CareStar

Intake Specialist - RN

Posted on:

July 6, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Ohio

Ready to join a growing company whose work profoundly impacts people’s lives in their community, who offers an excellent learning environment, opportunities to advance and the ability to work alongside talented business leaders/professionals? CareStar was founded in 1988 in Cincinnati, Ohio with the mission to Improve Communities by Improving Lives. We continue to be an industry leader in the field of Long-Term Care Case Management, Assessment, Population Health Management and Innovative Software Development Solutions. WHY YOU SHOULD APPLY Remote working opportunities. Shared ownership benefit through the CareStar Employee Stock Ownership Plan (ESOP). Competitive salary based upon experience, education and knowledge. Comprehensive benefits package with medical, dental, vision, and life-insurance. 401(k) with a generous Safe Harbor company matching contribution. Paid vacations and 10 holidays per year

CareStar, Inc. is currently seeking a Intake Specialist in the Clinical Department to conduct program assessments using program and CareStar identified tools and process. The Intake Specialist will provide recommendations for eligibility per program and CareStar guidelines. THE LOCATION: This position is open in Jackson County and is responsible for covering the surrounding counties.

Active License as RN. 12 months experience in home and community-based services within the past 5 years. Knowledge of Medicare, Medicaid, Home Health Care and Ohio Home Care waiver programs desirable. Adheres to the CareStar Rule in performance of job responsibilities. Understands and complies with CareStar Policies and Procedures. Maintains confidentiality as related to patient information. Any disclosures of confidential information made unlawfully outside the proper course of duty will be treated as a serious disciplinary offense. Follows the Acceptable Use Policy while using any information systems owned or controlled by CareStar, Inc.

Completes visits to assess for eligibility for specified program and conducts safety assessments, in compliance with CareStar and department guidelines. Documents all applicant and case-related contacts and interventions in applicants record per agency and CareStar policy, including standards of content and timeliness. Processes specific Program Eligibility Assessment Tool (PEAT) or other tools and all related documents per agency and CareStar policy. Provides assistance with community resource referrals as appropriate. Identifies and reports high-risk situations as required per agency and CareStar policy.

CVS Health

Utilization Management Nurse Consultant - Remote Work

Posted on:

July 6, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Iowa

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

Fully remote role in the USA. Requires Monday-Friday: 11:30am-8:00pm EST shift; 8:30am-5:00pm PST; or 9:30-6:00pm MST depending on the candidates time zone. Weekend/holiday coverage will occasionally be required. American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.

Required Qualifications: 1 year UM, concurrent review or prior authorization 5 years of clinical experience required 5 years Demonstrated to make thorough independent decisions using clinical judgement 5 Years Proficient use of equipment experience including phone, computer, etc and clinical documentation systems Required to attend the first 3 weeks on camera training required 100% participation during 8:30am-5pm Monday-Friday. A Registered Nurse that must hold an unrestricted license in their state of residence, with multi-state/compact privileges and have the ability to be licensed in all non-compact states. Preferred Qualifications: 1+ years Managed Care (MCO) preferred. 1+ years demonstrated experience working in a high volume clinical call center environment. Remote work experience. Education: Associate's nursing degree (RN) minimum required. Bachelor's degree preferred. Anticipated Weekly Hours

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function Function in a clinical telephone queue working with providers to secure additional information for prior authorization review. CVS health requires eligible colleagues identified as permanent work from home teleworkers, who need to use the internet for work purposes are required to use a residential broadband service with speeds of at least 25 mbps/3mbps in order to ensure sufficient speed to adequately perform their work duties. Verification of services will include confirmation of a named internet service provider, multi-port modem, minimum download speed of 25 Mbps and minimum upload speed of 3 Mbps and the modem IP Address must not begin with the number 10. Please also note the following nuances regarding internet service: No Wireless equipment No Satellite No Contracts No business class lines Installation and monthly service costs are paid by the user up front.

Optum

Preservice Review Nurse - Behavioral Health - Remote

Posted on:

July 6, 2025

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.

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 RN license in the state of residency or compact state Professional experience in direct patient care Proven exemplary clinical documentation skills; critical thinking skills Demonstrated proficiency in computer skills – Excel, Microsoft platforms, Outlook, clinical platforms Designated secure workspace and access to install secure high speed internet via cable/DSL in home Open to weekend rotation schedule Preferred Qualifications: Bachelor’s degree 2+ years of RN experience including experience in an inpatient/acute setting Behavioral Health experience Demonstrated background involving utilization review for an insurance company or experience in case management Proven excellent communication skills both verbal and written

Perform clinical coverage review services, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information Function as a member of a self-directed team to meet specific individual and team performance metrics Ability to communicate in writing and verbally, all types of benefit determinations including decisions regarding coverage guidelines Telephonic discussion with health care providers and/or members to explain benefit coverage determinations and to obtain additional clinical information Acts as a resource for others with less experience Work independently and collaborating with Medical Directors and non-clinical partners Adapt to a highly changing environment and a heavy case load

US Heart and Vascular

Registered Nurse - Triage

Posted on:

July 6, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Dallas/Fort Worth, known as the Metroplex, offers a vibrant urban life and peaceful suburban living, making it an enticing place to reside. Spanning across ten major cities and thirteen counties, it stands as the largest metroplex in the south. With its extensive range of recreational parks, renowned dining scene, five professional sports teams to root for, and two bustling airports facilitating over 2,000 daily flights, Dallas/Fort Worth provides residents with a multitude of reasons to consider it an excellent place to call home.

US Heart and Vascular is seeking a Remote Care Management RN to join our Value Based Care Management team in Irving, TX. Night and Weekend Coverage (24/7 Triage Line) Position Summary: The focus of the Virtual Care Center is to provide a Call Us First approach to patient care, giving patients a dedicated line to get access to 24/7 triage, medical advice, and decrease unnecessary emergency room visits for patients. Our team collaborates directly with the patient’s primary cardiology team to coordinate care and achieve optimal patient outcomes.

Requires excellent clinical, communication and organizational skills Requires multitasking and critical analysis Must be able to function independently within the limits of the position Ability to function in a team environment Demonstrate knowledge and competence in basic cardiovascular technology, i.e., EKG, patient assessment and management of care, labs/hospital test results Able to demonstrate interpersonal skills to be approachable and understandable to patients, families, and care team members Minimum of an associate's degree in nursing; graduate of an accredited nursing program. Currently licensed to practice as registered nurse with a compact license or licensure for Alabama, Arizona, Kansas, Louisiana, and Texas Current BLS for Healthcare Providers certification Experience in cardiovascular setting preferred but not required

Under the general guidance of nurse manager, practice physicians and advanced practice providers, the RN is primarily responsible for the following: Receives incoming patient calls on dedicated line in assigned phone queue Triage calls to determine patient need as it relates to medical questions, care needs, medication management, and coordinating care Assess patient symptoms and medical needs, guiding patients to appropriate level of care within internal and external health care delivery organizations Provides patient and caregiver education related to health conditions and plan of care Engages primary cardiology team and care management team to coordinate care Outreaches to patients to follow up on care coordination and as directed by primary cardiology team Engages with on call provider for escalations outside of clinic hours Assists patient in scheduling appointments and getting medication refills Accurately documents in EHR per policy and in compliance with standard operating procedures

TEHC Healthcare Services

Remote Telephone Triage Nurse (RN) – After-Hours

Posted on:

July 6, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Florida

TEHC Healthcare, LLC Health is a 5-Star Skilled Home Care Company based in Rockledge, Florida. We are looking for an after-hours phone nurse triage. Our mission is to deliver high-quality clinical care and exceptional patient communication from the comfort of your own home. We are seeking experienced and compassionate Registered Nurses who thrive in a fast-paced, technology-driven environment and are passionate about making a meaningful impact in patients’ lives.

As a Telephone Triage Nurse, you will assess and triage patient concerns over the phone ensuring patients receive the appropriate care instructions or are referred to after-hours providers when necessary. This role is ideal for a highly experienced RN with a strong background in Skilled Home Health.

Current, unrestricted Florida Registered Nurse license. Minimum of 3 years of hands-on Skilled Home Care RN experience. Home Care supervisory experience (preferred). Experience working with Wellsky EMR (preferred). Excellent communication skills to effectively interact with patients, families, and healthcare teams. Dedicated private home office environment that complies with HIPAA. Reliable Phone and high-speed internet connection (no dial-up). Willingness to Friday 5:00 pm – Monday 8:30 am, every other weekend.

Conduct patient assessments over the phone with accuracy and empathy. Collaborate with healthcare professionals to coordinate patient care effectively. Provide support and education to patients and their families regarding care. Clearly communicate assessment findings and next steps to patients or parents/caregivers. Document detailed, accurate, and timely notes for each patient interaction. Coordinate follow-up care and ensure appropriate referrals are made. Effectively use Wellsky EMR to reschedule after hours tasks as needed. Maintain confidentiality and always adhere to HIPAA regulations.

St. Luke's University Health Network

Clinical Triage Specialist, Registered Nurse - Per Diem, Weekends, Evenings, Nights Remote Position

Posted on:

July 5, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Pennsylvania

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The Clinical Triage Specialist (CTS) (RN) - Access Center will compassionately deliver an exceptional patient experience and provide clinical support to CTS-MA team members by serving as a clinical resource. The CTS-RN is responsible for using nursing judgment in answering/returning patient calls related to direct care provided by the practices. When appropriate, the caller’s symptoms will be assessed and triaged using approved nursing protocols and guidelines to assist in obtaining the appropriate level of care and/or self-care advice.

EDUCATION: Graduate of an accredited nursing program required. Registered Nurse with current license to practice in the State of Pennsylvania or seeking Pennsylvania licensure through reciprocity required. TRAINING AND EXPERIENCE: Minimum 2 years recent clinical experience in a physician office, home health, critical care and/or emergency room is required. Strong communication skills Focused on compliance Demonstrates continuous growth Quality-driven Service-oriented Excels at time management Strong problem-solving skills Ability to work from home in accordance with the Network Work from Home Policy if needed.

Answers telephones, prioritizes clinical triage calls, follows clinical protocols, and coordinates services, as needed. Verifies patient demographic information and accurately enters the updated information into electronic health record. Serves as an escalation point for clinical patient issues and other POD team members requiring clinical support, and provides clinical advice based on clinical protocols and procedures. Manages and responds to escalated electronic patient messages whenever not answering inbound patient calls and uses clinical judgment to prioritize and accommodate patients. Creates a positive patient experience at every encounter, attempting to independently resolve any issues or concerns of the patient at the time of the phone call, within the scope of the role. Consistently meets productivity, schedule adherence, and quality standards as set by the Access Center. Utilizes all resources and guidelines at his/her disposal to effectively assess, prioritize, advise, schedule appointments, or refer calls when necessary to the appropriate medical facility or personnel. Accurately documents symptoms/complaints, nursing assessment, advice provided and patient/caller response. Partners with other Access Center teams/PODs and respective practice clinical team on behalf of the patient to assist with clinical concerns, medication refills, or scheduling appointments. Other duties as assigned.

St. Luke's University Health Network

Clinical Triage Specialist RN, Connect to Care, Per Diem, Evening,Nights and Weekends, Remote

Posted on:

July 5, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Pennsylvania

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The Patient Engagement Partner – Access Center role is critical to an exceptional patient experience. This role provides a positive patient experience during all encounters and is responsible for answering patient calls, scheduling appointments, working referral work queues, and assisting the patient with their current needs. The Patient Engagement Partner establishes and maintains ongoing partnerships with designated practice and clinical partners to ensure achievement of aligned goals. We are exclusively considering applications from candidates residing in Pennsylvania and New Jersey, particularly those in close proximity to St. Luke’s University Health Network locations. Candidate must be available for approximately 3-6 weeks of onsite training in Allentown, PA upon hire.

PHYSICAL AND SENSORY REQUIREMENTS: Requires sitting for extended periods of time (up to 8 hours at time). Requires continual use of fingers, writing and computer entry. Requires ability to hear normal conversation and good general near and peripheral vision. EDUCATION: High School diploma or equivalent required TRAINING AND EXPERIENCE: Previous general computer experience with data entry required Minimum 1-2 years of demonstrated customer service excellence in a contact center preferred Previous healthcare experience with medical terminology preferred Previous experience with electronic medical record (EMR) preferred Competencies required: Excellent communication, facilitation, and presentation skills. Focused on compliance Demonstrates continuous growth Quality-driven Service-oriented Excels at time management Ability to work from home in accordance with the Network Work from Home Policy if needed.

