projects as assigned. Support testing for system updates and implementations as assigned. May help train new staff and teammates as assigned. Cross train in additional functional focus areas as assigned. Duties Specific To Functional Focus Area Benefit Management Review provider pre-service requests and determine benefit coverage according to Medicare, Medicaid and/or organizational guidelines Benefit Review Determine appropriate level of care and length of stay for inpatient members to include hospitals, skilled nursing facilities, long term acute care hospitals, inpatient rehabilitation hospitals, and respite care programs. Review inpatient admission for re-insurance clinical reporting. Appeals and Grievance Assemble evidence and build clinical cases for administrative hearings or Independent Review Entity (IRE) reviews. Function as a CareOregon representative in administrative hearings. Assist with the analysis and summary of data for written reports and public presentations as needed. Communicate with members, providers, health plan administrators to manage grievances and appeals and provide case status updates as needed. Investigate and use clinical judgement to identify quality of care or safety issues and present findings to an oversight committee. Health Related Services Review provider and member submitted HRSN and Flexible Services requests and determine benefit eligibility according to Medicaid and/or organizational guidelines. Organizational Responsibilities Perform work in alignment with the organization’s mission, vision and values. Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals. Strive to meet annual business goals in support of the organization’s strategic goals. Adhere to the organization’s policies, procedures and other relevant compliance needs. Perform other duties as needed.

Optum

Behavioral Health RN Case Manager - Remote

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

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

We're making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Telephone Case Manager RN with UnitedHealth Group, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Apply today! The Telephonic Case Manager RN Behavioral Health will identify, coordinate, and provide appropriate levels of care. The Telephonic Case Manager RN Behavioral Health is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. This is high volume, customer service environment. You'll need to be efficient, productive and thorough dealing with our members over the phone. Solid computer and software navigation skills are critical. You should also be solidly patient-focused and adaptable to changes. This is a full-time, Monday - Friday, 8am-5pm position in your time zone. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Current, unrestricted Compact RN license in the state of residence 1+ years of experience with mental health/behavioral health/substance use focus Proficiency in Microsoft Office Tools and Systems (Outlook, Word, Excel, Teams) Access to high-speed internet (DSL or Cable) Dedicated work area established that is separated from other living areas and provides information privacy Preferred Qualifications: BSN Certified Case Manager (CCM) 3+ years of experience with a mental health/behavioral health/substance use focus Case management experience Experience or exposure to discharge planning Experience in a telephonic role Background in managed care Bilingual in English and Spanish All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Make outbound calls and receive inbound calls to assess members current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self-management Make referrals to outside sources Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

CVS Health

Case Manager RN

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Arizona

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

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

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

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

Private Health Management

Associate Clinical Director - Oncology

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

NP/APP

State License:

California

Private Health Management (PHM) supports people with serious and complex medical conditions, helping them obtain the best possible medical care. We guide individuals and families to top specialists, advanced diagnostics, and personalized care. Trusted by healthcare providers and businesses, PHM offers independent, science-backed insights to help clients make informed decisions and access the best care.

As an Associate Clinical Director at PHM, you’ll help patients in their deepest moment of need to challenge the status quo and go beyond the standard of care to achieve the best possible health outcomes. Working from your home office, you’ll serve as the lead clinician and engagement manager collaborating with team members through our process to uncover opportunities to improve your client’s care. Team members may include additional clinicians, PhD scientists who mine the medical literature to identify data-supported care options, and care coordinators who manage care-related logistics. You will utilize your clinical expertise and curiosity along with your tenacious problem-solving skills to ascertain the key issues that must be addressed, identify and engage with top experts, and guide patients to optimized care plans. In collaboration with your personal care team colleagues, you will explore specialized diagnostics to better define the underlying mechanisms and array of treatment options beyond the current standard of care. Cutting through the barriers inherent to our chaotic healthcare system, you enable patients to access an unrivaled level of personalized care and attention while guiding them to the best possible treatment plan available.

Active NP or PA license in your home state A “Do what it takes to get the job done” attitude Five years of clinical experience managing complex medical issues in an oncology and/or hematology environment where careful assessment and critical thinking are required Exceptional client-facing skills including: Executive written & verbal communication, impeccable attention to detail and organization, and a highly professional demeanor under pressure. An insatiable clinical curiosity. You’re never satisfied by “the obvious answer” you think creatively, solve complex problems, and work successfully with others. Technically savvy and feel comfortable navigating various tech platforms to efficiently document your work and communicate with your colleagues Significant bonus points for oncology experienced mixed with another complex discipline.

What You’ll Accomplish: Building Strong Client Relationships. You’ll become the trusted guiding hand through a client's healthcare journey by managing complex medical issues, coordinating their care, facilitating best diagnostic and therapeutic treatment options available world-wide, and navigating being their guide to the healthcare system Demonstrating Strong Clinical Acumen. You’ll offer high level clinical management and education to clients and families in a caring, compassionate manner. Bring Together the Best Minds: Work closely with clinical and research team members at PHM to identify latest therapies and deliver comprehensive information on medical conditions, medications, treatments, and clinical trials Articulating needs for collaboration with external care providers, interdisciplinary team resources, and internal team rounding Networking with key opinion leaders to invite collaboration and build relationships that facilitate our ability to help our clients achieve best care Managing other clinical staff as it relates to a particular case or service line

Private Health Management

Nurse Advisor - Member Engagement

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Colorado

Private Health Management (PHM) supports people with serious and complex medical conditions, helping them obtain the best possible medical care. We guide individuals and families to top specialists, advanced diagnostics, and personalized care. Trusted by healthcare providers and businesses, PHM offers independent, science-backed insights to help clients make informed decisions and access the best care.

As a Nurse Advisor, Member Engagement, you’ll engage in a newly created role designed to bring clinical credibility and empathy into the earliest moments of a member’s journey to the best of what’s possible in medicine with PHM. This role serves as the first clinical touchpoint for members, helping them understand PHM’s value and guiding them toward the best steps in their care journey. In the role you’ll focus on outbound engagement, including proactive outreach, trust-building, and guiding members towards engaging with PHM’s service. Additionally, this role will offer support for inbound triage and member needs, helping ensure members receive timely guidance and are directed appropriately in coordination with the broader team. You’ll remove friction from the current process and create a seamless transition into PHM services for members facing cancer and other serious and complex illnesses, helping them get the absolute best of what medicine has to offer.

Required: Registered Nurse (RN) license with strong clinical judgment. Candidates with PA-C and Nurse Practitioner licensure will be considered as well. Proven ability to build trust quickly in phone-based or virtual interactions High emotional intelligence with the ability to navigate sensitive or skeptical conversations Comfort with outbound calling and engaging unfamiliar members Strong communication, active listening, and discovery skills Strong organization and ability to manage multiple interactions effectively Ability to operate in ambiguity with evolving workflows and expectations Nice to Have: Ability to work intermittent weekend days and/or cover Pacific & Mountain Time Zones Experience in outreach, engagement, or proactive communication roles Background blending clinical work with customer-facing or business responsibilities Experience in telehealth, call center, or remote care environments Experience in ER, triage, or case management settings

What You’ll Accomplish: Increase conversion from outreach to case opening through trust-based, clinically grounded conversations through direct outreach to eligible members Improve member responsiveness, including higher answer rates and sustained engagement Strengthen progression from initial contact to active case participation Build trust and credibility with employer partners through a high-quality engagement experience How You’ll Spend Your Days Outbound Member Engagement: Conduct outbound calls to eligible members, introducing PHM as a free and confidential benefit Establish trust quickly by clearly explaining privacy protections, independence, and value Navigate skepticism and emotional resistance with empathy and confidence Guide members toward a clear next step, including case initiation Maintain consistent outreach and thoughtful follow-up to drive engagement Support Triage RNs with by responding to inbound inquiries as needed Clinical Judgment & Member Navigation: Apply clinical credibility to strengthen engagement conversations Recognize when situations require escalation versus continued engagement Support smooth transitions into care teams Cross-Functional Collaboration: Partner with engagement, triage, and clinical teams to refine workflows and handoffs Contribute to the evolution of this role in a fast-changing environment

HealthHelp

Nurse, Concurrent Review

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Texas

WNS Healthhelp, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries, including Banking and Financial Services, Healthcare, Insurance, Shipping and Logistics, and Travel and Hospitality. We bring together deep domain excellence - WNS’ core differentiator - with AI-powered platforms and analytics to help businesses innovate, scale, adapt and build resilience in a world defined by disruption. Our purpose is clear: to enable lasting business value by designing intelligent, human-led solutions that deliver sustainable outcomes and a differentiated impact. With three global headquarters across four continents, operations in 13 countries, 65 delivery centers and more than 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact.

RN graduate from an accredited school of nursing (BSN preferred) Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent) Two (2) years of experience in an acute care setting, required Two (2) years of inpatient clinical nursing, utilization management, concurrent experience required Experience with InterQual or similar evidence-based clinical decision support criteria, preferred Willingness to complete and maintain InterQual certification and ongoing competency requirements Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements Knowledge of insurance terminology Experience working with state and federal regulatory and compliance standards, preferred Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required Good organizational and time management skills Excellent written and verbal communication skills Ability to utilize critical thinking skills Highly motivated, self-starter who can work efficiently and independently, or as a team member

Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including Admission reviews Continued stay reviews Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital) Related follow-up activities and documentation updates Engage in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions Facilitates resolution of escalated cases that may require special handling Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes Maintains written documentation according to HealthHelp’s documentation policy Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs Complies with URAC & NCQA standards or other requisite regulating bodies Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management Keeps current with regulation changes as provided by Compliance Department and Nursing Management Functions as subject matter expert to support Compliance Department initiatives and updates Collects and enters confidential information ensuring the highest level of confidentiality in all areas Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines Appropriately identifies and refers quality issues to UM Leadership Collaborates with client personnel to resolve customer concerns Provides quality customer service through interaction with providers, administrative staff, and others Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy Participates in the HealthHelp Quality Management Program, as required Performs other related duties and projects as assigned to meet business needs

Henry Ford Health

Registered Nurse-Access Care-UMC-Remote work-Afternoons - Contingent

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Michigan

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

Position: Contingent Shift: Afternoons Every other weekend and Holiday Rotations MUST be within driving distance of Elijah McCoy building in downtown Detroit for purposes of ongoing training and if internet is down at remote location

EDUCATION/EXPERIENCE REQUIRED: Bachelor's degree in nursing. Three (3) years of clinical experience. Experience facilitating InterQual reviews, admission process preferred. Experience with systems that support patient flow, admission, and transfer preferred. Ability to prioritize, meet deadlines and produce detailed and accurate work. Excellent clinical knowledge and assessment skills to evaluate and prioritize care issues. Ability to assess and handle highly sensitive and confidential matters with considerable discretion and independent judgment. Demonstrated positive work ethic and strong sense of teamwork/problem solving with co-workers. Understanding of Henry Ford Health policies and procedures preferred. CERTIFICATIONS/LICENSURES REQUIRED: Licensed as a Registered Nurse in the State of Michigan

Within the System Capacity Command Center (SC3) at Henry Ford Health, the Access Management Nurse operates under minimal supervision, to review and screen recommended admission cases at Henry Ford Health System Emergency Departments (ED). Utilizes clinical and regulatory knowledge and skills to reduce financial risk and exposure due to inappropriate admissions. Collaborates with ED physicians, attending physicians, and third-party payers regarding initial screening reviews. Facilitates throughput in the most cost-effective manner, through continuous assessments, problem identification, and education.