Answers incoming calls and performs a variety of actions including scheduling, rescheduling, or canceling appointments within established time frames and protocols in a fast paced, high volume Access Center environment. Determines how requests should be handled using expert questioning techniques to determine how a request should be scheduled, when to refer a call to a specific clinic or escalate the call to a nurse for immediate attention; coordinates services, as needed. Verifies and updates patient demographic and insurance information. Creates a positive patient experience at every encounter, attempting to resolve any issues or concerns of the patient at the time of the phone call, within the scope of the role. Manages and works referral work queues when assigned and provides supplemental inbound patient call support during high volume times using (and vice versa), and uses judgment to prioritize and accommodate patients, based on patient needs. Actively participates as a team member in resolution of problems as they are identified. Escalates any scheduling or insurance issue to the Patient Engagement Supervisor or Patient Engagement Manager to resolve. Consistently meets productivity, schedule adherence, and quality standards as set by the Access Center. Works with designated clinical partners to establish and maintain appropriate appointment scheduling protocols. Consistently acts to build positive relationships with our clinical partners. Other duties as assigned.

IntellaTriage

Remote Hospice Triage LPN- PT Evenings 3:30p12a rotating Sat & Sun 7:30-4p

Posted on:

July 5, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

LPN/LVN

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 nurses using client-customized protocols for patient-centered, compassionate care. We are growing rapidly and excited to support our clients’ nursing staff in the field by leveraging our outsourced team of nurses to manage after-hours care delivery. Our triage nurses become an extension of our clients’ care team, and they trust us to support them and their patients during their non-core hours.

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact LPN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence ** Must be willing to work 1 weekday shift 3:30p-12a CSt and rotating Sat & Sun 7:30p-4p CST

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

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

IntellaTriage

Remote Hospice Triage RN- PT 1-2 shift 3:30p-12a +rotating Sat & Sun 3:30p-12a

Posted on:

July 5, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 1-2 evening shift weekly 3:30p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 3:30p-12a CST

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

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

1st Call Triage

Phone Triage Nurse - Ob/Gyn

Posted on:

July 5, 2025

Job Type:

Role Type:

Triage

License:

RN

State License:

California

Remote Triage Nurse – OB/GYN (CA License Required) Overview: We are seeking an experienced and compassionate Triage Nurse with a background in OB/GYN outpatient or physician office care to join our remote clinical team. In this role, you will provide telephone triage and patient support for OB/GYN clinics, helping patients navigate symptoms, medication needs, and follow-up care—all from the comfort of your home. This is a critical role that ensures timely, appropriate care and supports continuity for women’s health patients.

Active California RN license (required) Minimum 2 years of recent OB/GYN clinical experience (physician office preferred) Strong assessment, communication, and critical thinking skills Comfortable working independently in a fast-paced remote environment EMR proficiency; prior experience with triage protocols (Schmitt-Thompson preferred) Experience with prenatal, postpartum, and women’s health populations

Assess patient symptoms over the phone and provide clinical guidance using standard protocols Triage calls based on urgency and escalate as needed Collaborate with providers and care teams to coordinate timely interventions Process medication refills, referrals, and prior authorizations Educate patients on routine care, prenatal/postpartum concerns, and follow-up needs Document all patient interactions clearly in the EMR Maintain compliance with clinical protocols and HIPAA standards

1st Call Triage

Pediatric Phone Triage Nurse

Posted on:

July 5, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Oregon

Triage Nurse – Remote Pediatrics (OREGON License Required) Full-Time | Work From Home | Pediatric Experience Required Overview: We are hiring a Registered Nurse with pediatric experience to join our remote triage team. This full-time, work-from-home role supports busy pediatric clinics by providing clinical phone assessments, symptom-based guidance, and care coordination. You’ll ensure timely and appropriate medical attention for children while working closely with providers and support staff.

Active RN license in Oregon (required) Minimum 2 years of experience in a pediatric physician office Strong communication, clinical decision-making, and patient education skills EMR proficiency and ability to work independently Triage protocol experience preferred (e.g., Schmitt-Thompson) BSN and remote nursing experience a plus

Conduct telephone assessments and triage pediatric patients using clinical protocols Prioritize care and escalate to physicians as needed Manage prescription refills, referrals, and prior authorizations Educate parents on home care, symptom monitoring, and follow-up instructions Accurately document all patient interactions in the EMR Provide safe, efficient support in a fast-paced virtual environment

Amedisys

Afterhours Triage Registered Nurse PRN Hospice

Posted on:

July 5, 2025

Job Type:

Role Type:

Triage

License:

RN

State License:

Tennessee

PRN- every other weekend and 4 holidays per year *must have multi-state RN license *Bilingual English/Spanish strongly preferred Day shifts- 10 hour shifts each day- must be flexible with times Are you looking for a rewarding career in homecare? If so, we invite you to join our team at Amedisys, one of the largest and most trusted home health and hospice companies in the U.S.

Current, unencumbered license to practice as a registered nurse in the state you are assigned to work. One year of experience as a registered nurse. Current CPR certification. Knowledge of physical, psychosocial, and spiritual needs of terminally ill patients and their caregivers. Must be comfortable with technology. Must be willing and eligible to obtain additional RN licenses in other states (reimbursed). Preferred: Previous hospice experience. Telephone triage experience. Spanish speaking.

Assesses physical, environmental, and emotional factors telephonically to determine hospice needs. Utilizes EHR, including the patient's plan of care to develop recommendations. Provides recommendations, patient/caregiver education/instructions and hospice support telephonically based on the situation and the plan of care. Collaborates with pharmacies, DME vendors and other agencies for effective patient management. Facilitates delivery or maintenance of provided medical equipment to meet patient needs. Assigns all visits, admissions and follow-up calls to on-call field staff (RN, LPN, HA, CH, SW) as needed. Submits accurate and detailed documentation in real-time to promote continuity of care. Utilizes a combination of agency resources and nationally recognized standards of practice to achieve excellent pain and symptom management and high-quality end-of-life care. Participates in agency performance improvement initiatives. Performs other duties as assigned.

SSM Health

Registered Nurse – Phone Triage, Pediatric Clinic

Posted on:

July 4, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

It's more than a career, it's a calling MO-REMOTE Worker Type: PRN Job Highlights: Department: Pediatric Clinic Schedule: PRN | M-F Day Shift | No Weekends or Holidays Starting Pay: 28.30+/hr. (Offers are based on years of experience and equity for this role.) Location: MO-Remote (Must Reside in Missouri) Job Summary: Provides direct nursing care in accordance with established policies, procedures and protocols of the healthcare organization.

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

Implements and monitors patient care plans. Monitors, records and communicates patient condition as appropriate. Serves as a primary coordinator of all disciplines for well-coordinated patient care. Notes and carries out physician and nursing orders. Assesses and coordinates patient's discharge planning needs with members of the healthcare team. May round with physician in an inpatient setting. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's Scope of Service. As an SSM Health nurse, I will demonstrate the professional nursing standards defined in the professional practice model. Uses the ANA Code of Ethics for Nurses to guide his/her response to the current and evolving health and nursing needs of our patients and our patient populations. Works in a constant state of alertness and safe manner. Performs other duties as assigned.

CVS Health

Utilization Management Nurse Consultant - Fully Remote

Posted on:

July 4, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

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

Position Summary Fully remote role in the USA. Requires Monday-Friday: 11:30am-8:00pm EST shift; 8:30am-5:00pm PST; or 9:30-6:00pm MST depending on the candidates time zone. Weekend/holiday coverage will occasionally be required. American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.

Required Qualifications: 1 year UM, concurrent review or prior authorization 5 years of clinical experience required 5 years Demonstrated to make thorough independent decisions using clinical judgement 5 Years Proficient use of equipment experience including phone, computer, etc and clinical documentation systems Required to attend the first 3 weeks on camera training required 100% participation during 8:30am-5pm Monday-Friday. A Registered Nurse that must hold an unrestricted license in their state of residence, with multi-state/compact privileges and have the ability to be licensed in all non-compact states. Preferred Qualifications: 1+ years Managed Care (MCO) preferred. 1+ years demonstrated experience working in a high volume clinical call center environment. Remote work experience. Education Associate's nursing degree (RN) minimum required. Bachelor's degree preferred. Anticipated Weekly Hours

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function Function in a clinical telephone queue working with providers to secure additional information for prior authorization review. CVS health requires eligible colleagues identified as permanent work from home teleworkers, who need to use the internet for work purposes are required to use a residential broadband service with speeds of at least 25 mbps/3mbps in order to ensure sufficient speed to adequately perform their work duties. Verification of services will include confirmation of a named internet service provider, multi-port modem, minimum download speed of 25 Mbps and minimum upload speed of 3 Mbps and the modem IP Address must not begin with the number 10. Please also note the following nuances regarding internet service: No Wireless equipment No Satellite No Contracts No business class lines Installation and monthly service costs are paid by the user up front.

UnitedHealth Group

Clinical Claims Review RN - National Remote

Posted on:

July 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Minnesota

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

As a Clinical Claims Review RN, you will conduct hospital bill audits by reviewing the medical record against the itemized bill to verify services were provided and documented. A hospital bill audit identifies overcharges, undercharges, unbundled items and applies client specific policies to their reviews. There will be a responsibility for scheduling on-site and off-site audits with flexibility to travel to a provider’s location when needed. This is a challenging and rewarding role for a RN with strong interpersonal and communication skills who likes independent, flexible, autonomous work. Should be detail-oriented and have a strong clinical background to conduct on-site and off-site hospital bill audits. Schedule: Monday – Friday, 8:00-5:00pm and potential travel to hospital locations for audit reviews within the region You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges

Required Qualifications: Associate’s degree (or higher) in Nursing Active and unrestricted RN license in the state of residence 2+ years of RN experience in an acute hospital setting Intermediate level of proficiency with Microsoft Office applications, including Word, Excel, and Outlook Reside within an hour away from the closest airport Ability to travel to hospital locations for audits (Overnight travel included) Preferred Qualifications: Bachelor’s degree in nursing (BSN) 2+ years of Medical Claims Review experience 1+ years of previous medical record review experience 1+ years of experience working in Auditing Ability to read and interpret medical business correspondence, procedure manuals, and specific plan documents. CPT & ICD-10 familiarity

Monitoring new case assignments Review medical records to verify services provided and charges are accurate – Identify overcharges, undercharges, and apply client specific policies Scheduling on-site and off-site reviews – work that is assigned, contact providers and schedule dates and times to perform onsite, travel onsite as needed and perform reviews Comply with HIPAA and other regulations regarding the confidentiality of patient information Ensuring charges are generated in the most cost-effective manner for the client 25% overnight travel to provider offices

WebTPA

Case Manager RN

Posted on:

July 4, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans.

Hours: Monday to Friday 8:00am to 5:00pm Central Time What is your impact? The RN Case Manager primary responsibility is to create, implement, and monitor treatment plans to assist patients/members in meeting their healthcare goals. You would use knowledge of healthcare and social services to assess needs and provide interdisciplinary care options in treatment planning for the member. This would include understanding the member's healthcare benefits and healthcare best practices needed for effective treatment planning.

5+ years related work experience with a professional background in clinical nursing and patient assessment. Related Bachelor’s degree or additional related equivalent work experience Graduate of an accredited school of nursing RN - Registered Nurse - State Licensure Compact State Licensure in good standing. Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices. Ability to collaborate with cross-operational areas within the organization. Ability to travel is approximately 10% of the time What We Prefer: Prior experience in utilization management or case management preferred, preferably within the managed care environment Intensive care or higher-acuity patient experience preferred. Knowledge of managed care in a self-funded employer population is preferred. Ability to identify problems such as underutilization or overutilization of services Ability to promote and maintain quality care through analysis

Case Management process includes assessing the member’s health status and care coordination needs. Can include inpatient review and discharge planning, as well as possible outpatient management. Contact with patient, family, physicians, additional health care providers, and community resources. Contact with provider business offices and with the employer/client may also be required. Identification of alternative treatment plans, which would have to be approved by all parties. These alternative care plans will be based on quality care within cost containment guidelines, allowing available claims dollars to be used in the most judicious manner possible. Assessment of the clinical status and resultant sequela to coordinate the most appropriate service to meet the individual’s health care needs. The Case Manager will then monitor the health status and the impact of the treatment plan for each client. The Case Manager will be responsible for altering the care plan as deemed appropriate by the dynamic, ever-changing client needs. Identification of services, resources, providers, and facilities that could best serve members in a timely and cost-effective manner, to promote optimum value for the client and reimbursement source. Development and implementation of Case Management goals, both short and long term, with documented care plans. Utilize technology/resources to evaluate the cost-effectiveness of the elected treatment plan, pre-implementation and post-implementation. This outcome measurement will be used in determining the effective results and in establishing future patient-centered care plans. Accurate and timely reporting as deemed appropriate by each client member. Medical record review to determine medical necessity of requested services. Interpreting individual health plans and authorizing/coordinating care in accordance with plan provisions.

HarmonyCares

Nurse Practitioner - Health Risk Assessments - Per Visit: Cook County, IL

Posted on:

July 3, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Illinois

HarmonyCares is one of the nation’s largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health and HarmonyCares Hospice. Our Mission – To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care. Our Shared Vision – Every patient deserves access to quality healthcare. Our Values – The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other.

The Nurse Practitioner delivers annual risk assessment in a residential setting or telehealth, within the scope of practice for a Nurse Practitioner, as delegated by the Collaborative Physician

Required Knowledge, Skills, and Experience: Active/unrestricted nurse practitioner license to practice in coverage states Board certification in one of the following: American Nurses Credentialing Center (ANCC), American Association of Nurse Practitioners (AANP) or National Commission on Certification of Physician Assistants (NCCPA) Active CPR Certification Current enrollment in Medicare/Medicaid Must maintain a valid driver’s license and good driving record Outstanding EHR skills Preferred Knowledge, Skills and Experience: Geriatric training/experience Skill in teamwork and maintaining effective working relationships with patients, medical staff, and the public Conditions of this role to be aware of: Adaptability to differing weather conditions and patients’ home/residential environments Full range of body motion including handling/lifting patients. Manual and finger dexterity, eye-hand coordination, normal visual acuity, normal hearing, standing, bending, walking and stair climbing Regular lifting/carrying items weighing up to 50 pounds Ability to ride in automobile or van up to 150 miles daily in urban and/or rural settings. Ability to drive, if necessary

Conduct comprehensive in-home health risk assessments to identify all active and chronic disease conditions, as well as determine all physical, mental, and social needs present at the time of the visit Takes history, examines, determines diagnoses. Provides written documentation of patient visit, per NCQA standards Takes patient vital signs, as necessary. Places case management referrals and communicates with PCP as necessary. Communicates with patients, caregivers, agency nurses, other providers and vendors as necessary to assure proper diagnosis. Performs all clinical duties while observing OSHA Universal Precautions Maintains patient confidentiality Attends required meetings and in-services and participates in committees, as requested Participates in professional development activities and maintains professional licenses and affiliations

IntellaTriage

Remote Hospice Triage RN- FT 10:30p-7a rotating Sat & Sun 11:30p-8a CST

Posted on:

July 3, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence Part- time schedule: Work a minimum 3 shifts weekly 10:30p-7a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 11:30p-5a CST

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

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

Medasource

Chart Conversion RN - Weekends

Posted on:

July 3, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Chart Conversion RN - weekends only Location: 100% remote - equipment provided to you Start: ASAP Shift: Saturday and Sunday - 8:00a - 8:00p EST Length: Through the end of December 2025

Indiana RN license or Compact/Multi-state RN License Proficient in MCG and InterQual 1+ years of experience in a UR/UM role or similar

We are seeking a detail-oriented Registered Nurse with a Compact or Indiana RN license to join our team and assist with a Chart Conversion project. This position focuses on reviewing and refining patient charts to ensure accurate conversion to inpatient status. Proficiency in MCG and InterQual criteria is essential. Ideal candidates will have strong clinical judgment and experience with utilization review.

Medix™

Utilization Management Nurse - 216041

Posted on:

July 3, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Illinois

Medix is currently hiring RN UM nurses to do outpatient reviews for a health plan. We are looking for someone that can start July 14th and be comfortable using their own equipment. The position is a contract with potential to hire.

The Health Plan provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity reviews on prior authorization requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.

Current licensed Registered Nurse (RN) Must retain active and unrestricted licensure throughout employment. Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint) Must be able to work independently. Adaptive to a high pace and changing environment. Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review. Working knowledge of URAC and NCQA. 2+ years’ experience in a UM team within managed care setting. 3+ years’ experience in clinical nurse setting preferred. TPA Experience preferred.

Perform prospective utilization reviews and first level determinations for members using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures. Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments. Collaborates with healthcare partners to ensure timely review of services and care. Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed. Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate. Triages and prioritizes cases and other assigned duties to meet required turnaround times. Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements. Experience with outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.

Concierge Home Care

Virtual Care Nurse, Weekends Fri-Sun 8am-8pm

Posted on:

July 3, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Florida

At Concierge Home Care, we believe in the power of home health care to change lives—for patients and team members alike. Our mission, “Caring for people who care for people,” is the foundation of who we are and what we do. Guided by our values—Integrity, Caring, Quality, Service, Innovation, and Team—we are dedicated to delivering compassionate, high-quality care that empowers patients to heal in the comfort of their own homes. Since we opened our doors in 2015, Concierge Home Care has grown to serve over 57 counties across Florida, offering incredible opportunities for growth and career advancement.

Based in: supporting high-risk patients remotely.

Active and unencumbered Florida Licensed Practical Nurse (LPN) license (required). Medicare OASIS documentation proficiency (required). Minimum of two (2) years of experience as a home health clinician. Strong clinical background with experience in triage and hospitalization prevention (required). Proficiency in Microsoft Office (preferred).

Support the Complex Care Team by providing virtual care to patients at high risk for hospitalization. Conduct virtual visits to assess patient needs and provide education on managing medical conditions. Monitor telehealth systems and track patient data to identify hospitalization risks. Collaborate with the care team to facilitate patient care across the continuum of services. Attend rehospitalization-related meetings, conferences, and symposiums to enhance patient care strategies. Assist in developing and implementing best practices for virtual care. Manage virtual care and telehealth systems through assessments, education, and data tracking.

Concierge Home Care

Virtual Care Nurse

Posted on:

July 2, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Florida

At Concierge Home Care, we believe in the power of home health care to change lives—for patients and team members alike. Our mission, “Caring for people who care for people,” is the foundation of who we are and what we do. Guided by our values—Integrity, Caring, Quality, Service, Innovation, and Team—we are dedicated to delivering compassionate, high-quality care that empowers patients to heal in the comfort of their own homes. Since we opened our doors in 2015, Concierge Home Care has grown to serve over 57 counties across Florida, offering incredible opportunities for growth and career advancement.

Based in: supporting high-risk patients remotely.

Active and unencumbered Florida Licensed Practical Nurse (LPN) license (required). Medicare OASIS documentation proficiency (required). Minimum of two (2) years of experience as a home health clinician. Strong clinical background with experience in triage and hospitalization prevention (required). Proficiency in Microsoft Office (preferred).

Support the Complex Care Team by providing virtual care to patients at high risk for hospitalization. Conduct virtual visits to assess patient needs and provide education on managing medical conditions. Monitor telehealth systems and track patient data to identify hospitalization risks. Collaborate with the care team to facilitate patient care across the continuum of services. Attend rehospitalization-related meetings, conferences, and symposiums to enhance patient care strategies. Assist in developing and implementing best practices for virtual care. Manage virtual care and telehealth systems through assessments, education, and data tracking.

Veracity Software Inc

RN Care Manager

Posted on:

July 2, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

California

The definition of Veracity is accuracy and habitual truthfulness. This truly defines our brand in simplistic terms. At Veracity, we believe in doing everything in the ‘Right Way’, which means you have to challenge your own innovations and solutions all the time. Our strength lies in our employees, and with the right blend of business and technical expertise, we set the bar high for Veracity. From inception, Veracity focused on building cloud based SaaS solutions while using the latest and most advanced technology stack. We have delivered cloud based customized solutions and services to various clients across both North America and India. We have a global headquarter in Woodbridge, NJ while our offshore office is in Pune, India. We believe in bringing Global talent together, which helps us in delivering cost effective, yet highly scalable and efficient solutions. With the vision of trying to be one of the trusted IT partners as well as one of the most respected solution providers with an onsite/offshore model, Veracity is equipped with the right set of highly skilled individuals who have expertise in delivering the most effective business services and solutions for our clients. Veracity’s mission is to become the Trusted IT Partner for various businesses across globe.

RN Care Manager *F/T Variable* Santa Monica, California Full Time RN Care Manager with our Care Management Team at our Cedars-Sinai Tarzana Medical Center in Tarzana, CA. This is a full-time position that will work 8-hour Variable shifts. Must have availability to work 8 am - 4:30 pm or 4:30 pm – 1 am with weekend rotations. Ideal Candidate Holds an active California RN license Have a Bachelor's Degree in Nursing (BSN) Minimum 2 years experience working as a RN in a hospital / inpatient setting Minimum 2 years experience working as a RN directly in Case Management or Discharge Planning in a hospital setting

Bachelor's Degree Nursing. Or equivalent educ/experience All Registered Nurses without a minimum of a bachelor's degree in nursing must obtain a bachelor's degree in nursing or higher within 3 years of hire. Any previously agreed upon effective date for obtaining a bachelor's degree in nursing between individual and facility will remain in effect. Any collective bargaining contract with specific time frames for obtaining a bachelor's degree in nursing will supersede the above point and will remain in effect. Exceptions will be considered on a case-by-case basis at each ministry by the Director of Care Management in consultation with the Human Resources. RNs employed prior to 8/2021 are encouraged to obtain a bachelor's degree or higher degree in Nursing, but obtaining the degree will not be a condition of employment. Upon hire: California Registered Nurse License 2 years' Experience in Healthcare related field (Acute, Ambulatory, Post-Acute, etc.) 2 years' Experience in Case Management (Care Coordination or Utilization Management) or successful completion of the Transitions in Practice (TIP) program for Care Manager. TIP candidates must have experience in same type of nursing unit in which the CM position is available. Preferred Qualifications: Master's Degree Nursing or Healthcare related field. Upon hire: Certification in Case Management (ACM or CCM)

Fallon Health

Transitions of Care Coordinator- RN - Flexible/remote

Posted on:

July 1, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Massachusetts

Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality. Fallon Health’s Summit ElderCare® is a Program of All-Inclusive Care for the Elderly–PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE— in the region.

The Transitions of Care Coordinator uses a multidisciplinary approach to ensure that SE participant transitions of care to and from inpatient facilities are appropriate, timely, and successful. In collaboration with the SE IDT ascertains that participants are in receipt of high quality cost efficient care and outcomes

Education: Associate of Science in Nursing, Bachelor of Science in Nursing (preferred) License/Certifications: Licensed by the Commonwealth of Massachusetts Board of Registration in Nursing as a Registered Nurse. Valid Driver’s License CCM or similar certification desired Experience: Three to five years nursing experience with one year experience working with a frail or elder population. Recent case management or utilization management experience and knowledge of criteria for medical necessity determination preferred. Must possess strong interpersonal, analytical and communication skills.