Henry Ford Health

Registered Nurse-Access Care-UMC-Remote work-24 Hours-Midnights - Detroit

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Michigan

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

Position: 24 hours per week Shift: Midnights Every other weekend and Holiday Rotations Benefits: part time benefit package MUST be within driving distance of Elijah McCoy building in downtown Detroit for purposes of ongoing training and if internet is down at remote location

EDUCATION/EXPERIENCE REQUIRED: Bachelor's degree in nursing. Three (3) years of clinical experience. Experience facilitating InterQual reviews, admission process preferred. Experience with systems that support patient flow, admission, and transfer preferred. Ability to prioritize, meet deadlines and produce detailed and accurate work. Excellent clinical knowledge and assessment skills to evaluate and prioritize care issues. Ability to assess and handle highly sensitive and confidential matters with considerable discretion and independent judgment. Demonstrated positive work ethic and strong sense of teamwork/problem solving with co-workers. Understanding of Henry Ford Health policies and procedures preferred. CERTIFICATIONS/LICENSURES REQUIRED: Licensed as a Registered Nurse in the State of Michigan

Within the System Capacity Command Center (SC3) at Henry Ford Health, the Access Management Nurse operates under minimal supervision, to review and screen recommended admission cases at Henry Ford Health System Emergency Departments (ED). Utilizes clinical and regulatory knowledge and skills to reduce financial risk and exposure due to inappropriate admissions. Collaborates with ED physicians, attending physicians, and third-party payers regarding initial screening reviews. Facilitates throughput in the most cost-effective manner, through continuous assessments, problem identification, and education.

Henry Ford Health

RN Coordinator Clinical Denial Recovery/Full Time/Remote - Michigan Residents

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Michigan

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

This is a great place to work where you can use your clinical knowledge and experience to support the medical necessity of our patients being admitted to the hospital. You fight for the services that were performed and what should be appropriately paid for. We currently are working remotely. Yes sometime this could change but as of now it is remotely.

EDUCATION AND EXPERIENCE: Registered Nurse with a valid, unrestricted, State of Michigan License required. Minimum 3-5 years of clinical experience required. Bachelor of Science Nursing required or three years Denial/Appeal/Utilization Management experience. Knowledge of hospital billing and payer regulations, including criteria for patient status determination, and tools/software used for determination.

Under minimal supervision, this RN specializes in follow-up of denied and rejected claims from all commercial, contracted and non-contracted payers, including preparing appeal letters. Working within a centralized department, reviews all denials for medical necessity and appeal ability utilizing clinical judgment and applying appropriate medical necessity criteria. Provides clinical utilization management expertise to provide education, formal and informal and facilitates denial management strategies. Serves as a liaison to key customers that include, hospital ancillary departments, physicians, and payers.

Henry Ford Health

Registered Nurse-Access Care-UMC-Remote work-36 Hours-Midnights - Detroit

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Michigan

Serving communities across Michigan and beyond, Henry Ford Health is committed to partnering with patients & members along their entire health journey. Henry Ford Health provides a full continuum of services – from primary and preventative care, to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care & other healthcare retail. It is one of the nation’s leading academic medical centers, recognized for clinical excellence in cancer care, cardiology and cardiovascular surgery, neurology and neurosurgery, orthopedics and sports medicine, and multi-organ transplants. Consistently ranked among the top five NIH-funded institutions in Michigan, Henry Ford Health engages in thousands of research projects annually. Equally committed to educating the next generation of health professionals, Henry Ford Health trains more than 4,000 medical students, residents and fellows every year across 50+ accredited programs. With more than 50,000 valued team members, Henry Ford Health is also among Michigan’s largest and most diverse employers. President and CEO Bob Riney leads the health system and serves a growing number of customers across more than 550 sites across Michigan. That includes: 13 acute care hospitals; 3 behavioral health facilities including two world-class addiction treatment centers; a state-of-the-art orthopedics and sports medicine facility; multiple cancer care destinations including the Brigitte Harris Cancer Pavilion, Henry Ford Health’s premier location in Detroit; & more options than ever for primary care for patients and families across the region.

Position: 36 hours per week Shift: Midnights 12 Hour Shifts Every other weekend and Holiday Rotations Benefits: Full time benefit package MUST be within driving distance of Elijah McCoy building in downtown Detroit for purposes of ongoing training and if internet is down at remote location

Education/Experience Required: Bachelor's degree in nursing. Three (3) years of clinical experience. Experience facilitating InterQual reviews, admission process preferred. Experience with systems that support patient flow, admission, and transfer preferred. Ability to prioritize, meet deadlines and produce detailed and accurate work. Excellent clinical knowledge and assessment skills to evaluate and prioritize care issues. Ability to assess and handle highly sensitive and confidential matters with considerable discretion and independent judgment. Demonstrated positive work ethic and strong sense of teamwork/problem solving with co-workers. Understanding of Henry Ford Health policies and procedures preferred. Certifications/Licensures Required: Licensed as a Registered Nurse in the State of Michigan

Within the System Capacity Command Center (SC3) at Henry Ford Health, the Access Management Nurse operates under minimal supervision, to review and screen recommended admission cases at Henry Ford Health System Emergency Departments (ED). Utilizes clinical and regulatory knowledge and skills to reduce financial risk and exposure due to inappropriate admissions. Collaborates with ED physicians, attending physicians, and third-party payers regarding initial screening reviews. Facilitates throughput in the most cost-effective manner, through continuous assessments, problem identification, and education.

Highmark

Complex Case Manager RN - Maternity (Remote)

Posted on:

April 24, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

An independent licensee of the Blue Cross Blue Shield Association, Highmark Inc., together with its Blue-branded affiliates, collectively comprise the fifth largest overall Blue Cross Blue Shield-affiliated organization in the country with approximately 7.1 million members in Pennsylvania, Delaware, West Virginia and western and northeastern New York.

This job has primary ownership and oversight over a specified panel of members that range in health status/severity and clinical needs. The incumbent assesses health management needs of the assigned member panel and utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent will be supported by a multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent will manage an active case load of members in his/her panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but is not limited to: developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial and functional) for the specified panel of members.

Required High School Diploma/GED Substitutions None Preferred Bachelor's Degree in Nursing EXPERIENCE Required 7 years of any combination of clinical, case management and/or disease/condition management experience, provider operations and / or health insurance experience Preferred Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT) Experience working with the healthcare needs of diverse populations Understanding of the importance of cultural competency in addressing targeted populations LICENSES AND CERTIFICATIONS Required Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) or WV or DE or NY is required. Other RN license(s), if applicable, must be obtained within the first 6 months of employment. Preferred Certification in Case Management SKILLS Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion Broad knowledge of disease processes Understanding of healthcare costs and the broader healthcare service delivery system Proficiency in MS Excel and strong analytic skills with ability to interpret, evaluate and act on clinical and financial data, including analysis of statistical data Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization Ability to work in a high performing team environment that requires flexibility Demonstrated ability to handle multiple priorities in a fast paced environment. Excellent organizational, time management and project management skills Self-directed; self-starter, ability to work successfully with indirect supervision and moderate autonomy LANGUAGE REQUIREMENT (Other than English) None TRAVEL REQUIREMENT 0% - 25% PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS Position Type Office-Based Teaches/Trains others regularly Rarely Travels regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (Sales employees) Does Not Apply Physical Work Site Required No Lifting: up to 10 pounds Rarely Lifting: 10 to 25 pounds Rarely Lifting: 25 to 50 pounds Rarely

Maintain oversight over specified panel of members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support. For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment. Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved. Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards. Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization. Other duties as assigned or requested.

Harbor Health

Utilization Management LVN (Remote, Texas-based)

Posted on:

April 24, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Texas

At Harbor Health, we’re transforming healthcare in Texas through collaboration and innovation. We’re seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you’re ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!

Candidate should reside in Texas Harbor Health is seeking a dedicated Utilization Management (UM) LVN. The UM LVN supports prior authorization and utilization review activities to ensure timely and appropriate access to care. This role collaborates with the UM team, providers, and members to facilitate authorization processes, coordinate clinical information, support medical necessity determinations, and maintain regulatory compliance. The UM LVN also provides ongoing communication and coordination support for high-need and high-cost members to promote appropriate utilization and continuity of care. Shifts and Business Hours This position is fully remote Monday-Friday 8am - 5pm with the exception of Saturday coverage once every 5 weeks on rotation for 4 hours.

Desired Professional Skills & Experience: Current, unrestricted LVN license. Minimum of 2–3 years of clinical experience; prior Utilization Management or Case Management experience preferred. Knowledge of Texas social service programs for members in need both local and state-wide preferred Familiarity with NCQA processes and requirements Knowledge of CPT codes and prior authorization requirements. Familiarity with utilization review processes and medical necessity determinations. Strong organizational and workflow management skills. Excellent written and verbal communication skills. Ability to assess member needs, provide education, and escalate concerns appropriately. Proficiency in Google Workspace, EHR systems and electronic UM platforms Ability to manage multiple cases while meeting regulatory timelines Ability to work independently and within a team-based model to deliver excellent care.

Coordinate and manage prior authorization workflows in collaboration with the Utilization Management (UM) team. Monitor incoming authorization requests via fax and phone and ensure timely case entry into the designated tracking system and UM platform. Review submitted clinical documentation and verify CPT codes to determine prior authorization requirements. Prepare and submit applicable cases to the contracted utilization review (UR) vendor for medical necessity determinations. Maintain accurate case documentation and track status to ensure compliance with regulatory turnaround times. Draft provider, facility, and member notification letters based on determination outcomes. Coordinate mailing and faxing of approved determination letters to appropriate parties and ensure proper documentation. Obtain and coordinate concurrent clinical documentation from hospitals, post-acute facilities, and other treating providers. Communicate with providers and facilities regarding required or missing clinical information to facilitate timely review. Provide clear communication to members and requesting providers regarding authorization status and documentation needs. Support high-need and high-cost members through ongoing communication and coordination to promote appropriate utilization and continuity of care. Assist with transitions of care and post-discharge coordination as applicable. Perform all duties in compliance with organizational policies and applicable state and federal regulatory requirements. Provide direct support to members with chronic diseases, ensuring continuity of care across chronic care pathways. Communicate regularly with members to assess progress, resolve barriers to care, and promote adherence to treatment plans.

Guidehealth

Remote RN Case Manager

Posted on:

April 24, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Illinois

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.  As a growing and innovative organization, we operate with a high degree of agility. Employees are expected to adapt to evolving business needs, step in to support cross-functional initiatives, and contribute beyond traditional role boundaries when needed. This collaborative and flexible mindset is essential to our success. We encourage cross-training, ongoing development, and a commitment to learning across all areas of the business—ensuring we continue to grow and you continue to thrive as a high-performing, mission-driven team.

The RN Case Manager serves as a trusted clinical partner to patients, families, providers, and interdisciplinary teams, guiding individuals through complex health journeys with compassion, clinical excellence, and purpose. This is a primarily remote position with telephonic and virtual engagement and occasional in‑person participation as program needs require. This position blends strong nursing judgment with a whole-person approach to care management, addressing medical, behavioral, and social needs to support optimal health outcomes. The RN Case Manager is responsible for assessment, care planning, coordination, monitoring, and evaluation of services for a defined population, including members with chronic, complex, and high-risk conditions. Working closely with primary care providers, patient navigators, and other care team members, the Care Manager – Registered Nurse ensures safe, effective, equitable, and patient-centered care within a value-based care model.

Active, unrestricted IL state Registered Nurse (RN) license in good standing Minimum of 3–5 years of clinical nursing experience, including care management, case management, or chronic/complex condition management. Strong clinical assessment, critical thinking, and care coordination skills. Experience working collaboratively within interdisciplinary teams. Proficiency with EMRs and comfort learning multiple documentation and care management platforms. Excellent written and verbal communication skills, including the ability to engage patients telephonically and virtually. Ability to work independently in a remote environment while maintaining strong team engagement. WHAT WE'D LOVE FOR YOU TO HAVE: Bachelor’s degree in nursing (BSN). Specialty certification in care management (CCM, ACM) or willingness to obtain within a defined timeframe. Experience in value‑based care, population health, managed care, or outpatient care settings. Supervisory or informal leadership experience. Multilingual skills.

Clinical Care Management: Conducting comprehensive clinical, psychosocial, and functional assessments to identify patient needs, risks, and goals. Developing, implementing, and maintaining individualized, evidence‑based care plans in collaboration with patients, families, PCPs, and the interdisciplinary care team. Providing clinical interventions and nursing support aligned with care plan goals, protocols, and accreditation standards. Monitoring patient progress through ongoing outreach, data review, and reassessment; adjust care plans as indicated. Developing patient‑specific escalation plans with providers for acute but non‑emergent changes in condition. Care Coordination & Advocacy: Coordinating care across providers, settings, and services to ensure continuity, safety, and quality. Partnering with patient navigators and non‑clinical team members to address social determinants of health, including access to transportation, food, housing, and community resources. Serving as a clinical advocate, assisting patients in accessing services requiring nursing licensure, clinical expertise, or care management oversight. Facilitating referrals and follow‑up to ensure timely connection to recommended services and resources. Patient & Family Engagement: Building meaningful, trusting relationships with patients and families through empathetic, culturally responsive communication. Providing education on conditions, treatment options, self‑management strategies, and navigation of the healthcare system. Empowering patients to make informed decisions and achieve greater health autonomy. Quality, Compliance, & Documentation: Maintaining accurate, timely, and compliant documentation in electronic medical records and care management systems. Utilizing evidence‑based clinical guidelines, internal protocols, and defined quality metrics (e.g., NCQA, HEDIS). Participating in quality, utilization management, and performance improvement activities as applicable. Maintaining strict confidentiality and adhere to all regulatory, accreditation, and organizational standards.

IntellaTriage

Remote Hospice Triage RN PT Weekend Only 7:30a-6p CST

Posted on:

April 24, 2026

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

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

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

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

Optum

Registered Nurse, Appeals Drafting Service - Remote

Posted on:

April 24, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

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

Here at UnitedHealth Group, you're expected and empowered to be your best, to grow and to develop your skills. Join us and help people live healthier lives while doing your life's best work. Be part of an exciting team within Optum where you can utilize your Operations experience to support multiple internal teams as well as providers and patients. Work Schedule: Must be able to work Monday - Friday with a set schedule of hours between 7am - 7pm CST. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: The Specialty Appeals Registered Nurse role fills an integral role in drafting and submitting appeals for specialty patients with acute and chronic disease states. In this role you will be preparing appeal letters for submission, obtaining support documents, following up on prior authorization outcomes, and addressing issues and handling concerns from other corresponding departments.

Required Qualifications: Active, Registered Nurse License Willingness to obtain Case Management Certification (CCM) once eligible 2+ years of clinical experience as a Registered Nurse 1+ years of experience working with prior authorization, pre-certification, utilization review, and / or appeals experience Understanding of clinical documentation from physician offices Proficiency with MS Word, Excel, SharePoint Proven ability to work independently (At home or office) Preferred Qualifications: Bachelor's degree RN licenses in multiple states (outside of compact states) Case Management Certification (CCM) PBM and / or Managed Care experience Prior Authorization/Appeal Experience Knowledge of healthcare insurance plans, denials, and appeal procedures Advanced computer skills; Experience in a paperless role

Communicate with providers, patients, and pharmacy staff to obtain necessary clinical documentation, prior authorizations, and appeal letters Facilitate appeals process between the patient, physician, and insurance company by requesting denial information and facilitates obtaining the denial letter from the insurance, patient or physician. Composes clinical appeals letters based off of specific denial reason and patients clinical presentation. Ensures all clinical information and documentation are obtained prior to appeal submission Accessing multiple Optum resources to check PA, insurance and appeal status and benefits. Utilization of and proficiency in multiple internal processing systems for record keeping and tracking of letter determinations Interpret and utilize clinical documentation from providers, and different pharmacy/computer systems Utilizing multiple platforms, researching clinical studies for points of argument for appeals Write and return assigned appeals to providers Utilization of and proficiency in multiple internal processing systems for record keeping and tracking of determinations Assign appeal requests to coworkers as needed (rotating schedule) Perform other related duties as assigned You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

UnitedHealthcare

Clinical Appeals RN - Commercial Plan (Weekend Shift) - Remote

Posted on:

April 24, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

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

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. This role will require the ability to work a on Saturday either in a traditional 5 day work week schedule or working 4-10 hour shift but MUST be able to work until 5pm in residing time zone.

Required Qualifications: Active, unrestricted RN license in state of residence 5+ years of clinical experience as an RN including in an acute, inpatient hospital setting Experience applying benefits and criteria to clinical review Utilization Management, pre-authorization, concurrent review or appeals experience Solid computer skills including proficiency in Microsoft Office Word, Outlook, and Internet applications Ability to access multiple computer platforms Access to install secure high-speed internet (minimum speed 5 download mps & 1 upload mps) via cable/DSL in home (wireless / cell phone provider, satellite, microwave, etc. does NOT meet this requirement) Designated quiet workspace in your home (separated from non-workspace areas) and able to be secured to maintain Protected Health Information (PHI) and/or Protected Information (PI) Ability to work a on Saturday either in a traditional 5 day work week schedule or working 4-10 hour shifts Ability to work until 5pm in residing time zone Preferred Qualifications: Medical Coding experience/knowledge Experience using Interqual Experience with the following systems: UNET, iCUE/HSR, ATS, ETS or Cirrus Experience analyzing medical records, benefit plans, medical policies and other various criteria Demonstrated ability to work independently with solid self-discipline and time management skills Demonstrated excellent communication, interpersonal, problem-solving, and analytical skills

Conducts reviews of member and provider appeals Analyzes claim adjustment and claim history Reviews history of previous reviews Reviews denied services in conjunction with policies and procedures, benefit plans, federal and state regulations, and clinical criteria to and renders approval when appropriate Extrapolates and summarizes medical information for review by Medical Director, as needed Balances the need to produce high quality work with meeting timeframes and production goals You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

UnitedHealthcare

Clinical Appeals RN - Commercial Plan (M-F)- Remote

Posted on:

April 24, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Nevada

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

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Please see requirements for the schedules.

Required Qualifications: Active, unrestricted RN license in state of residence 5+ years of clinical experience as an RN including in an acute, inpatient hospital setting Experience applying benefits and criteria to clinical review Utilization Management, pre-authorization, concurrent review or appeals experience Solid computer skills including proficiency in Microsoft Office Word, Outlook, and Internet applications Ability to access multiple computer platforms Access to install secure high-speed internet (minimum speed 5 download mps & 1 upload mps) via cable/DSL in home (wireless / cell phone provider, satellite, microwave, etc. does NOT meet this requirement) Designated quiet workspace in your home (separated from non-workspace areas) and able to be secured to maintain Protected Health Information (PHI) and/or Protected Information (PI) Ability to work Monday - Friday Ability to work until 5pm in residing time zone Preferred Qualifications: Medical Coding experience/knowledge Experience using Interqual Experience with the following systems: UNET, iCUE/HSR, ATS, ETS or Cirrus Experience analyzing medical records, benefit plans, medical policies and other various criteria Demonstrated ability to work independently with solid self-discipline and time management skills Demonstrated excellent communication, interpersonal, problem-solving, and analytical skills

Conducts reviews of member and provider appeals Analyzing claim adjustments and histories, and reviewing previous decisions Evaluate denied services in accordance with policies, benefit plans, federal and state regulations, and clinical criteria, rendering approvals when appropriate Summarize medical information for review by the Medical Director as needed You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Berkley Medical Management Solutions (a Berkley Company)

Part-Time: Workers Compensation Telephonic Nurse Case Manager (Remote)

Posted on:

April 24, 2026

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

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

This is a part-time position scheduled for 20 hours per week, working 4 hours per day, Monday through Friday, within standard business hours between 8:00 AM and 5:00 PM. As a Telephonic Nurse Case Manager, you will assess, plan, coordinate, monitor, evaluate and implement options and services to facilitate timely medical care and return to work outcomes of injured workers.