Attends daily IDT meetings to discuss inpatients and suggest discharge plans Utilize a checklist to ensure that the components of a safe transition of care occur Communicates daily with primary team members to address potential barriers to discharge or transition to lesser care setting Participates in family meetings as needed Participates in contracted facility case management meetings to address potential barriers/facilitate successful discharge planning. Collaborate with facilities, IDT members and others involved in participants plan of care to ensure safe, efficient transitions from facility to facility and to the home setting Facilitate pertinent record exchange to and from facilities for continuity of care and medication reconciliation Acts as a liaison between facilities and IDT members to convey progress Access resources out of network to meet participant needs Utilize Collective Medical to track transitions in real time Supports the fundamental mission of the Summit ElderCare program Determines tier of service at subacute facilities Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services Recognizes, identifies, and implements appropriate opportunities to help meet Utilization goals Knowledge of managed care, quality, and risk management principles Participates in the SE Utilization Committee Generate Ad Hoc request when required Concurrent and retrospective review utilizing a multitude of systems and electronic records Enters authorizations in applicable systems to ensure that claims are adjudicated efficiently Documents all inpatient care transitions and case management progress notes within the electronic health record Generate Transitions of Care Templates to accurately reflect transitions and level of care Track Vendor Denials Identify quality/risk factors in continuum of care and report to Medical Director and Quality Team Utilize clinical judgement and critical thinking to suggest alternative measures for provision of care

ExamWorks

Nurse Planner (29704)

Posted on:

July 1, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Georgia

The ExamWorks Group platform, family company services, applications and portals for the management of independent medical claim review are the assets of choice among claims professionals. Our global service network and private cloud-based computing platform connects medical professionals, case managers, and claimants to property, casualty, and disability insurers, third-party administrators, and legal professionals so they can provide evidence-based independent expert medical opinions and analysis for claims resolution. Secure, streamlined, automated, customized, independently audited and accredited workflows assist clients to manage costs by verifying the validity, nature, cause, and extent of claims, identifying fraud and providing fast, efficient and quality IME services.

Are you are RN and passionate about healthcare? Do you want to contribute to a dynamic, values-oriented workplace? If so, you’ll fit right in with the team at ExamWorks Clinical Solutions (ECS). The Nurse Planner works autonomously to develop any and/or all of the following: Life Care Plans, Medical Cost Projections, Limited Medical Cost Projections, Medicare Set-Aside Allocations, Legal Nurse Reviews, Complex Nurse Reviews, Bill Reviews and other reports as needed within their scope of licensing and certifications. This is a full-time position, Monday-Friday, 8am-5pm.

Education and/or Experience: Minimum of an Associates degree or equivalent certification preferred. A minimum of two years workers’ compensation and/or case management experience preferred. A minimum of one year experience in Medicare Set Asides required. Certificates, Licenses, Registrations: Will recognize any of the following: Active unrestricted Nursing license (including but not limited to RN, NP LVN, LPN). Active unrestricted Adjuster license. Certification in Medicare Set Asides and/or certifications in Life Care Planning or Legal Nurse Consulting. QUALIFICATIONS: Knowledge of the disability and workers' compensation industry including rules and regulations and a full understanding of Medicare rules and regulations. Must be able to adequately operate a general computer, fax, copier, scanner, and telephone. Must have adequate knowledge of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet. Ability to demonstrate critical thinking and problem solving skills. Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed. Must be able to work independently, prioritize work activities and use time efficiently. Ability to concentrate and multitask in a fast paced work environment. Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met. Must be able to maintain confidentiality. Must be able to demonstrate and promote a positive team -oriented environment. Must be able to work well under pressure and/or stressful conditions. Must possess the ability to manage change, delays, or unexpected events appropriately. Must be able/willing to work on a flexible schedule when needs arise. Must possess excellent skills in English usage, grammar, punctuation and style. Demonstrates reliability and abides by the company attendance policy. LANGUAGE/COMMUNICATION SKILLS: Ability to read, analyze and interpret common to complex correspondence, medical records, various reporting records, legal contracts and/or related case documents. Ability to write clearly and informatively to all required audiences and edit own work for appropriate spelling and grammar. Ability to respond appropriately and professionally to all inquiries or complaints from clients, physicians, upper management, regulatory agencies, and/or members of the business community. Ability to effectively present information one-on-one, in small groups, and/or clients or vendors of the company. Demonstrates reliability and abides by the company attendance policy. LANGUAGE/COMMUNICATION SKILLS: Ability to read, analyze and interpret common to complex correspondence, medical records, various reporting records, legal contracts and/or related case documents. Ability to write clearly and informatively to all required audiences and edit own work for appropriate spelling and grammar. Ability to respond appropriately and professionally to all inquiries or complaints from clients, physicians, upper management, regulatory agencies, and/or members of the business community. Ability to effectively present information one-on-one, in small groups, and/or clients or vendors of the company. PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This position generally consists of: Sitting 5-7 hours per day during office time requirements. During day travel sitting, standing and/or walking for blocks of time may be required. Occasionally climbing one or more flight of stairs Occasionally lifting and/or carrying up to 10 lbs. Occasionally pushing/pulling up to 10 lbs. Occasionally subject to bending, squatting or twisting. WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Extended hours are occasionally required beyond the regular eight (8) hour work day. Works in a home office environment and/or occasionally from an office environment. The noise level in the work environment is usually moderate, but may vary during travel.

Collects, reviews and analyzes health data from medical records and/or other sources as provided. Identify future medical needs utilizing medical standards of care and guidelines, in addition to historical trend of care. Work autonomously and collaborates with all company personnel as needed; including communicating with the accounts and attorneys as needed. Maintain a quality work product evidenced by acceptable quality scores/score cards. Participate in company orientation, management meetings and/or conference calls as required to improve self-knowledge and/or for the improvement of the company. Attend all scheduled conference calls as mandated by management. Maintain any required credentials and adhere to all codes of ethics required by these credentials. Ensures all federal Centers for Medicare and Medicaid Services (CMS) requirements and/or state mandates are adhered to at all times. Provides insight and direction to management on report quality and compliance with all company policies and procedures, client specifications, URAC and CMS guidelines. Promote effective and efficient utilization of company resources. Participate in various educational and or training activities as required. Perform professional duties as assigned by the Manager or upper management.

MDA Edge

Licensed Practical Nurse (LPN)

Posted on:

July 1, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Iowa

Our objective is to establish an exceptional ecosystem by connecting individuals, technology, and prospects through the application of human intelligence. MDA Edge is a process-oriented company and our expertise lies in providing comprehensive Workforce Solutions, specifically focusing on Contingent Staffing, Bulk/Project Staffing, RPO/KPO/BPO, and Direct Hire services. We cater to a wide range of industries, including Infrastructure Consulting, Engineering Consulting, IT Consulting, Healthcare, Life Sciences, Pharmaceutical Consulting, Consumer Goods, Education, Transportation & Logistics, Media & Entertainment, Telecom, BFSI, Manufacturing, Utilities & Energies, and Corporate Recruitment. Moreover, we have developed a dedicated focus on Government Consulting. Our company prides itself on a meticulous approach, ensuring that we meet your specific needs. We have established a robust network of highly skilled professionals who are readily available to fulfill your requirements. With a strong commitment to excellence, we consistently deliver exceptional results for clients in India, Denmark, France, Germany, Ireland, Japan, Spain, Thailand, the USA, Canada and Mexico, with ongoing expansion efforts to serve more new regions in the near future. We consistently uphold the highest standards of quality by providing resources, time, and materials to design, implement, and support efficient operations for organizations. Our track record of measurable accomplishments demonstrates our commitment to cultivating a balanced work and societal ecosystem. Our continuous growth, successful customer engagements, and strong customer retention exemplify our achievements. Furthermore, our passion lies in streamlining complex business processes through the application of suitable technology, which has been integral to our success. We extend an invitation to join our dynamic workplace, offering rapid growth opportunities, excellent employee benefits, and a positive work-life balance.

We are seeking a dedicated and skilled Licensed Practical Nurse (LPN) to join our Medical Unit 4E team. The ideal candidate will demonstrate exceptional patient care skills, proficiency in telemetry, and a strong understanding of Epic systems. This role involves distributing medications, assisting with care, and collaborating with a multidisciplinary team to ensure optimal patient outcomes. Weekly Hours: 36 hours

Education/License: Active and valid BLS and LPN license. Experience: Minimum of 1 year of relevant clinical experience. Skills: Proficiency in Epic and telemetry, with a commitment to providing competent and compassionate patient care.

Assess and evaluate patients' physical, psychosocial, environmental, and educational needs, collaborating with the team to achieve desired outcomes. Support the development and implementation of care plans, including discharge planning, by applying critical thinking and clinical expertise. Facilitate patient and family education as outlined by the Registered Nurse (RN), tailoring learning opportunities to individual needs. Adapt proactively to changes in the healthcare environment by embracing new technology and processes. Communicate effectively with RNs and multidisciplinary caregivers regarding changes in patient conditions. Attend departmental meetings and educational opportunities with a required participation of 80%, including in-person and webinar attendance. Maintain confidentiality, adhering to HIPAA regulations and safety protocols. Document patient information accurately in the electronic and/or paper medical record systems. Delegate and receive tasks appropriately, based on patient needs and scope of practice. Participate in process improvement teams and support initiatives enhancing patient satisfaction and clinical outcomes. Take responsibility for personal and professional development, setting yearly performance goals and advancing clinical expertise. Serve as a steward of hospital resources, meeting unit productivity expectations and supporting staffing needs across departments when required.

CVS Health

Utilization Management - Specialty Medical Prior Authorization - LPN

Posted on:

June 30, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Texas

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

Must have Prior Authorization experience Will work from home office Position Summary: You will provide processing and communication of specialty medication prior authorization (PA) requests reviewed by the Aetna Specialty Medical Prior Authorization department. Reporting to the Pharmacy Operations Manager, you will work with physician office staff and customer service, admissions and pharmacy operations departments to communicate prior authorization status. You will also oversee fax processing and provide telephone call assistance for prescriber office staff, pharmacies and members based on program criteria.

Required Qualifications: Must have active, current and unrestricted Licensed Practical/Vocational Nurse in state of residence 2+ years of LPN/LVN clinical experience with experience in Prior Authorization 1+ years of experience using Microsoft Teams, including Word, Excel and Outlook Must be willing and able to work Monday through Friday, Sunday through Thursday or Tuesday through Saturday between hours of 8am to 8pm CST zone Preferred Qualifications: 1+ years prior work experience Prior work experience working prior authorizations in Novologix Excellent interpersonal skills Demonstrated problems solving ability and attention to detail Ability to work effectively in a team environment with great dependability Excellent oral and written communication skills Ability to quickly assess and adapt to constantly changing situations, phone and PC use Required to possess a high mental agility and alertness Ability to effectively communicate with pharmacists, other clinical colleagues, healthcare professionals and members Ability to effectively prioritize work while exhibiting a high level of urgency with all calls and assignments Ability to effectively train and mentor representatives on the PA team Education: Diploma or Certification from approved LPN/LVN program

Responsibilities include answering inbound phone calls, processing cases, loading authorizations, and making follow-up phone calls. Maintaining complete and accurate, documentation of all necessary information is necessary and will involve computer system data entry, data management, and reporting. Review criteria-based prior authorizations following policy and procedure Provide on-call after hours nurse availability for urgent PA requests Provide internal nurse support to the PA team and member services department Refer cases not meeting clinical criteria to the Pharmacist and MD team(s). Shift priorities while exhibiting a high level of urgency with all calls and assignments. Excellent verbal and written skills. You will work with pharmacists, other clinical colleagues, healthcare professionals and members. Follow all prior authorization procedures to guarantee an accurate process on each prior authorization. Complete other PA assignments as delegated by the PA leadership team.

OpenLoop

Remote Registered Nurse (RN) - (Telehealth, Contract)

Posted on:

June 30, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

OpenLoop is a health tech leader delivering full-stack, white-labeled clinical support to companies scaling virtual care services across the nation. Founded with the vision to bring healing anywhere, OpenLoop’s solutions are thoughtfully designed to simplify telehealth delivery across an expansive array of specialties, in all 50 states.

Looking to practice on your terms? Or to pick up a few extra shifts to boost your savings from the comfort of your home? As a Remote Registered Nurse (RN) with OpenLoop, you can do what you love from home with flexible contract part and full time schedules. About the Remote Registered Nurse (RN) Position This is an incredible work opportunity in a fast-paced, innovative company that puts the patient at the center. This role is for a clinical care professional who delivers nursing care using telemedicine modalities exclusively, including video, phone, connected devices, and asynchronous messages (chat/email). Remote Registered Nurses are members of an interdisciplinary care team working as staff clinicians with OpenLoop. As a, you'll be at the forefront of healthcare delivery, providing vital support to patients over the phone. Your role will involve assessing patient needs, offering medical advice, coordinating care plans, ensuring optimal health outcomes, and providing an outstanding patient experience. If this sounds like a team you want to join - we'd love to connect! This position offers an opportunity to make a meaningful impact on patient satisfaction and quality of care while contributing to the continuous improvement of healthcare services. If you are a dedicated RN with a passion for patient advocacy, excellent communication skills, and love using technology to work in fast-paced environments, , we encourage you to apply for this rewarding position.

Must have an Active and Unencumbered Compact Registered Nursing license, preference for additional licensure This licensure MUST be reflected on a current CV or provided upon application to be considered MUST live in the state in which the Compact was granted to be considered Must have Associate degree in Nursing (A.D.N) from an accredited school of nursing required; Bachelor of Science in Nursing (B.S.N): Registered Nurse (RN) license At least 3+ years of clinical experience in settings such as telemedicine, acute care, or case management Strong interpersonal and communication skills, with the ability to empathize with patients and effectively convey information Above average proficiency in using telecommunication technology and electronic health record (EHR) systems Commitment to providing high-quality patient-centered care. Ability to work independently and as part of a team in a fast-paced environment. Excellent organizational skills and attention to detail, with the ability to manage multiple tasks simultaneously in a fast-paced environment Minimum of 20-hours per week availability required Full-time, evening, and Weekend availability preferred Timely and professional Telemedicine or virtual care experience a plus Fluency in Spanish (both written and spoken) is a plus

Conduct outbound calls to patients who have been discharged from the hospital within a specified time frame. Conduct outbound calls to communicate patient lab results. Receive inbound calls from patients who have clinical questions or concerns. Provide medication administration support, recommendations for managing side effects, and care plan support. Engage with patients in a courteous and empathetic manner, demonstrating sensitivity to their healthcare needs and concerns. Complete detailed documentation of patient care interactions in the ticketing system and electronic medical record. Collaborate with healthcare providers, clinical leaders and other team members to follow up on any issues or discrepancies identified during the survey process. Maintain confidentiality and adhere to HIPAA regulations when handling patient information. Participate in ongoing training and professional development activities to stay updated on survey protocols, healthcare regulations, and best practices. Meet productivity targets and quality standards established by the organization.

Apidel Technologies

Case Management Nurse

Posted on:

June 30, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Ohio

Apidel is a WMBE (Women & Minority Based Enterprise) & E-verified Global Staffing company. Vision To change the staffing landscape, to create value, make a difference & evolve to be a preferred staffing organization by all. Mission To be the leading staff augmentation organization preferred by client organizations as a preferred vendor & trusted by job-seekers as a go-to staffing firm. We are governed by core principles & values; as Client Value Creation, Diversity, Teamwork, Persistence, Hard-work, Humility & Integrity. Our network of recruitment specialists in India & the U.S. allows us to stay updated on local market conditions. Our recruiters work on client needs in their specific areas & make it their goal to fill open positions with the right candidates. Result: a mutually beneficial appointment where both; client & talent are confident of finding the best fit. Advantage Apidel is appreciated by all its clients for its dedication & singular vision to bring the best talents to the table. Our ability to look beyond the standard client / staffing firm bond; & as such work together to be partners for the foreseeable future has created our unique identity in the eyes of our clients. At almost all of our engagements; we have managed to make a mark with our clients to an extent of being a Top Staffing Agency within the first 3 months of inception.

Job Title: Nurse Case Manager Location: 70% travel role and positions located in Hamilton County, Butler County, Clermont County, Warren County (Cincinnati Area) Schedule: Monday to Friday (8am EST - 5pm EST) Contract Duration: 3 months contract role Job Summary: The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

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

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

1ST CALL TRIAGE LLC

Telephone Triage Registered Nurse

Posted on:

June 30, 2025

Job Type:

Contract

Role Type:

Triage

License:

RN

State License:

California

We are seeking a highly skilled Registered Nurse with ob/gyn clinical to join our remote telephone triage team. As a remote triage nurse, you will be responsible for providing exceptional patient care over the phone for busy ob/gyn clinics. In addition, you'll assist with medication refills, prior authorizations, referrals, and other patient needs. Your primary goal will be to ensure that patients receive the appropriate medical attention they need in a timely and efficient manner. You will work closely with physicians and other healthcare professionals to provide the best possible quality care to patients. You must have a California nursing license for this position.

Minimum Qualifications: Active Registered Nurse license - California Minimum of 2 years of experience in a clinical setting Experience caring for ob/gyn patients Excellent communication and interpersonal skills Ability to work independently and as part of a team Proficiency in electronic medical records (EMR) Preferred Qualifications: Bachelor's degree in Nursing Experience in remote patient care, telephone triage Experience utilizing standard protocols to guide care advice, Schmitt-Thompson protocols Experience working with diverse patient populations across the lifespan Skills: As a remote triage nurse, you will utilize your exceptional communication and interpersonal skills to provide remote patient care and telephone triage. You will also use your proficiency in electronic medical records (EMR) to maintain accurate and up-to-date patient records. Your ability to work independently and as part of a team will be crucial in collaborating with physicians and other healthcare professionals remotely in a busy face-paced environment. Additionally, your experience in remote patient care and telephone triage will be beneficial in providing the best possible care to our patients. This is a 1099 contract position. You must be available between the hours of 8-5 PST Monday - Friday. 8-10 hours per week

Conduct remote patient assessments and provide telephone triage to patients in need of medical attention Collaborate with physicians and other healthcare professionals Process prescription refills and prior authorizations for medications Maintain accurate and up-to-date patient records Provide patient education and counseling on various health topics Adhere to all relevant healthcare regulations and guidelines

Froedtert Health

RN SNF UTILIZATION REVIEW, POST ACUTE CARE

Posted on:

June 30, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

The Froedtert & the Medical College of Wisconsin regional health network is a partnership between Froedtert Health and the Medical College of Wisconsin supporting a shared mission of patient care, innovation, medical research and education. Our health network operates eastern Wisconsin's only academic medical center and adult Level I Trauma center engaged in thousands of clinical trials and studies. The Froedtert & MCW health network, which includes ten hospitals, nearly 2,000 physicians and more than 45 health centers and clinics draw patients from throughout the Midwest and the nation.

EXPERIENCE DESCRIPTION: A minimum of 3 years of acute care nursing experience is required; Prior utilization management or case management experience is required. A minimum of 5 years of acute care nursing experience is preferred. Experience with Interqual, MCG care web QI or Indicia evidence based guidelines is strongly preferred. EDUCATION DESCRIPTION: Bachelor's Degree in Nursing is required. SPECIAL SKILLS DESCRIPTION: Knowledge of Medicare guidelines for skilled nursing needs. Knowledge of skilled nursing facilities care delivery model. LICENSURE DESCRIPTION: Requires current state of Wisconsin Registered Nurse License or a Multi-state Nursing License from a participating state in the NLC (Nurse Licensure Compact). MCG certification is preferred. Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification preferred.

Assumes responsibility for assessing a patient's functional status upon skilled nursing facility admission and weekly to determine the optimal length of stay based on therapy goals, nursing care needs and other clinical factors directly related to the rehabilitation plan and aligns expectations of the skilled nursing facility multidisciplinary team, patient and families for discharge planning. Refers cases to the physician advisor consult as needed. Facilitates communication with the multidisciplinary team as it relates to the patient and identified treatment plan. Assure patients’ progress toward discharge goals and assists in resolving barriers. Engages with patients and families on identified recovery goals, length of stay and discharge planning activities initiated by the skilled nursing facility to support a successful transition of care. Works in accordance to established policies and procedures to ensure optimal patient outcomes. Has the ability to work with variable service lines and with multiple care teams. Other duties as assigned.

Atrius Health

After Hours Pediatric Triage RN Evenings/Weekends/Holidays

Posted on:

June 30, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Massachusetts

Atrius Health/Part of Optum, an innovative healthcare leader, delivers connected care for more than 690,000 adult and pediatric patients at 30 medical practice locations in eastern Massachusetts. Atrius Health’s 645 physicians and PCPs, along with 420 additional clinicians, work in close collaboration with hospital partners, community specialists and skilled nursing facilities. Our vision is to transform care to improve lives. Atrius Health/Part of Optum provides high-quality, patient-centered, coordinated, and value-based care to every patient we serve. Through shared decision making, respect, understanding and trust with every patient, Atrius Health/Part of Optum enhances health and enriches lives. Through its partnership with Optum, a leading national value-based care system, Atrius Health continues its longitudinal growth in the Massachusetts healthcare provider and delivery market.

Under the direction of the Clinical Director, Nurse Leader or designee, the professional licensed registered nurse provides patient centric, after-hours phone and/or telehealth support for all Atrius pediatric patients and their caregivers.

EDUCATION/LICENSES/CERTIFICATIONS: Graduate of a state-approved school of nursing, Bachelor of Science in Nursing (BSN) preferred Possess a current RN license to practice professional nursing in the Commonwealth of Massachusetts American Heart Association Basic Life Support (BLS) required EXPERIENCE: Minimum of 2 years of direct patient care within an acute care or primary care setting. Experience with an electronic medical records system required. REQUIRED HOURS: Full time remote Pedi RN 3pm-11:30pm AND 3.0 FTE for adult RN 3pm-11:30, with an every other weekend requirement and a holiday rotation requirement. Adult 8am-8pm alternating weekend positions and see what we get ,this should be an internal and external posting. Holiday rotation requirements for all positions in Telecom. SKILLS: Strong critical thinking, problem solving, interpersonal and patient interviewing skills. Remote work includes strong comfort level working independently with technology proficiency. Systems include but are not limited to Epic Hyperspace EMR, Avaya phone system, Outlook, QGenda scheduling, and pdf documentation management. Remote workers must adhere to all Atrius policies irrespective of remote status. Proficient ability to interpret clinical information, assess the effectiveness of treatment, identify actual and or potential acute changes, develop, and implement a plan of care. Recognize when additional support is needed with clinical decision making and use resources appropriately, efficiently, and safely within the RN scope of practice. Demonstrate ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands. Demonstrate excellence in practice, communication, documentation, and cost-effective care utilization. Maintain high patient satisfaction. Support and collaborate with colleagues to work effectively as a team. REMOTE REQUIREMENTS: Home internet capability must include10 Megabit per second and is supplied by employee.

This position is responsible for effective triage, acuity leveling, age-appropriate nursing care/education, and disposition management for pediatric patients within the primary care, and limited specialty service lines. The RN utilizes the nursing process and adheres to current standards of nursing practice. The RN communicates and coordinates effectively with all entities involved in the care of the patient to promote safe and high-quality care. The RN practices critical decision-making using evidence-based nursing practice.

Atrius Health

After Hours Adult Triage RN Evenings/Weekends/Holidays - Part Time - Remote

Posted on:

June 30, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Massachusetts

Atrius Health, an innovative healthcare leader, delivers an effective system of connected care for more than 690,000 adult and pediatric patients at 30 medical practice locations in eastern Massachusetts. Atrius Health’s 645 physicians and primary care providers, along with 420 additional clinicians, work in close collaboration with hospital partners, community specialists and skilled nursing facilities. Our vision is to transform care to improve lives. Atrius Health provides high-quality, patient-centered, coordinated, cost effective care to every patient we serve. By establishing a solid foundation of shared decision making, understanding and trust with each of its patients, Atrius Health enhances their health and enriches their lives. Atrius Health is part of Optum, a health services company focused on building the leading value-based care system in the country.

EDUCATION/LICENSES/CERTIFICATIONS: Graduate of a State-approved school of nursing, Bachelor of Science in Nursing (BSN) preferred. Possess a current license to practice professional nursing in the Commonwealth of Massachusetts. American Heart Association Basic Life Support (BLS) required. Advanced Cardiac Life Support (ACLS) may be required based on specialty. EXPERIENCE: Strongly prefer minimum of 2 years of RN experience. Experience with an electronic medical records system required. SKILLS: Must exhibit strong critical thinking, problem solving, interpersonal and patient interviewing skills. Highly motivated and self-directed. Possesses ability to interpret clinical information, assess the implication of treatment and develop and implement a plan of care. Demonstrates ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands. Is up to date with current standard of nursing care in Specialty. Demonstrates excellence in practice, documentation and cost effective care utilization. Maintains high patient satisfaction. Possesses ability to work effectively as part of a team. Fluent in basic computer skills.