Qualifications: Minimum 2 years of experience in workers compensation insurance and medical case management preferred Minimum of 4 years medical/surgical clinical experience required Exhibit strong communication skills, professionalism, flexibility and adaptability Possess working knowledge of medical and vocational resources available to the Workers’ Compensation industry Demonstrate evidence of self-motivation and the ability to perform case management duties independently Demonstrate evidence of computer and technology skills Oral and written fluency in both Spanish and English a plus Education: Graduate of an accredited school of nursing and possess a current RN license. RN compact license preferred, CCM preferred, Bachelor of Nursing preferred

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

Acentra Health

Clinical Reviewer - LPN/LVN or RN

Posted on:

April 24, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

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 Reviewer - LPN/LVN or RN (remote U.S.) to join our growing team. Job Summary: The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements. ***This position is remote within the United States, but applicants must be clinically licensed for the State of Indiana or have a compact license.*** ***Work Schedule: Five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays***

Required Qualifications: Active, unrestricted LPN/LVN or RN license in the state of Indiana or a Compact state clinical license. Associate's degree (bachelor's preferred) or Practical/Professional nursing diploma/certificate from an accredited nursing school, college, or university. 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience. 2+ years of medical necessity review experience. 1+ years of InterQual criteria and/or Milliman Care Guidelines (MCG) experience. Knowledge of medical records, medical terminology, and disease processes. Strong clinical assessment and critical thinking skills. Excellent written and verbal communication skills. Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively. Flexibility and strong organizational skills. Ability to work five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays. Preferred Qualifications: 3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment. Knowledge of current National Committee for Quality Assurance (NCQA) standards. Knowledge of Utilization Review Accreditation Commission (URAC) standards. Ability to work in a team environment. Proficient in Microsoft Office. Efficient time management, including the ability to prioritize tasks, and meet deadlines. Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance when assessing relevant issues.

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 quality monitoring activities. Maintains current knowledge base related to review processes and clinical practices. Functions as providers' liaison for customer service issues and problem resolution. Performs all applicable review types as workload indicates. Fosters positive and professional relationships with internal and external customers. Attends training and scheduled meetings for current/updated information. Cross trains to provide 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. The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.

Capstone Care Service

Telephonic Nurse Case Manager

Posted on:

April 24, 2026

Job Type:

Contract

Role Type:

Telehealth

License:

RN

State License:

Colorado

At Capstone Care Services, our telephonic case management service is designed to achieve effective medical management and facilitate timely return-to-work outcomes in accordance with established guidelines. Our team of professionals is committed to delivering superior service, focusing on achieving optimal outcomes, providing strong advocacy, and ensuring client satisfaction.

Certifications- Registered Nurse (RN)- Certified Case Manager (CCM)- Certified Rehabilitation Registered Nurse (CRRN), Worker Compensation Experience a plus. This is a 1099 role.

Comprehensive Case Assessment- Conduct thorough assessments to identify the unique needs of injured workers and develop tailored action plans to support their recovery and return to work. Telephonic Support- Provide expert guidance, coordination, and support exclusively via phone to ensure appropriate and timely care delivery. Resource Coordination- Connect injured workers with the right resources, bridging gaps between services and support networks to facilitate recovery Licensed Professionals- Ensure all registered nurses hold a Compact License, maintaining compliance and professionalism. Administrative Efficiency- Provide administrative support for referral assignments with a 3-day turnaround time to ensure prompt service delivery. Caseload Oversight- Manage and oversee caseloads to meet 5-day memo and monthly reporting guidelines, ensuring accountability and timely communication Technology Expertise- Utilize multiple case management software products, including ICMS, to streamline processes and enhance efficiency. Timely Initial Contact- Ensure initial 3–4-point contact with injured workers within the specified timeframe to initiate case management promptly.

HealthSense LLC

Remote Nurse Care Manager (Geriatric Care Management)

Posted on:

April 24, 2026

Job Type:

Part-Time

Role Type:

Care Management

License:

RN

State License:

New York

We are a care management company based in New York City, dedicated to supporting older adults and their families through high-quality, personalized care coordination. Our concierge-style approach helps seniors maintain independence, improve quality of life, and remain safely at home. We value collaboration, clear communication, and thoughtful, client-centered care.

We are seeking an experienced Remote Nurse Care Manager to support daily care coordination for our geriatric clients. This role focuses on clinical coordination, communication, follow-up, and documentation. You will work closely with clients, families, physicians, and field-based providers to ensure care plans are implemented smoothly and client needs are addressed promptly. This is an ideal role for a nurse who enjoys care coordination, problem-solving, and building relationships.

Skills & Qualifications: Active Registered Nurse (RN) license Minimum 5 years of nursing experience, with at least 1 year in geriatric care management, home health, or a related setting Strong experience with care coordination and working with interdisciplinary teams Excellent organizational and time-management skills Clear, compassionate communication skills with clients and families Comfortable working remotely and managing multiple clients simultaneously Proficient with EHR systems and basic healthcare technology Core Competencies: Client-centered, compassionate approach to care Strong attention to detail and follow-through Ability to prioritize tasks in a fast-paced, remote environment Collaborative mindset and professionalism

Care Coordination & Client Support: Coordinate day-to-day care needs for elderly clients in collaboration with families, physicians, and care providers Support the development, implementation, and ongoing updates of individualized care plans Conduct follow-ups related to appointments, services, and care recommendations Communication & Collaboration: Serve as a consistent point of contact for clients and families Communicate care updates clearly and professionally with field nurses and other providers Escalate concerns or changes in condition appropriately and in a timely manner Documentation & Follow-Up: Maintain accurate, timely documentation in the electronic health record (EHR) Track care activities, outcomes, and next steps to ensure continuity of care Address issues identified during in-person visits and ensure proper follow-up Client Advocacy: Advocate for client preferences, safety, and quality of care Monitor outcomes and assist with adjustments to care plans as needed

Partners Health Management

Health Edu & Aging Resources Team (HEART), RN-NC

Posted on:

April 24, 2026

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

North Carolina

You will often hear people call Partners a North Carolina local management entity/managed care organization or LME/MCO. We think of ourselves as an MCO…a Member Care Organization™. Partners manages Medicaid, state and local funds for mental health, intellectual/developmental disability, substance use disorder and traumatic brain injury services. The system of care we manage is shaped by the choices of our members and their families and designed to meet the unique needs of each of the communities we serve. Partners manages care in Burke, Cabarrus, Catawba, Cleveland, Davidson, Davie, Forsyth, Gaston, Iredell, Lincoln, Rutherford, Surry, Stanly, Union and Yadkin Counties.

This is a primarily remote position, but will require in-person training and travel to Gaston, Lincoln, Burke, and Catawba counties.** Competitive Compensation & Benefits Package! Position eligible for – Annual incentive bonus plan Medical, dental, and vision insurance with low deductible/low cost health plan Generous vacation and sick time accrual 12 paid holidays State Retirement (pension plan) 401(k) Plan with employer match Company paid life and disability insurance Wellness Programs Public Service Loan Forgiveness Qualifying Employer See attachment for additional details. Office Location: Primarily remote position, but will require in-person training and travel to Gaston, Lincoln, Burke, and Catawba NC counties. Projected Hiring Range: Depending on Experience Closing Date: Open Until Filled Primary Purpose of Position: The primary duty of this position is to provide formal training, education, and consultation to community organizations that may include Adult Care Homes, Family Care Homes, Nursing Homes, Adult Day Programs, Senior Centers, Faith Based Organizations, Home Health Agencies, Home Care Agencies, Meals on Wheels Programs, Veterans Affairs, Departments of Social Services, and Law Enforcement/Judicial System staff/caregivers that serve geriatric or adult residents with geriatric like needs that may have mental illness and/or Dementia. The goal is to build community awareness and skills for addressing the unique needs of these individuals. Goal of HEART Program: To increase the ability of people working in community agencies/organizations in providing services and support to older adults with mental health, substance use issues, and/or dementia.

Knowledge, Skills And Abilities: Extensive knowledge of behavioral health issues within geriatric and adult population, potential for crisis issues, confidentiality laws and program protocols/policies Extensive knowledge of N.C. Mental Health Laws, Regulations and of Partners operations Knowledge and understanding of managed care and tailored plan and impact on population served Knowledge of resource information and ability to identify ongoing training resources for caregiver staff Skill in quickly identifying needs and responding, particularly in crisis situations Skill in computer functions required for the position and standard office software Ability to provide training and education to staff and caregivers on topics relevant to younger adults with mental illness RN staff must have knowledge of current psychopharmacology utilization within geriatric population and whole person care Ability to establish and maintain effective working relationships with stakeholders, facility staff and other LME/MCO staff, and to provide individualized technical support and education as needed Education and Experience Required: Registered Nurse with three (3) Years of documented experience working with older adults with mental illness and various forms of dementia. Education and Experience Preferred: Masters Prepared therapist and three (3) Years of documented experience working with older adults with mental illness or Registered Nurse with three (3) Years of documented experience working with older adults with mental illness and various forms of dementia. Licensure/Certification Requirements: RN licensure with the appropriate professional board of licensure in the state of North Carolina

60% In-Service Training/Marketing: Provide training, education, consultations on Mental Illness and cognitive disorders (delirium, dementia). Marketing HEART trainings to stakeholders in order to obtain opportunity to train. HEART RN completes all requested medication trainings, and trainings tailored to Integrated Care and Tailored Plan. Only RN staff are permitted to provide these trainings. 15% Community Resources/Agency Collaboration: Will provide input into annual needs assessment. Will collaborate with community agencies as needed, including Department of Social Services, Senior Center, Life Enrichment, and other HEART Teams in N.C. Will participate in any requested MCO meetings or events as assigned by supervisor. 10% Continuing Education/Cooperative Efforts: Attendance at required LME/MCO training and annual updates, staff meeting and professional development classes. 15% Other Duties: Other duties as assigned, including maintenance and care of audio-visual equipment used for training, attendance at community meeting, assisting in ongoing updates to training materials. Will establish and maintain effective working relationship within the unit and demonstrate tact and diplomacy in working with contract providers and other community partners. Actively participates in local collaborative related mental health issues. Maintains documents for GAST program including monthly and quarterly reports.

argenx

Nurse Case Manager, East Coast (EST)

Posted on:

April 24, 2026

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Massachusetts

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

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

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

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

Mindlance

RN Case Manager (Care Manager)

Posted on:

April 23, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

North Carolina

Mindlance is a global Talent, Teams, Projects, and Workforce Solutions partner, serving leading enterprises across industries since 1999. With a 5,000 strong footprint across multiple countries, we deliver scalable, AI native solutions that help organizations build, optimize, and transform their workforce.