Under the direction of the Department Chief, Nurse Leader or designee, this registered professional nurse provides practice support to a clinical team, recognizing the patient as the central focus, providing age appropriate nursing care to patients across the lifespan. This position is responsible for effective care delivery and management of patient care within a specialty, utilizing the nursing process and adhering to current standards of nursing practice. Communicates and coordinates effectively with all entities involved in the care of the patient to promote safe, high quality care. Makes decisions reflecting critical thinking and evidence based nursing practice.

Gainwell Technologies LLC

Nurse Reviewer- Registered Nurse (Remote)

Posted on:

June 30, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

We are seeking a talented individual for a Nurse Reviewer (RN) who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy/regulatory support for determinations. This position is intended for pipelining. We will accept applications on an ongoing basis. What you should expect in this role: This is a full-time job. Health benefits (medical, dental, vision) and paid time off begin on Day 1 of employment. Company-provided computer. Remote/work-from-home role; employees must be located within the continental U.S. Home workspace must be quiet, secure, free from distractions and recording devices. May require up to 10% travel, depending on business needs.

What we're looking for: Proficiency in computer and typing skills (e.g., Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers). Active, unrestricted RN license from the United States and in the state of primary home residency. An active compact multistate unrestricted RN license (as defined by the Nurse Licensure Compact – NLC) is required and will be verified during the post-offer background check. Minimum of 5 years clinical experience in an inpatient hospital setting. At least 2 years of utilization review or claims auditing experience. Experience using Milliman or InterQual criteria is required. Ability to work standard business hours, as this role involves regular interactions with internal teams and other departments. May occasionally require extended hours to meet business needs.

Review and interpret medical records and compare them against criteria to determine appropriateness and reasonableness of care. Apply critical thinking and decision-making skills to assess if the documentation supports the need for the service, while maintaining production goals and quality standards. Document decisions and rationale to justify review findings or no findings. Determine approval or initiate a referral to the physician consultant, and process physician consultant decisions—ensuring the denial rationale is clearly detailed and completed within the contractual deadline. Perform prior authorization, precertification, and retrospective reviews; prepare decision letters as needed in support of the utilization review contract. Assist management with training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education. Maintain up-to-date knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure. Attend training and scheduled meetings to strengthen working knowledge of clinical policies, procedures, rules, and regulations. Cross-train to perform reviews of multiple claim types to ensure workforce flexibility and meet client needs. Recommend, test, and help implement process improvements, audit concepts, and technology enhancements that increase productivity, quality, and client satisfaction.

Call 4 Health

LPN

Posted on:

June 30, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

LPN/LVN

State License:

Compact / Multi-State

Are you a licensed practical nurse looking for a meaningful, patient-focused role that offers flexibility and work-life balance? As an LPN at Call 4 Health, you’ll be a key player in improving patient outcomes—all from the comfort of your home. You’ll support our clients by managing Electronic Health Records (EHRs), coordinating care, and educating patients, to help individuals take charge of their health.

Licenses & Certifications Required: Nurse Licensure Compact Licensed Practical Nurse LPN Certificate and an active eNLC license (additional state licenses are a plus). 2-4 years of hands-on clinical experience, particularly in primary care, pediatrics, geriatrics, OB/GYN, orthopedics, ambulatory care, or home health. Experience working with at least two EHR systems. A quiet, HIPAA-compliant workspace at home with reliable high-speed internet. Why You’ll Love Working Here: Make a meaningful impact by supporting patients and easing provider workload. Work remotely with the flexibility to balance your personal and professional life. Grow in a supportive environment where your expertise is valued. Join a mission-driven team that prioritizes both patients and caregivers.

Manage patient inquiries via EHR inboxes and portals, ensuring timely, compassionate responses. Process prescription refills per protocol and coordinate follow-up care for post-op and post-discharge patients. Support chronic disease management by tracking RPM data and educating patients on conditions like diabetes, hypertension, and COPD. Facilitate referrals and prior authorizations, working closely with providers, hospitals, public health agencies, and other healthcare entities. Screen patients for clinical trials, provide follow-up support, and deliver essential health education. Be a trusted resource for patients, providers, and healthcare teams—helping to reduce provider workload while enhancing patient care.

Call 4 Health

(RN) Registered Nurse

Posted on:

June 30, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Education and/or Experience: Bachelor’s or Associate’s Degree in Nursing. Minimum of 2-4 years of full-time clinical experience as a Registered Nurse, preferably in areas such as ER/Urgent Care, Adult, Pediatric, OB/GYN, Orthopedic, Ambulatory Care, Home Health, or ICU. Previous telephone triage experience using electronic triage systems and at least two different Electronic Health Record (EHR) software systems. An active unencumbered e-NCL or Enhanced Nurse Licensure Compact license, additional non-compact state licensure would be considered an asset; candidates should also be willing to obtain additional licenses at the company’s request. Qualifications & Skills Teamwork: Demonstrated ability to collaborate effectively with peers, cross-functional teams, and leadership. Leadership: Proactive in stepping up to lead, when necessary, capable of motivating colleagues, and sharing knowledge for the enhancement of team performance. Customer Service: Exceptional empathy, patience, and active listening skills to understand and address patient needs effectively. Quality: Strong attention to detail in charting, utilizing correct grammar, spelling, and medical terminology to ensure complete and accurate patient documentation. Organization and Time Management: Highly organized, capable of handling and documenting at least four calls per hour during peak times. Physical Requirements: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee must be able to sit for extended periods, talk, and engage in active listening without visual contact with patients. Occasional standing and the use of hands for operating office equipment are required, with infrequent stooping, kneeling, or crouching. Ability to hear in normal range and wear a headset/ earpiece Good visual acuity to read computer screens, scripts, forms etc. Able to work remotely at home in a private HIPAA compliant workspace Able to house company equipment needed to perform job Broadband Internet Access Participation (via telephone or video) in staff meetings Work Environment Able to thrive in a fast-paced environment. Demonstrated capability to maintain professional relationships with diverse personalities. Must be flexible and adaptable to change, managing stress effectively. May require occasional overtime or adjusted start times.

The following duties and responsibilities reflect the expectations of this position but are not all-inclusive. Track and respond to calls for a multi-state nurse triage telephone service, receiving inbound calls from patients and placing outbound calls, while utilizing Schmitt Thompson telephone triage protocols to document patient interactions effectively within clients’ EHR and/or a Call 4 Health platform. Provide clinical assessment based on established protocols and triage patients by phone or through patient portal. Provide administrative support and perform clinical tasks such as medication prescription refills per established protocols, notifying providers of critical results, and coordinating follow-up care post-discharge or post-operative. Facilitate referrals and collaborate on addressing prior authorization requests that require clinical consultation, while also assisting with requests from other agencies such as hospitals, nursing homes, funeral homes, and Departments of Labor or Motor Vehicles. Participate in Remote Patient Monitoring (RPM) initiatives by tracking patients' vital signs and delivering education on managing chronic diseases such as diabetes, hypertension, and COPD. Screen and qualify patients for clinical trials. Perform follow-ups and patient education. Carry out additional responsibilities as needed to assist the healthcare team and enhance the delivery of patient care.

Community Health Network

Registered Nurse Ambulatory Triage (RN) - Orthopedic Specialty Care - East

Posted on:

June 30, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Community Health Network was created by our neighbors, for our neighbors. Over 60 years later, “community” is still the heart of our organization. It means providing our neighbors with the best care possible, backed by state-of-the-art technology. It means getting involved in the communities we serve through volunteer opportunities and benefits initiatives. It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients. And above all, it means exceptional care, simply delivered — and we couldn’t do it without you.

Category: Nursing Job Family: Remote / Work from Home / Virtual Department: Ortho Specialty Care East Schedule: Full-time Facility: Community Physician Network Indianapolis Eastside 1 Indianapolis, IN 46219 United States Shift: Day Job Hours: Monday-Friday; 8am-5pm

Graduate of National League for Nursing (NLN), Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), or National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA) accredited school of nursing, or three years of related professional nursing experience. Licensed as a Registered Nurse (RN) with a valid license to practice in the state of Indiana as listed in the Nurse Licensure Compact (NLC). Three years or more of nursing experience required. Previous medical office/outpatient experience preferred. Phone triage experience a plus. Excellent communication skills. Excellent team skills. Compassionate and caring. Accountable and self-directed. EPIC experience a plus.

The Ambulatory Triage Registered Nurse functions as a member of the Orthopedic Specialty Care team, conducting duties such as: phone triage, patient education, scheduling appointments, prior authorizations, prescription refill, referrals, care coordination and other related tasks as needed. The nurse will primarily work from home once training has been completed and will support the Orthopedic Specialty Care office located on the east side of Indianapolis. Must reside in the Indianapolis area or surrounding counties.

Florida Cancer Specialists & Research Institute

Oncology Triage Registered Nurse - Remote

Posted on:

June 30, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Since 1984, Florida Cancer Specialists & Research Institute & Research Institute (FCS) has built a national reputation for excellence. With over 250 physicians, 220 nurse practitioners and physician assistants and nearly 100 locations in our network. Utilizing innovative clinical research, cutting-edge technologies, and advanced treatments, we are committed to providing world-class cancer care. We are recognized by the American Society of Clinical Oncology (ASCO) with a national Clinical Trials Participation Award, FCS offers patients access to more clinical trials than any private oncology practice in Florida. Our patients have access to ground-breaking therapies, in a community setting, and may participate in national clinical research studies of drugs and treatment protocols. In the past five years, the majority of new cancer drugs approved for use in the U.S. were studied in clinical trials with FCS participation prior to approval. Through our partnership with Sarah Cannon, we are one of the largest clinical research organizations in the United States. Often, FCS leads the nation in initiating research studies and offering ground-breaking new therapies to patients.

A Triage Nurse i s a professional registered nurse with oncology-specific clinical knowledge that offer s individualized care and clinical guidance to patients, families, and caregivers to assist with ongoing healthcare needs .

WORK SCHEDULE: Must be available to work Monday to Friday between the hours of 8:00am to 5:00pm in the Eastern Time Zone. Three (3) years or more of experience as an RN Two (2) years or more of oncology experience required Registered Nurse multistate or Florida single state licensure required EDUCATION/CERTIFICATIONS & LICENSES: Registered Nurse multistate or Florida single state licensure required Minimum of Associate Degree in Nursing , Bachelor’s Degree preferred. Certification as an Oncology Certified Nurse ( OCN®) preferred EXPERIENCE: Three ( 3 ) years or more of experience as an RN Two (2) years or more of oncology experience required CORE COMPETENCIES, KNOWLEDGE/SKILLS/ABILITIES: Strong organizational skills Ability to prioritize and reprioritize quickly Ability to develop collaborative relationships both internally and externally Strong written communication skills Strong telephonic assessment and communication skills Ability to work autonomously and with a virtual team in a remote work environment Strong oncology side effect/ triage management Proficient in Microsoft Word, Excel, Outlook Possess high level critical-thinking skills VALUES: Patient First – Keeping the patient at the center of everything we do Accountability – T aking responsibility for our actions Commitment & Care – Upholding FCS vision through every action Team – Working together, one team, one mission

Under general supervision, following established policies, procedures, and professional guidelines, provides care to patients by triaging oncology patient calls regarding treatment, surgery, and appointment information. Monitor and provide patient symptom management. Manage high risk , complex patient care with the goal of minimizing emergency department and inpatient readmission . Assess barriers to care to address patient, care giver, or family needs to achieve optimal patient outcome . Provide patient-centered individualized ongoing education, resources, and referrals to internal and external resources to patient and caregivers. A ssist the physician and PA-C/ARNP with specific patient/family interaction needed to resolve clinical issues . C omplete requested clinical documentation as needed. Establish and maintain professional role boundaries with patients, caregivers, and the multidisciplinary care team in collaboration with manager as defined by job description. Facilitate communication among members of the multidisciplinary cancer care team to prevent fragmented or delayed care that could adversely affect patient outcomes. Reviews, evaluates, and reports diagnostic tests to assess patient's condition . Provides patient education and clinical direction by answering questions following chemotherapy, radiation, and i nfusion treatments and post-surgery. Work as an integral team player and is expected to adhere to and abide by the rules and regulations set forth by the Florida State Board of Nursing.

UnitedHealth Group

Senior Clinical Quality Nurse RN, Quality Operations Call Center - Remote

Posted on:

June 29, 2025

Job Type:

Full-Time

Role Type:

Telehealth

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.

The Clinical Performance Quality (CPQ) Clinical Programs Operations team supports Optum’s Care Delivery Organizations by delivering patient-centered, clinically collaborative telephonic outreach to help people live healthier lives. Our team focuses on the design, execution, and delivery of telephonic and digital engagement strategies designed to close Medicare STARS/HEDIS gaps in care, including medication adherence, care for older adults, medication reconciliation post discharge, A1c, Blood pressure and statin therapy in patient with diabetes and cardiovascular disease. Our interdisciplinary service delivery team is comprised of Pharmacists, Registered Nurses, Pharmacy Technicians, and Care Coordinators. The Registered Nurse will report into the Director of Clinical Programs. The Registered Nurse will perform telephonic, patient-centered clinical consults focused on Care for Older Adults annual pain and functional assessments. In addition, the RN will outreach telephonically for Transition of Care following hospital discharge to complete reviews as well as assist with appointment scheduling. The RN will be required to meet or exceed established productivity and quality metrics and work to support the hours of operation of the business (Mon-Fri 9am-6pm Central). You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Active, unrestricted Registered Nurse eNLC Compact licensure in state of residency Currently have or be able to obtain additional RN licensure in one or more of the following states: Rhode Island, Massachusetts, Pennsylvania, Michigan, Illinois, California, Connecticut, Nevada, New York, Oregon 5+ years of RN experience, including experience in a managed care setting 2+ years of experience in HEDIS/Star programs, preferably in a clinical quality consultant role 2+ years of Call Center or Telephonic Outreach experience 2+ years of experience with data analysis and/or quality chart reviews, Must be able to review paper and electronic medical records and charts Experience with and extensive knowledge of the Medicare HEDIS/Stars measures Experience managing multiple complex, concurrent projects Experienced using Microsoft office applications, including databases, word-processing, outlook, and excel spreadsheets with intermediate or better Excel skills Preferred Qualifications: Undergraduate degree preferred, post graduate degree Billing and CPT coding experience Clinical data abstraction experience Bilingual with preference given to Spanish and Vietnamese Competencies: Demonstrated ability to interact with medical staff, peers, and internal company staff at all levels Excellent written and verbal communication and relationship building skills Solid problem-solving skills; the ability to analyze problems, draw relevant conclusions and devise and implement an appropriate plan of action Excellent customer service skills and communication skills Physical & Mental Requirements: Ability to lift up to 10 pounds Ability to sit for extended periods of time Ability to use fine motor skills to operate office equipment and/or machinery Ability to receive and comprehend instructions verbally and/or in writing Ability to use logical reasoning for simple and complex problem solving Ability to use fine motor skills to operate office equipment and/or machinery

Strictly adheres to department’s metrics and established advanced protocols and to handle incoming contacts including, but not limited to, prescription refill requests, lab results, x-ray results, medical inquiries, patient education and referral requests Primarily to make outbound calls and will help manage the inbound call queue from patients, patient representatives, providers and other medical staff, while strictly adhering to established protocols and scripting Review patient chart (in EMR) to ensure core measures are being addressed and met per protocol and takes appropriate action when they are not, i.e., schedule services Complete patient assessments for Transition of Care Medication Reconciliation Post Discharge, Care for Older Adults Pain and Function Assessments Educate patients on health conditions and necessity of routine screening and assisting with appointment scheduling (A1c, Controlling Blood Pressure, Breast Cancer Screening, Colorectal Cancer Screening, Diabetic Eye Exam, etc.) Communicate with providers and offices to obtain needed evidence of completed lab work, screenings and care provided Review available medical records for core measures to submit for closure of HEDIS/STARS measures Assist patients with identification of and connectivity to community and program resources to assist with non-medical needs Document thoroughly all calls and actions taken within core systems. Performs all other related duties as assigned

CVS Health

Utilization Management Nurse Consultant - Behavioral Health (Remote)

Posted on:

June 29, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

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

Schedule: Monday–Friday (11:30am-8:00pm EST Hours; Shift times may vary based on business needs) Location: 100% Remote (U.S. only) American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. We are seeking a dedicated Utilization Management (UM) Nurse to join our remote team.

Remote Work Expectations: This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications: Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed. Minimum 5 years of relevant nursing experience. Minimum 3 years of clinical experience in Behavioral Health and/or Substance Abuse including acute care, residential treatment center, partial hospitalization and intensive outpatient programs. At least 1 year of Utilization Management experience in concurrent review or prior authorization. Strong decision-making skills and clinical judgment in independent scenarios. Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications: 1+ year of experience in a managed care organization (MCO). Experience in a high-volume clinical call center or prior remote work environment. Education: Associate's degree in nursing (RN) required, BSN preferred

Apply critical thinking and evidence-based clinical criteria specific to Behavioral Health and Substance Abuse to evaluate inpatient and outpatient services requiring precertification. Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information. Use established guidelines to authorize services or escalate to Medical Directors as needed. Navigate multiple computer systems efficiently while maintaining accurate documentation. Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills. Perform sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer. Flexibility to provide coverage for other Utilization Management (UM) nurses across various UM departmental teams as needed, ensuring continuity of care and operational support. Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements.

University of Miami

Nurse Navigator 1 - Site Disease/Remote - Full Time

Posted on:

June 29, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Florida

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

Education: Bachelor’s degree in relevant field Certification and Licensing: Valid State of Florida Registered Nurse (RN) license Experience: Minimum 2 years of relevant work experience Knowledge, Skills and Attitudes: Ability to maintain effective interpersonal relationships. Ability to communicate effectively in both oral and written form. Skill in collecting, organizing and analyzing data. Proficiency in computer software (i.e. Microsoft Office).

Triages new patient appointments to the appropriate provider(s) and assures timely scheduling of initial appointments. Reviews outside medical records for appropriate scheduling. Assess barriers to care and refers to support services, local, and national organizations when needed. Educates on the treatment plan for patients based on diagnosis. Supports patients throughout the care continuum. Counsels individuals and patients on positive health practices. Collaborates with a multidisciplinary team of experts to outline best treatment for patients. Performs holistic evaluation of specialty population, making use of enhanced proven techniques and procedures to achieve better results. Implements the improvement of patient care, and healthcare policies and resources. Mentors other healthcare professionals by functioning as a preceptor or coordinating preceptors for visiting professionals, students, new graduates, and orienteers. Maintains professional knowledge by affiliating with professional and technical organizations, and participating in applicable continuing education programs, conferences, seminars, and workshops. Adheres to University and unit-level policies and procedures and safeguards University assets.

Blue Cross and Blue Shield of Minnesota

RN Specialist Complex Case Management - Maternity

Posted on:

June 29, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Minnesota

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

In this role you will utilize key principles of case management to research and analyze the member’s health needs and health care cost drivers and will work closely with an interdisciplinary care team to ensure members have an effective plan of care that leads to optimal, cost-effective outcomes. Leveraging clinical expertise, strong critical thinking skills and a keen business sense, you will work closely with the member and their family to avoid unnecessary hospitalizations and emergency department utilization, optimize site of care whenever possible, and ensure evidence-based treatment is being applied. An experienced case manager with managed care experience with maternity and NICU will be successful in this role.

Registered nurse with current MN license and with no restrictions All relevant experience including work, education, transferable skills, and military experience will be considered. 5 years relevant clinical care experience CCM Certificate or ability to obtain within 3 years of starting in the position Excellent telephonic skills Keen business skills Excellent communication skills Excellent conceptual thinking skills Excellent relationship management skills Excellent organizational skills Computer application proficiency Strong resiliency and flexibility skills Excellent research, analytical, and creative problem-solving skills Flexibility to work varied hours High school diploma (or equivalency) and legal authorization to work in the U.S. Preferred Skills and Experience: Maternity, Post Partum, NICU experience 2+ years of managed care experience; e.g. case management/health coach, utilization management and/or auditing experience (may be included in the 5 years relevant clinical experience) Cultural competency. Experience working across races and cultures.

Receives referral for member identified with high cost, complex medical conditions and telephonically outreaches to the member, family and providers to engage in complex case management program. Conducts clinical assessments with members and providers utilizing motivational interviewing; gathers, analyzes, synthesizes and prioritizes member needs and opportunities based upon the clinical assessment and research and collaborates with the interdisciplinary care team to develop a comprehensive plan of care. Collaborates and communicates with the health care team; e.g. member, family, designated representative, health care provider on a plan of care that produces positive clinical results and promotes high–quality, cost effective outcomes. Identifies relevant BCBSMN and community resources and facilitates program and network referrals. Monitors, evaluates, and updates plan of care over time. Ensures member data is documented according to BCBSMN application protocol and regulatory standards. Maintains outstanding level of service at all points of customer contact. Understands the strategic and financial goals of the department, complex care management teams, and the enterprise Knowledgeable of health plan operations (e.g. networks, eligibility, benefits) Promotes innovative solutions to improve day to day functions and enhance the overall operation of the department. Collaborates with interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member’s needs and health care cost drivers. Engage providers telephonically in reviewing and understanding treatment plans, including alignment with benefits and medical reimbursement policies to facilitate optimal treatment plans, care coordination, and transition of care between settings. Identifies and implements cost saving opportunities to ensure optimal and cost-effective health outcomes.

Optum

RN Clinical Signoff Reviewer - National Remote

Posted on:

June 29, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Minnesota

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.

You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Associate’s degree (or higher) Active, unrestricted RN (Registered Nurse) license in the state of residence 1+ years of DRG/ICD-10 Official Coding Guidelines experience, and/or CCS/CIC certified Preferred Qualifications: CCS or CIC certification Experience with prior DRG concurrent and/or retrospective overpayment identification audits Experience with DRG encoder tools (ex. 3M) Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry Healthcare claims experience Managed care experience Knowledge of health insurance business, industry terminology, and regulatory guidelines Soft Skills: Ability to use a Windows PC with the ability to utilize multiple applications at the same time Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail Ability to work independently in a remote environment and deliver exceptional results Excellent time management and work prioritization skills

Confirm findings on completed clinical validation reviews to verify the accuracy of DRG assignment and reimbursement as it pertains to clinical criteria with a focus on overpayment identification Perform, and provide oversight for clinical coding review to ensure accuracy of medical coding by utilizing clinical expertise and judgment to determine correct coding and billing Utilize solid command of anatomy and physiology as it pertains to ICD-10-CM code assignment Write/edit clear, accurate and concise rationales in support of clinical findings in conjunction with ICD-10-CM Official Coding Guidelines, and AHA Coding Clinics Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly Demonstrate knowledge of and compliance with changes and updates to clinical guidelines, reimbursement trends, and client processes and requirements Maintain and manage daily case review assignments, with a high emphasis on quality Provide clinical support and expertise to the other investigative and analytical areas Work in a high-volume production environment that is matrix driven

Headlands ATS

Triage Nurse

Posted on:

June 29, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Are you seeking integrity, purpose, and meaning in your work? Would you like to make an impact toward improving access to quality addiction medicine services? Consider joining the Headlands ATS provider team. Headlands Addiction Treatment Services is an industry leader in providing addiction and psychiatric services to treatment centers. Our mission is to improve the standards of patient care that exist in residential and outpatient addiction and mental health treatment programs. Our group is comprised of dedicated healthcare professionals who are passionate about delivering evidenced based patient care, education, and organizational improvements to a historically underserved patient population. Why Work with Headlands? Work with a company that values integrity, patient safety, and high-quality care Ongoing supervision and support from experienced addiction medicine and psychiatric providers Comprehensive training in addiction medicine and mental health care Join a collaborative, mission-driven team of NPs, PAs, psychiatrists, and addiction specialists Growth opportunities within a rapidly expanding organization

Position Overview: THIS POSITION IS OPEN TO BOTH RN AND LVN/LPN LICENSED NURSES. Schedule and Availability Schedule: M-Th overnight, 9 or 10 PM start Schedule: F-Sun evening, 4P-2A Schedule: F-Sun overnight, 9p or 10 PM start Schedule: F-Sun, daytime, 6 am start Remote Triage Nurse (RN or LVN/LPN) – Temp-to-Hire | 30 Hours/Week 6–8 Month Assignment | Potential for Long-Term Role After 1 Year This position is 100% remote and accepting applications from applicants with COMPACT LICENSES living in the following states: CA, AZ, NV, WA, CO, NE, KS, OK, TX, MO IL, IN, TN, FL, MD, NJ, WI, and NC. About the role: As a Remote Triage Nurse at Headlands ATS, you will play a critical role in providing high-quality care to patients dealing with addiction and mental health conditions. Working closely with our dedicated team of healthcare professionals, you will manage nursing requests, triage patient needs, and ensure seamless communication between patients, providers, and programs—all from the comfort of your home. In this role, you will utilize your clinical expertise to: Address and resolve patient care issues using established protocols within your scope of practice. Coordinate and delegate tasks such as admissions and follow-ups to providers, ensuring timely and effective care. Support providers by managing medication orders and refill requests. Serve as a compassionate and responsive point of contact for patients and programs, fostering trust and positive relationships.