100% Remote - ONLY 28 states North Carolina, Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming will be allowed to maintain their current residence and work remotely.

Required Skills: Computer Skills, Telephonic Nice to have Skills: Social worker utilization review (using MCG or internal policy that an insurance company would use for their review) prior off review, Skilled home health background Years of Experience: 3-5 years of experience. If they have not done managed care they need more years of experience Education/Certifications Required: Cert Case Manager Industry Specific Experience – required, ideal, necessary? Medicare, Home Health What is this role’s main focus for the 1st 90 days? Breakdown of Duties/Typical Day: Provider facing (ineracting with providers if they need to get additional information to review a case). Reviewing cases for medicial necessity and making authorization determination. Will log into the system to work cases throughout the day this will be specifically for Home Health. Will be doing all levels of care. Basically is the one deciding if BCBSNC will be the one to pay for the service Hiring Requirements: RN with 3 years of clinical experience or LPN with 5 years of clinical experience. For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience. Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.

Clinical Evaluation and Review Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME) Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations. Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards Provide notifications to member and/or provider, according to regulatory requirements. Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed. May coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines Collaboration and Documentation Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.

Health Advocate

Population Health Nurse Coach

Posted on:

April 23, 2026

Job Type:

Full-Time

Role Type:

Coaching

License:

RN

State License:

Compact / Multi-State

Health Advocate is the nation’s leading provider of health advocacy, navigation, well-being and integrated benefits programs. For 20 years, Health Advocate has provided expert support to help our members navigate the complexities of healthcare and achieve the best possible health and well-being. Our solutions leverage a unique combination of best-in-class, personalized support with powerful predictive data analytics and a proprietary technology platform to address nearly every clinical, administrative, wellness or behavioral health need. Whether facing common issues or an unprecedented challenge like COVID-19, our team of highly trained, compassionate experts work together to go above and beyond expectations, making healthcare easier for our members and ensuring they get the care they need.

Behavioral Health - Population Health Nurse Coach Drive Outcomes. Transform Lives. Elevate Care. At Health Advocate, Population Health is not a checklist—it’s a catalyst for transformation. We’re seeking a Population Health Nurse Coach—an RN with health coaching certification or demonstrated experience applying coaching methodologies in practice—who knows how to turn clinical expertise into meaningful, sustainable behavior change—especially in members navigating behavioral health challenges such as stress, anxiety, depression, and low engagement. This role is for a nurse who understands that real impact happens beyond education—it happens through trust, consistency, and coaching that actually shifts how people live. This role requires a deep understanding of the connection between mental, emotional, and physical health—and the ability to coach through resistance, ambivalence, and behavior patterns that impact outcomes. Reporting into Clinical Leadership, you’ll manage a panel of members with complex chronic and behavioral health conditions—guiding them toward sustainable health improvements while reducing risk, utilization, and gaps in care. If you’re energized by coaching, behavior change, and helping people take ownership of their health—we want to meet you. Your Mission: What Success Looks Like Your primary accountability is to improve member health outcomes by driving engagement, behavior change, and self-management across a diverse population. You will support members with complex medical and behavioral health needs, requiring a compassionate, proactive, and outcomes-driven approach. Many members you support will not struggle with knowledge—but with follow-through. Your role is to identify and address the behavioral and emotional barriers driving that gap. Member Engagement & Activation Build trust-based relationships that drive consistent participation in coaching programs Re-engage at-risk or disengaged members through proactive outreach and connection Meet members where they are—while guiding them toward where they need to be Health Outcomes & Behavior Change Improve clinical and behavioral outcomes through personalized coaching and care planning Support members in developing sustainable habits that reduce risk and improve quality of life Address root causes of non-adherence, not just symptoms Care Coordination & Continuity Ensure members experience seamless, coordinated care across providers and services Reduce gaps in care through proactive follow-up and navigation support Act as a consistent, trusted guide within a complex healthcare system Program Impact & Utilization Contribute to reduced hospitalizations, ER visits, and overall cost of care Drive measurable improvements in program engagement, adherence, and satisfaction Ensure members fully utilize available Health Advocate programs and resources

You’re not just a clinician—you’re a behavior change leader. You understand that knowledge alone doesn’t change outcomes. People do. You bring: 3–5+ years of experience in chronic condition management, population health, health coaching, or behavioral health A strong foundation in motivational interviewing, behavior change science, and the ability to coach members navigating behavioral health challenges (e.g., anxiety, depression, stress-related barriers) An active, unrestricted RN license (multi-state preferred) The ability to connect, influence, and build trust quickly in a virtual environment Strong clinical judgment paired with empathy and emotional intelligence Excellent communication skills—you can simplify complexity without losing meaning A proactive, ownership-driven mindset with strong problem-solving abilities Comfort working independently while collaborating within a multidisciplinary team You are comfortable working with members who are resistant, overwhelmed, or disengaged—and know how to guide them without judgment or control Preferred Experience Health Coach Certification and/or Certified Diabetes Educator (CDE) (or in progress) Required or strongly preferred: Experience supporting members with both chronic medical and behavioral health conditions, with a focus on behavior change and engagement Experience in telephonic or virtual care delivery models Mental and Physical Requirements This is a fully remote role requiring a HIPAA-compliant home workspace • Work is primarily sedentary with prolonged computer and phone use • Requires sustained focus, active listening, and continuous communication throughout the day • Ability to manage multiple members, priorities, and documentation requirements in a fast-paced environment

Member Coaching & Behavior Change Deliver high-impact telephonic and virtual coaching sessions using motivational interviewing and evidence-based strategies Help members translate clinical recommendations into realistic, sustainable daily actions Navigate behavioral health dynamics such as anxiety, avoidance, low motivation, and emotional overwhelm that directly impact follow-through Support lifestyle changes related to chronic conditions, mental health, and overall wellness Clinical Assessment & Care Planning Conduct comprehensive assessments across physical health, behavioral health, and social determinants Develop personalized, goal-driven care plans aligned to each member’s needs and readiness for change Continuously evaluate and adjust care plans based on progress, setbacks, and evolving conditions Care Coordination & Advocacy Coordinate care across providers, behavioral health specialists, and community resources Help members navigate healthcare systems, benefits, and available services Advocate for members to ensure they receive appropriate, timely, and effective care Proactive Monitoring & Risk Management Maintain consistent follow-up to monitor progress and reinforce accountability Identify early warning signs of deterioration or disengagement and intervene quickly Provide support following hospitalizations, ER visits, or critical health events Education & Empowerment Simplify complex medical information into clear, actionable guidance Equip members with tools, resources, and confidence to manage their health independently Engage caregivers and support systems to strengthen long-term success Outcomes Tracking & Documentation Accurately document all interactions, care plans, and outcomes in compliance with regulatory standards Track key metrics including engagement, adherence, and health outcomes Use data insights to continuously improve coaching effectiveness and program impact

Health Advocate

Personal Health Advocate

Posted on:

April 23, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Health Advocate is the nation’s leading provider of health advocacy, navigation, well-being and integrated benefits programs. For 20 years, Health Advocate has provided expert support to help our members navigate the complexities of healthcare and achieve the best possible health and well-being. Our solutions leverage a unique combination of best-in-class, personalized support with powerful predictive data analytics and a proprietary technology platform to address nearly every clinical, administrative, wellness or behavioral health need. Whether facing common issues or an unprecedented challenge like COVID-19, our team of highly trained, compassionate experts work together to go above and beyond expectations, making healthcare easier for our members and ensuring they get the care they need.

At Health Advocate, we are committed to providing our customers with services that improve the health, well-being and productivity of their employees. The Personal Health Advocates are a dedicated team of Registered Nurses who assist our members in navigating the healthcare system by facilitating access to healthcare providers, health and benefit information, health services and resources and entitled benefits coverage.

Minimum Qualifications Education- BSN or RN degree from an accredited college or university required Minimum three to five years clinical and/or medical management experience Active and unrestricted State or Multi-State RN License Understanding of medical terminology to assist in locating appropriate care options Strong Communication skills and phone etiquette Strong ability to explain complex issues to employees/retirees Highly effective listening skills Strong problem solving/issues resolution skills Excellent customer service and customer resolution skills Organizational and administrative skills Experience with Microsoft Word and Excel Ability to work in a team environment Mental and Physical Requirements- This position is a remote position. The employee will need to have a dedicated HIPPAA compliant work space. Have access to internet and router. The nature of the work in this position is sedentary and the incumbent will be sitting most of the time Essential physical functions of the job include fingering, grasping, pulling hand over hand, and repetitive motions to utilize general computer software/hardware continuously throughout the work day Essential mental functions of this position include concentrating on tasks, reading information, and verbal/written communication to others continuously throughout the work day

Receive calls from members in regards to various healthcare issues (e.g., infertility, disease, medication, etc.) and determine best course of action/s to assist the members while adhering to established policies, procedures, and key performance indicators (KPIs) (e.g. case close targets, abandon rates, member follow up, all quality indicators, etc.) Build relationships with members in order to collaborate and develop plans of action by going above and beyond members’ initial requests, taking responsibility for members’ case records, and encouraging members to call back with future issues/ questions. Assist and educate members in understanding their medical conditions, associated health testing, test result interpretation, and health options available to them. Provide members choices in medical care providers and services based on the members’ clinical needs, geographic locations and available benefit offerings. Research providers through credentialing, education checks and affiliations with notable medical centers within the member’s plan Facilitate communication among members, treating physicians, and insurance carriers, which may include assisting members with asking necessary health questions to physicians or clarifying insurance plan provision Take appropriate steps on behalf of members by assisting with scheduling health appointments, re-scheduling health appointments, facilitating record and information transfers, and researching and resolving various problems as applicable Document cases in the department’s case management system using approved processes and procedures Escalate cases appropriately and on a timely basis to supervisor or internal resources for review as applicable Keep up-to-date on patient care procedures which include diagnosis, pre-certification, prior authorization, pre-service and post-service denials Continuously stay up to date on various health issues and medical procedures necessary to offer top of the line feedback to members Intercede for the member to obtain an earlier appointment. Help members obtain prescriptions Help members with pre-service fee negotiations Place outbound follow up calls for issues that cannot be resolved during the initial call Respond to member cases in delegate box, answers and after hours calls Mentor new team members Team Interfaces/Customer Service Establish and maintain a professional relationship with internal/external customers, team members and department contacts Cooperate with team members to meet goals or complete tasks Provide customer service that exceeds customer expectation Treat all internal/external customers, team members and department contacts with dignity/respect Escalate work flow and communication issues to supervisor Related Duties as Assigned :The job description documents the general nature and level of work but is not intended to be a comprehensive list of all activities, duties, and responsibilities required of job incumbents Consequently, job incumbents may be asked to perform other duties as required Also note, that reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above Please contact your local Employee Relations representative to request a review of any such accommodations

Brighton Health Plan Solutions

Workers Compensation Nurse Case Manager

Posted on:

April 23, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

New York

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

Workers Compensation Nurse Case Manager Brighton Health Plan Solutions REMOTE – 100% FULL TIME Brighton Health Plan Solutions (BHPS) provides Utilization Review/Medical and Case Management services for Group Health and Workers’ Compensation and other Casualty clients. The Workers’ Compensation Nurse Case Reviewer collaborates with medical care providers, employers, employees, and at times, attorneys to support the appropriate return to work, the provision of necessary medical services, and the evaluation of coverage under the Plan. The Nurse Case Reviewer reports to the Casualty Department Manager.

Currently licensed Registered Nurse (RN).......NY State preferred....if not with ability to secure NY State license Must maintain current licensure(s) and specialty certifications that are relevant to this position; CCM is encouraged. Bachelor’s degree preferred. Minimum of 4 years’ experience in a clinical environment required. Previous workers’ compensation case management experience required. Previous experience in utilization review/medical management preferred. Strong skills in medical assessment/medical record review. Excellent customer service skills. Ability to define and solve problems, collect data, establish facts and make effective decisions a must. Must be detail oriented and have strong organizational and time management skills, and the ability to work independently Ability to work proficiently on a computer (PC) with working knowledge of Microsoft Office, especially Word, Excel and Outlook.

Collaborates with workers' compensation patients, employers, providers, and claims adjusters to coordinate medical and disability services for timely return to work. Provides utilization review, continued stay reviews, and utilization management based on clinical judgment and state WCB Medical Treatment Guidelines. Knowledgeable and compliant with New York State Workers’ Compensation Law, Medical Treatment Guidelines, ERISA, HIPAA confidentiality requirements, and NY Formulary Review process. Proven ability to anticipate claimant's treatment or recovery milestones. Provides Case Management services, including assessing barriers to recovery and determining treatment alternatives. Facilitates and expedites discharge planning as needed. Produces accurate electronic records of individual cases. Ensures timely, cost-effective medical care for injured workers' recovery. Answers provider calls and assists with Casualty Department workload as necessary. Kind, caring, and positive with all customers and fellow employees. Adheres to established quality assurance standards and MagnaCare policies and procedures. Participates in up to 10% of employed time in QA activities.

AlediumHR

Nurse Practitioners – Remote (HRT Focus) FT or PT

Posted on:

April 23, 2026

Job Type:

Contract

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

AlediumHR represents a rapidly growing national telehealth provider focused on modernizing hormone care and preventive health. This organization is built around performance-driven wellness, helping patients take control of long-term health through clinically guided hormone optimization. You’ll work strictly within hormone optimization and wellness, no urgent care or unrelated casework.

Flexible scheduling with both part-time and full-time options. 1099 structure with malpractice coverage included. You’ll have full support across admin, compliance, and technology—so your time stays focused on patient care. This opportunity is designed for Nurse Practitioners with real-world experience in hormone replacement therapy (HRT) who want to operate in a more focused, protocol-driven environment. This is a fully remote role in which you will deliver care through a structured virtual platform designed specifically for hormone management and preventive wellness. We are seeking experienced Nurse Practitioners with direct experience in HRT for both male and female patients

Active Nurse Practitioner licenses across multiple U.S. states (8–10 preferred) Priority given to candidates licensed in California, Texas, New York, and Colorado Active, unrestricted DEA license Ability to prescribe controlled medications in accordance with all regulations Experience: At least 1 year of hands-on HRT experience Experience treating both male and female patients Strong clinical knowledge of hormone optimization and preventative care strategies Comfortable managing ongoing lab work and adjunct therapies

Conduct virtual patient visits centered on hormone balance and overall wellness Analyze lab results and identify hormonal deficiencies or imbalances Develop and manage individualized treatment plans using established HRT protocols Prescribe and oversee therapies, including testosterone and estrogen-based treatments Track patient outcomes through ongoing lab monitoring and follow-up care Provide clear education on treatment plans, expectations, and long-term health impact Ensure accurate and compliant documentation within the telehealth system Work alongside clinical and operational teams to maintain a high-quality patient experience

X Benefit Group

Virtual Primary Care RN/LPN

Posted on:

April 23, 2026

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Florida

X Benefit Group provides shared services that help businesses grow stronger, smarter, and more efficiently. From branding and marketing to HR, finance, operations, and technology solutions, we act as the operational backbone for a portfolio of forward-thinking companies. Our centralized approach creates efficiencies, reduces complexity, and allows our partners to focus on what they do best. We’re here to support sustainable growth, operational excellence, and long-term success.

Position Title: Virtual Primary Care RN/LPN Department: Clinical Services Reports To: Chief Medical Officer FLSA Status: Exempt Work Location: 100% Remote (Multi-State Licensure Preferred) Position Summary: The Virtual Primary Care RN/LPN supports longitudinal, relationship-based patient care through a secure telehealth platform. This role focuses on chronic disease management support, preventive care coordination, patient education, triage, and care navigation. The RN/LPN collaborates closely with physicians, advanced practice providers, and interdisciplinary team members to ensure high-quality, patient-centered virtual care delivery.

Knowledge, Skills & Abilities (KSAs)Knowledge Telehealth workflows and documentation standards. HIPAA and patient privacy regulations. Clinical protocols relevant to role scope. Chronic disease management standards. Preventive screening guidelines. Telehealth triage protocols. HIPAA and patient privacy regulations. Care coordination workflows in value-based models.Skills Clear patient communication. Efficient EHR documentation. Time management and prioritization. Clinical triage and assessment. Motivational interviewing. Clear patient communication. Care coordination and follow-up tracking.Abilities Ability to recognize and escalate clinical concerns. Ability to manage workload in virtual environment. Ability to adapt to evolving digital tools. Ability to manage panel-based patient populations Ability to identify care gaps. Ability to work independently in remote setting. Ability to escalate appropriately. Education & Experience Active professional license (RN/LPN where applicable). Medical Assistant certification preferred for MA roles. 1–2+ years relevant clinical experience preferred. Telehealth experience preferred. RN: Active, unrestricted RN license. Associate or Bachelor’s degree in Nursing. 2+ years primary care, population health, or care coordination experience preferred. LPN Active, unrestricted LPN license. 1–2+ years ambulatory or primary care experience preferred. Telehealth experience preferred.Working Conditions 100% remote work environment. Prolonged computer use. Flexible scheduling including evenings/weekends as needed. Performance expectations tied to quality and productivity. Secure workspace and reliable high-speed internet required.

Conduct virtual intake assessments and clinical screening. Perform telephonic/video triage in accordance with clinical protocols. Support chronic disease management (HTN, DM, HLD, obesity, behavioral health conditions). Reinforce care plans and medication adherence. Coordinate referrals, labs, imaging, and follow-up care.Patient Education & Engagement Provide virtual education regarding preventive screenings and wellness. Support remote patient monitoring workflows. Address patient questions regarding treatment plans. Promote patient activation and self-management.Documentation & Compliance Maintain accurate EHR documentation. Ensure HIPAA compliance. Support quality and population health metrics. Additional Responsibilities: Responsibilities are representative and not exhaustive. Additional duties may be assigned to support patient care delivery, operational needs, and regulatory compliance, consistent with scope of practice.Scope of Practice & Regulatory Compliance All duties shall be performed in accordance with applicable state scope of practice laws, organizational policies, and federal and state regulatory requirements.

CuraSenseAI

Clinical Nurse Specialist (Remote)

Posted on:

April 23, 2026

Job Type:

Contract

Role Type:

Clinical Operations

License:

None Required

State License:

Compact / Multi-State

CuraSenseAI connects healthcare professionals with high-quality remote and global opportunities across healthcare, life sciences, and AI-driven medical domains. We curate and share roles from leading organizations working in clinical research, healthcare operations, medical AI, and digital health—helping candidates access structured and reliable hiring pipelines worldwide. Our focus is on bridging top healthcare talent with forward-thinking teams building the future of healthcare.

Nursing Talent Network Remote · Contract · Immediate Start · Competitive rates Role Overview We are looking for nursing professionals to join our expert network and help advance AI systems in healthcare through real-world clinical expertise. If you think clinically, communicate clearly, and can apply nursing knowledge to structured problem-solving, this opportunity is for you.

Professional experience in patient care, monitoring, and medication administration Strong understanding of clinical documentation and care protocols Strong communication skills with the ability to explain clinical reasoning clearly Ability to work independently in a remote environment Preferred: Experience engaging with training, evaluation, or healthcare workflows

Contribute to training and evaluating AI models in nursing contexts Create tasks and deliverables based on real-world patient care scenarios Provide domain-specific feedback to improve AI system performance Support development of AI systems through applied clinical reasoning

FitCam Health

Bilingual RN (Arabic – Iraqi/Syrian) for Remote Patient Monitoring

Posted on:

April 23, 2026

Job Type:

Contract

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

FitCam Health is a leading digital health platform specializing in pain management. We work with pain clinics to offer comprehensive Remote Therapeutic Monitoring (RTM) programs, helping patients manage their pain through personalized home exercise programs and cognitive behavioral therapy (CBT) techniques.

We are currently seeking licensed Bilingual Registered Nurses (Arabic – Iraqi/Syrian) to join our remote team and provide monitoring services for our RTM programs. This is an excellent opportunity to be part of a cutting-edge digital healthcare service that enhances patient care while providing a flexible work schedule.

Prior experience in telehealth, pain management, or monitoring patients remotely is preferred. Tech-Savvy: Comfortable using digital health tools, apps, and telehealth platforms for patient monitoring and engagement. Strong Communication Skills: Ability to effectively communicate and engage with patients and care teams through various channels. Nice to Have: Experience as a Psychiatric Nurse, understanding the psychological aspects of chronic pain management, and mental health care. Benefits: Flexible Work: Choose part-time or full-time hours to suit your schedule. Competitive Pay: Hourly rates with the potential for performance-based bonuses. Remote Opportunity: Work from the comfort of your home, while still making a direct impact on patient care. Ongoing Training: Access to continuous professional development through FitCam Health's training programs. Apply Now

Monitor Patient Data: Track patients’ progress, including therapy adherence, pain levels, and overall health data reported through the FitCam Health Console. Patient Communication: Engage with patients via in-app messaging, phone, and video calls to answer questions, offer guidance, and ensure they are following prescribed treatment plans. Program Customization: Work closely with physicians and other healthcare providers to tailor patient programs based on real-time data, adjusting treatments to optimize outcomes. Patient Education: Provide information on managing pain through the FitCam platform, guiding patients on self-care techniques and therapy adherence. Documentation and Reporting: Maintain thorough patient records and ensure all RTM interactions meet regulatory requirements. Compliance: Ensure adherence to HIPAA regulations and clinic protocols during patient interactions. Qualifications: Licensure: Active Registered Nurse (RN) license in one or more of the following states: Compact License, Alaska, New Jersey, New York, Ohio, South Carolina, California.

Oscar Health

Complex Case Management Nurse

Posted on:

April 23, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

You will educate members on improving health outcomes, assist with transitions from care settings, participate in process improvement and other pilot programs as they arise, and work with support teams to ensure exceptional care for our members. You will report into the Associate Director, Clinical. Work Location: This is a remote position, open to candidates who reside in: Alabama; Arizona; Arkansas; Colorado; Connecticut; District of Columbia; Florida; Georgia; Idaho; Illinois; Indiana; Iowa; Kansas; Kentucky; Maine; Maryland; Massachusetts; Michigan; Minnesota; Missouri; Nevada; New Hampshire; New Jersey; New Mexico; North Carolina; Ohio; Oregon; Pennsylvania; Rhode Island; South Carolina; Tennessee; Texas; Utah; Vermont; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $39.28 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.

Requirements: Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license Ability to obtain additional state licenses to meet business needs 2+ years of clinical experience to include payer, hospital, outpatient or community based care management 1+ years of experience in Care Coordination and Navigation Bonus points: CCM Certification NCQA knowledge and accreditation experience Bilingual in spanish and or creole reading, writing, speaking BSN Working knowledge of Milliman Guidelines

Assist in the coordination of care across a variety of settings (inpatient, outpatient, post acute, ER, home care) Actively reach out to members undergoing difficult health challenges and develop care plans Proactively reach out to hospital case managers to assist with discharge planning Communicate with members via phone or secure messaging to provide education on health conditions, new medications, and procedures Ensure compliance with all CCM NCQA standards in day to day practice and workflows. Compliance with all applicable laws and regulations Other duties as assigned

Oscar Health

Care Navigation Nurse

Posted on:

April 23, 2026

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

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

This role requires extensive clinical knowledge and initiative to perform in-depth research, problem-solving, and decision-making to source and route to medically appropriate care, verify network gaps, escalate issues to appropriate stakeholders, guide the Care Navigation team in searches, and improve member experience. Additionally, you will provide ongoing clinical education to non-clinical teams to provide a strong foundation to be utilized in their workings with members. You will report into the Clinical Care Navigation Lead. Work Location: This is a remote position, open to candidates who reside in: Alabama; Arizona; Arkansas; Colorado; Connecticut; District of Columbia; Florida; Georgia; Idaho; Illinois; Indiana; Iowa; Kansas; Kentucky; Maine; Maryland; Massachusetts; Michigan; Minnesota; Missouri; Nevada; New Hampshire; New Jersey; New Mexico; North Carolina; Ohio; Oregon; Pennsylvania; Rhode Island; South Carolina; Tennessee; Texas; Utah; Vermont; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. Pay Transparency: The base pay for this role is: $39.28 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.

Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license Ability to obtain additional state licenses to meet business needs 3+ years of clinical experience to include hospital, outpatient or community based care management 3+ years of experience in Care Coordination and Navigation

Help coordinate care across a variety of settings (inpatient, outpatient, post acute, ER, home care) Actively reach out to members undergoing difficult health challenges and develop care plans Proactively reach out to hospital case managers to assist with discharge planning Communicate with members via phone or secure messaging to provide education on health conditions, new medications, and procedures. Compliance with all applicable laws and regulations Other duties as assigned

Omega Healthcare Management Services

CDI RN Lead

Posted on:

April 22, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Florida

Founded in 2003, Omega Healthcare Management Services® (Omega Healthcare) is an AI-driven healthcare solutions company that partners across the healthcare ecosystem to deliver breakthrough results by reimagining and elevating revenue operations. Powered by the Omega Digital Platform®, our agentic AI engine leverages adaptive intelligence to drive automation, complemented by deep human expertise to help optimize performance and deliver sustained financial and clinical outcomes—while enhancing patient satisfaction. Omega Healthcare empowers organizations across provider, payer, and life sciences sectors to navigate today’s healthcare challenges while building the agility to adapt as healthcare and technology continue to evolve rapidly. Recognized by industry analysts, Omega Healthcare has consistently been ranked a leader in driving operational performance excellence.

The CDI RN Lead serves as a clinical subject matter expert and frontline leader for the Clinical Documentation Improvement program. This role is responsible for coordinating program elements, mentoring staff, and driving physician engagement to ensure documentation accurately reflects patient complexity, severity of illness, and risk of mortality. The Lead ensures to program aligns with compliance standards and organizational goals while fostering a culture of continuous improvement.

Key Success Indicators/Attributes: Ability to prioritize and multi-task in a multifaceted environment. Demonstrate strong organizational skills and be detail oriented. Demonstrate ability to self-motivate, set goals, and meet deadlines. Demonstrate mentoring and interpersonal skills. Demonstrate excellent presentation, verbal, and written communication skills. Ability to develop and maintain relationships with key business partners by building personal credibility and trust. Maintains courteous and professional working relationships with employees at all levels of the organization. Demonstrate successful leadership skills with the use of critical thinking, problem solving, and deductive reasoning required. Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred Work Environment This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones. 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. While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus. Position Type/Expected Hours of Work This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work. Travel Minimal travel required; up to 5% Required Education and Experience Bachelor’s degree in nursing (BSN) or a healthcare related field. Active, unrestricted Registered Nurse (RN) license. 3-5 years of experience in a Clinical Documentation Improvement Program. Minimum of 3 years in a management, supervisory, or Lead role within a clinical quality or CDI environment. Deep understanding of Medicare Part A and B, DRG assignment, and MCC/CC impact. CCDS (ACDIS) or CDIP (AHIMA) preferred. Additional Eligibility Qualifications None required Security Access Requirements In addition to the specific security access required by the employee’s client engagement, the employee will have access to the Omega systems set forth in "Standard Field Employee” profile. Microsoft Office: E1 Level Access ADP: Standard Employee Level Access Oracle: Standard Level Access

Acts as a primary point of contact for the CDI team; coordinates and maintains all program elements to meet organizational goals and balanced scorecard metrics. Ensures timely, accurate and complete clinical documentation to support high-quality data for physician and hospital outcome reporting. Serves as a liaison between CDI and Coding professionals; proactively resolves discrepancies and facilitates a unified approach to clinical code assignment. Analyzes program data and key performance indicators; creates comprehensive reports to identify trends, gaps, and opportunities for documentation improvement. Develops and delivers education for CDI staff and physicians; provides ongoing mentorship to team members to enhance clinical knowledge and query proficiency. Maintains effective communication with stakeholders (e.g. Quality, Revenue Cycle, Physician Leaders) to build credibility and trust. Ensures all departmental activities comply with company policies, HIPAA regulations, and official coding guidelines.

Blue Sun Healthcare

Wound Care Technician LPN/PRN

Posted on:

April 22, 2026

Job Type:

Contract

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Missouri

Blue Sun Healthcare is a mobile wound care health group dedicated to achieving excellent patient outcomes and optimal healing. Driven by our mission—providing the right care, at the right time, in the right way—we strive to deliver compassionate and effective care to our patients. We are committed to improving the health and well-being of our patients through our specialized, proprietary wound care services across the country.

We are seeking a Licensed Practical Nurse (LPN) to join our team as a PRN Ultra-Mist Technician, delivering advanced wound care treatments across multiple facility types and within patient homes. This is an ideal role for an LPN looking for flexibility, autonomy, and a specialized clinical focus in wound care.

Licensed Practical Nurse (LPN) license and expertise in general Nursing practices Experience in Wound Care and the ability to utilize best practices for wound healing Demonstrated skills in Home Care and in delivering compassionate, patient-centered care Strong collaboration, communication, and documentation skills Ability to work effectively in a fast-paced, hands-on clinical environment, autonomously Commitment to continuous learning and professional skill development Familiarity with compliance standards in healthcare settings is a plus Experience in a similar role or relevant certifications in wound care are highly desirable

Responsibilities include providing wound care to patients via ultrasonic debridement machines, monitoring the healing progress, documenting care, and ensuring proper patient education on wound management. The technician will collaborate with clinical team leaders to ensure high-quality, compassionate care and adherence to evidence-based practices. Additional duties may include assisting with home care visits and maintaining compliance with medical standards.

Ways2Well

Remote Functional Nurse Practitioner - CA / FL / KY / OH / WA Licensure

Posted on:

April 22, 2026

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

Ways2Well is redefining the future of healthcare. As a leader in regenerative and preventive medicine, we empower patients to take control of their health through data-driven, personalized care. We’re breaking away from outdated models—leveraging cutting-edge technology, digital care platforms, and bold thinking to deliver high-impact healthcare at scale.

As a Nurse Practitioner, you will provide evidence-informed, patient-centered care via telemedicine. Your role involves conducting comprehensive health assessments, interpreting advanced lab results, designing personalized wellness and hormone optimization plans, and supporting patients through lifestyle and supplement-based interventions. You will collaborate with a multidisciplinary team in a fast-paced, fully virtual environment.

Required Qualifications: Active and unencumbered Nurse Practitioner license in at least 5 U.S. states (multi-state licensure required) National certification (e.g., AANP, ANCC) Active DEA Minimum of 2 years of NP experience, with exposure to functional, integrative, or hormone therapy preferred Strong knowledge of hormone replacement therapy (HRT) (testosterone, estrogen, thyroid), peptides, and targeted supplementation preferred Prior experience in a telehealth or digital health setting is strongly preferred Comfortable navigating EHRs, telemedicine platforms, and cloud-based tools Exceptional communication, patient engagement, and clinical documentation skills Work Environment & Physical Requirements: Primarily clinic/office-based setting for telehealth visits Remote work environment; home office or dedicated workspace required Must be able to work independently with minimal supervision Virtual meetings via video conferencing (camera on expected) Reliable high-speed internet connection required Must maintain a distraction-free, professional background for video calls Schedule: Monday – Friday, 8am–5pm Central

Conduct virtual consultations using both asynchronous and synchronous telehealth platforms Review and interpret functional and traditional lab results (e.g., hormone panels, micronutrients, inflammatory markers) Develop personalized care plans focusing on hormonal balance, metabolic health, nutrition, and preventive strategies Educate patients on treatment options, supplement protocols, and lifestyle modifications Document thoroughly and accurately in the EHR system (i.e., Charm or similar) Collaborate with clinical support staff, pharmacists, and health coaches to ensure continuity of care Adhere to state and federal telehealth regulations and best practices Participate in ongoing training, case reviews, and team huddles to support professional development and care quality

Insight Global

Remote Clinical Review Nurse

Posted on:

April 22, 2026

Job Type:

Contract

Role Type:

Telehealth

License:

RN

State License:

Georgia

Insight Global is an international talent and consulting company that delivers business outcomes in an ever-changing world. We obsess over solving problems and building solutions that move our customers further, faster. With access to top talent in more than 50 countries, our tech-enabled recruiters can build teams quickly. Our technical experts across Cloud, AI, Data, Enterprise Operations, and Applied Engineering deliver solutions tailored to each customer’s needs. As those needs evolve, so do we. As we evolve, though, we stay true to our purpose: to develop people personally, professionally, and financially so they can be the light to the world around them. It shows up in everything we do, from investing in our people to delivering results for our customers to making a meaningful impact in our communities.

A client of Insight Global is hiring for Telehealth Nurses, for a contract through the end of 2026, with potential for extension. This role will be remote, 40/hr per week, with oppotunity for overtime if you would like.

Must be a Registered Professional Nurse with current licensure, with 2 years of professional experience Knowledge of OSHA, FDA, and HIPAA compliance Will be reviewing cases to assess the documentation needed follow-up based on client guidelines, also reviewing for accuracy. Review medical records and documentation received for accuracy and completeness Adding medical codes from the case clinical notes to define symptoms using MedDRA

Sentara Health

Maternity Behavioral Health Care Coordinator/RN/LPC/LCSW/LMFT- Remote in Virginia

Posted on:

April 22, 2026

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Virginia

Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees. Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals. We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health.

Sentara Health Plans is hiring for a Maternity Behavioral Health Care Coordinator/RN/LPC/LCSW/LMFT- Remote in Virginia Status: Full-time, permanent (40 hours/week) Standard Working Hours: 8 AM to 5 PM EST, M-F Location: Remote in Virginia. The role includes travel of approximately 3 to 4 times per year to attend baby showers through the outreach program in Virginia.

Education: Master’s degree in Counseling, Social Work, or Marriage and Family Therapy required. For Registered Nurses, a Bachelor of Science in nursing is REQUIRED Certification/Licensure REQUIRED license must be valid in state of practice. One of the following qualifies: Licensed Clinical Social Worker (LCSW) - State license - Virginia Department of Health Professionals (VADHP) OR Licensed Clinical Social Worker (LCSW) - State license - North Carolina Social Work Certification and Licensure Board (NCSWCLB) OR Licensed Professional Counselor (LPC) - State license - Virginia Department of Health Professionals (VADHP) OR Licensed Professional Counselor (LPC) - State license - North Carolina Board of Licensed Clinical Mental Health Counselors (NCBLCMHC) OR Licensed Marriage and Family Therapist (LMFT) - State license - Virginia Department of Health Professionals (VADHP) OR Licensed Marriage and Family Therapist (LMFT) - State license - North Carolina Marriage and Family Therapy Licensure Board (NCBMFT) OR Registered Nurse (RN) Single State - Nursing License - Virginia Department of Health Professionals (VADHP) OR Registered Nurse (RN) Single State - Nursing License - North Carolina Board of Nursing (NCBON) OR Registered Nurse (RN) Multi State - Nursing License - Virginia Department of Health Professionals (VADHP) OR Registered Nurse (RN) Multi State - Nursing License - North Carolina Board of Nursing (NCBON) Experience: 2 years of behavioral health REQUIRED 1 year of case management REQUIRED Experience in a Maternal Health (Labor & Delivery, Postpartum care, Mother and Baby, High Risk Pregnancy, Prenatal Care) and experience in Serious Mental Illness, Substance Abuse Disorder preferred.

This position will provide case management for members under Sentara Health Plans for Maternal Health (Labor & Delivery, Postpartum care, Mother and Baby, High Risk Pregnancy, Prenatal Care) and Behavioral Health (Serious Mental Illness, Substance Abuse Disorder).

Medix™

Utilization Management Nurse - 252773

Posted on:

April 22, 2026

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

California

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

Now Hiring: Utilization Management Specialist (RN) Remote | Contract Opportunity (6 Months) with potential for hire We’re looking for a skilled Utilization Management Specialist (UMS) to join our growing team! This is a 6-month contract opportunity, open to candidates nationwide, making it a great fit for experienced RNs seeking impactful work. About the Role: The Utilization Management Specialist plays a critical role in determining appropriate levels of care using clinical criteria, Medicare guidelines, and payer requirements. This position partners closely with physicians, case management, revenue integrity, and payers to support accurate admissions, reduce denials, and ensure compliance. Schedule Monday–Friday: 8:00 AM – 4:30 PM EST (flexible start times available) Weekend rotation: Ideally every 3rd weekend (flexible options available) Additional Details: This is a 6-month contract role with potential hire If converted to permanent employment, eligibility is limited to candidates residing in: AZ, CT, FL, MA, ME, MD, MI, NJ, NH, NC, OH, PA, RI, TX, WI

Active RN license Graduate of an accredited nursing program (BSN preferred) 2+ years of utilization review with a hospital syste Strong knowledge of payer guidelines, medical necessity criteria, and utilization management practices Ability to work independently and collaborate across interdisciplinary teams Excellent communication and critical thinking skills

Review admissions for appropriate patient status and authorization compliance Apply clinical criteria and Medicare Inpatient Only List to determine medical necessity Collaborate with physicians, APPs, and case managers to recommend appropriate level of care Manage payer interactions, including denials and peer-to-peer (P2P) reviews Document clinical findings and authorization details in the medical record Partner with Revenue Integrity and Denials teams to support accurate billing and appeals Conduct admission, continued stay, and discharge reviews Identify trends and support quality improvement initiatives

Infinit-O

Telehealth Triage RN | Nurse Advice Line

Posted on:

April 22, 2026

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Infinit-O empowers finance and healthcare organizations to thrive in a digital-first world by combining specialized industry expertise, innovative technology, and a commitment to process optimization. As a trusted partner, we navigate complex industry landscapes to drive transformative outcomes, helping businesses streamline operations, enhance customer experience, and achieve sustainable growth.

This role is built for working nurses who want to put their clinical skills to use on their days off — without picking up a second job that demands a second schedule. As a Telehealth Triage RN on our nurse advice line, you'll assess patient symptoms, provide evidence-based guidance, and support safe clinical decision-making — all from home, on your own time. There are no mandatory hours, no shift minimums, and no schedule commitments: you pick up available shift blocks when it works for you.

Requirements: Active Florida RN license in good standing — OR a multistate license (MSL) issued through an eNLC compact state (no additional Florida registration required for RNs under the enhanced Nurse Licensure Compact) Minimum 2+ years of acute care, emergency, or similar clinical experience — you should be comfortable making independent clinical assessments with confidence Tech-comfortable — able to learn and navigate a proprietary telehealth platform; onboarding and training are provided, but a baseline comfort with technology is expected Reliable high-speed internet connection and a quiet, private home workspace suitable for patient calls Active professional liability / malpractice insurance (required; as a 1099 contractor, you are responsible for maintaining your own coverage) Excellent verbal communication skills — calm, clear, and effective with patients under stress Nice to Have: Prior telehealth, nurse advice line, or call center triage experience AAACN Telehealth Nursing Certification (TNC) Emergency Department (ED) or ICU background Experience working with structured triage tools (e.g., Schmitt-Thompson protocols)

Conduct structured telephone and video triage assessments for patients presenting with a wide range of symptoms and concerns Apply evidence-based clinical protocols and decision-support tools to guide appropriate care pathways Advise patients on self-care, home management, or the appropriate level of care to seek (urgent care, ED, 911, etc.) Provide clear, accurate patient education tailored to each caller's situation and health literacy level Document all interactions thoroughly and accurately within the company's platform Escalate calls appropriately and efficiently when a patient requires emergency intervention Follow established escalation pathways and communicate with on-call clinical supervisors as needed Maintain patient confidentiality and adhere to HIPAA standards on every call Participate in required onboarding training and periodic protocol updates

Home Health Focus AI

Clinical Patient Access Specialist- MA, LPN EMT Required

Posted on:

April 22, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

Home Health Focus AI's mission is to help home healthcare professionals find meaningful opportunities that prioritize patient care. We are not a staffing firm or agency. Home Health Focus AI does not hire for these roles—we identify and verify them from care providers directly. Employer Industry: Healthcare Services

Why Consider This Job Opportunity Work from home opportunity after training (equipment provided) Paid time off and comprehensive medical, dental, and vision benefits 403b retirement plan with matching contributions Opportunity for growth within the organization Positive and supportive work environment focused on patient care

Active certification or license as LPN, CMA, RMA, or EMT Minimum of one year of experience in a clinical setting relevant to certification Ability to comply with applicable laws and regulations, including HIPAA, OSHA, and CLIA Strong documentation skills in electronic medical records (EMR) Excellent communication skills to effectively interact with patients and healthcare providers How To Stand Out (Preferred Qualifications) Experience in a call center or patient access role within a healthcare environment Familiarity with medical scheduling systems and patient management software Additional certifications related to healthcare access or patient care Proven ability to manage multiple tasks and prioritize effectively Strong interpersonal skills and a passion for patient care

Relay reviewed normal, expected, or abnormal results to patients as directed by providers Manage large volumes of inbound calls, documenting and communicating pertinent medical information Schedule appointments for patients according to office scheduling guidelines Verify and update patient demographic and insurance information Maintain effective communication with patients, providers, and other team members to resolve issues