Skills and Experience: Exceptional customer service skills and a compassionate bedside manner. Strong multitasking abilities and advanced computer proficiency, including navigating multiple software programs simultaneously. Proven experience in nursing with exceptional organizational and workflow management skills. A strong work ethic, reliability, and commitment to improving the lives of patients dealing with mental health conditions and addiction. A track record of longevity in previous roles, with strong references. A current, active California nursing license in good standing (required). A Nursing Compact License/Multi-State (required). Reside in one of the following states: AZ, CA, CO, FL, IL, IN, KS, MD, MO, NV, NE, NJ, NC, OK, TN, TX, WA, WI.

Managing nursing requests from various treatment programs, per established protocols and within scope of practice. Triage and delegation of admissions to on-call Nurse Practitioner, Physician Assistant and/or Physician providers. Managing common patient care issues that do not require provider involvement, per established protocols. Triage and delegation of patient followup visits with appropriate providers. Assisting providers with medication orders orders and refill requests. Providing friendly, helpful, and responsive, service oriented experience for programs and patients.

Elevance Health

Nurse Practitioner, Bilingual, 100% Virtual, CareBridge

Posted on:

June 29, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

Compact / Multi-State

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

CareBridge Nurse Practitioner (Bilingual) – 100% Virtual Sign-On Bonus: $10,000 Location: Virginia, New Jersey and Florida This role enables associates to work virtually full-time, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. The CareBridge Nurse Practitioner (Bilingual) – 100% Virtual is responsible for collaborating with company physicians, the patient’s other physicians and providers, and their family members to develop complex plans of care in accordance with the patient’s health status and overall goals and values. Provides clinical and non-clinical support to patients.

Minimum Requirements: Requires an MS in Nursing. Requires an active national NP certification. Requires valid, current, active and unrestricted Family or Adult Nurse Practitioner (NP) license in applicable states. Experience working with Electronic Medical Records (EMR) required. Experience in managing complex care cases for developmental disabilities and chronically ill patients strongly preferred. Bi lingual or Multi-language skills required. RN Compact license is required. Preferred Skills, Capabilities and Experiences: Possession of DEA registration or eligibility preferred. 2+ years of experience in managing complex care cases is preferred. Experience in managing complex care cases for developmental disabilities and chronically ill patients strongly preferred Bilingual abilities are strongly preferred

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

PurposeMed

Nurse Practitioner (Freddie USA)

Posted on:

June 28, 2025

Job Type:

Part-Time

Role Type:

Primary Care

License:

NP/APP

State License:

Compact / Multi-State

PurposeMed was founded in 2019 with the mission of improving access to complex care for underserved communities. We’ve grown quickly in our first few years, and now our exceptional team serves thousands of patients each month across our multiple verticals. PurposeMed consists of three complex care business units: Freddie, Frida, and Foria, and partners with Affirming Care Pharmacy. Freddie is focused on improving sexual health through education, prevention, and treatment with a focus on the LGBTQ2S+ community—we’re the #1 rated PrEP provider in North America, serving patients in both Canada and the USA! Frida is changing the lives of patients with easier access to adult ADHD diagnosis, and fast and affordable treatment. Foria Clinic provides trans, non-binary, and gender-diverse Canadians with gender-affirming healthcare. Affirming Care Pharmacy is a specialty pharmacy with locations in Calgary, Alberta, and Mississauga, Ontario. This partnership provides our patients with an end-to-end healthcare experience, from treatment, to prescription delivery, to continuous affirming care. We’re proud to be ranked #2 on Deloitte’s 2024 list of Canada’s 50 fastest-growing tech companies and recognized as one of Canada’s Most Admired Corporate Cultures for two consecutive years. Driven by a strong mission, our team is passionate about making healthcare accessible to those who need it most—and we make sure to have fun along the way!

Independent Contractor, part-time opportunity through OpenLoop Targeting 5-10 hours/week with flexible hours and schedule This role offers the flexibility to work primarily on your own schedule, completing 5-10 hours of synchronous (live) patient consultations and daily asynchronous tasks (completed at times most convenient for you). Earnings are based on the amount of work you choose to take on, making this role ideal for those seeking a dynamic and adaptable work schedule. Location: Remote (USA) Though we have an office based in Calgary, Canada, this is a remote position that is open to candidates across the USA. PurposeMed's office is located on the unceded and traditional territories of the peoples of the Treaty 7 region in Southern Alberta, which includes the Blackfoot First Nation tribes of Siksika, the Piikani, the Kainai, the Stoney Nakoda First Nations tribes of Chiniki, Bearspaw, and Wesley and the Tsuut’ina First Nation. The city of Calgary is also homeland to the historic Northwest Métis and to Métis Nation of Alberta, Region 3. Who we hope to find: We are looking for a caring and compassionate Nurse Practitioner licensed in multiple states (including Pennsylvania and New Jersey) to provide high-quality virtual care to Freddie USA patients. Our patients are our #1 priority, and we strive to provide compassionate and understanding care that goes beyond the traditional and stigmatized doctors' office visits. As a Freddie Nurse Practitioner, you will be given the opportunity to work with both our Clinical and Operations teams in order to provide the best care for our patients.

A Master's degree in Nursing and Primary Health Care Nurse Practitioner diploma Active Nurse Practitioner licenses in at least 5 states, with at least one being in New Jersey or Pennsylvania (other preferred states: Missouri, Wisconsin, Louisiana, Kentucky, Utah, Vermont, Kansas or Connecticut) 2-3 years of experience in primary/urgent care Excellent communication skills and empathetic care delivery Experience working in HIV prevention and/or with the LGBTQ2S+ community Availability and commitment (ideally daily) to complete asynchronous patient care tasks (reviewing labs, prescribing, and providing follow-up communication) in addition to 5-10 hours per week of live consultations. Please note: The number of hours needed may vary based on the needs of the clinic. It would also be great if you have: Experience working with gender and sexually diverse communities Experience providing virtual care Experience working in the private sector, a start-up, or a technology company Experience working in an independent or autonomous practice setting Licenses beyond what is listed above

Delivering inclusive, expert virtual care through scheduled synchronous consultations through our virtual care platform Providing asynchronous care to ensure timely and continuous support for patients, including ordering labs and diagnostics, interpreting results, prescribing medication, and clinical follow-up Maintaining accurate, detailed patient records in our Electronic Medical Record (EMR) system, using a wide-variety of virtual tools to chart, prescribe and connect with patients Driving an outstanding 11/10 star patient experience by serving as a resource for Registered Nurses and working collaboratively with our support teams

Alignment Health

Remote RN Case Manager, SNP (Bilingual)

Posted on:

June 28, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

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

Alignment Health is seeking a remote, bilingual RN Case Manager, Special Needs Program (SNP) to join the case management, team (California RN License Required). The Case Manager SNP is responsible for health care management and coordination, within the scope of licensure, for members with complex and chronic care needs. Delivers care to members utilizing the nursing process and effectively interacts with members, care givers, and other interdisciplinary team participants. Assist with closing gaps in care and resolving barriers that prevent members from attaining improved health. Reaches out and connects with members via the telephone. Schedule: Monday - Friday, 8:00 AM - 5:00 PM Pacific Time (Required)

Supervisory responsibilities: N/A Job Requirements Experience Required: Minimum 2 years' clinical experience Minimum 1 year case management experience. Preferred: Health Plan experience preferred Education Required: Successfully passing Post High School courses to obtain an RN licensure or AS in Nursing. Preferred: BSN or Bachelor's Specialized Skills Required: Possess a high level of understanding of community resources, treatment options, home health, funding options and special programs Extensive knowledge of the management of chronic conditions Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors; Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others. Ability to operate PC-based software programs including proficiency in Word, Excel and PowerPoint Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. Report Analysis Skills: Comprehend and analyze statistical reports. Licensure Required: Must have and maintain an active, valid, and unrestricted RN license in California (Non-Compact) Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company. Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Coordinates care by serving as a resource for the member, their family, and their physician. Ensures access to appropriate care for members with urgent or immediate needs facilitating referrals/authorizations within the benefit structure as appropriate. Completes comprehensive assessments within their scope of practice that includes assessing the member's current health status, resource utilization, past and present treatment plan, and services. Collaborates with the member, the PCP, and other members of the care team to implement a plan of care. Interfaces with Primary Care Physicians, Hospitalists, Nurse Practitioners, and specialists on the development of care management treatment plans. Provides education and self-management support based on the member’s unique learning style. Assists in problem solving with providers, claims or service issues. Works closely with delegated or contracted providers, groups, or entities to assure effective and efficient care coordination. Maintains confidentiality of all PHI in compliance with state and federal law and Alignment Healthcare Policy.

Alignment Health

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

Posted on:

June 28, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

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

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

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

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

Trinity Health

Full-Time Home Health Clinical Intake RN Coordinator (Remote)

Posted on:

June 28, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Michigan

Trinity Health At Home is a national home care, hospice and palliative care organization serving communities throughout eleven states. As a faith-based, not-for-profit agency, we serve patients and families in the comfort of home, offering skilled nursing, therapy (physical, occupational, speech) and medical social work. We are Medicare-certified and accredited by The Joint Commission.

Employment Type: Full time Shift: Evening Shift Description: Must be within a 50-mile radius of Livonia, MI or a Trinity Health At Home Office Work shift 12:30pm – 9:00pm EST Will work a weekend rotation, one every 4 weeks Will work a holiday rotation, one – two per year The above hours may flex with business needs

In CA: Must have one year of professional nursing experience by regulation. Graduate of an approved Nursing education program. Current Registered Nurse licensure in the state in which practicing. 2+ years of Home Health RN experience. Must be proficient with Epic and/or Home Care EMR Software. Must be proficient in the use of computer office software. Must possess excellent and clear oral & written communication skills 1-3 years prior experience in a customer service, homecare intake or admissions role preferred.

The Clinical Intake Coordinator is responsible for gathering necessary information from referral sources, promoting Agency services, and functioning as a clinical resource and customer service representative. Evaluates referrals for client appropriateness for home health services. Receive and document medical orders, accept for services if appropriate and fully process (or delegate) referrals in an accurate and timely manner.

U.S. Renal Care

Admissions Triage Nurse

Posted on:

June 28, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Texas

USRC's greatest strength in being a leader in the dialysis industry is our ability to recognize and celebrate the differences in our diverse workforce. We strongly believe in recruiting top talent and creating a diverse and inclusive work climate and culture at all levels of our organization.

The Admissions Triage Nurse plays a critical role in accelerating new patient admissions and improving referral conversion by conducting timely and thorough medical records reviews. This position ensures that patients are clinically appropriate for acceptance into U.S. Renal Care (USRC) or Satellite Healthcare (SHC) facilities. The Triage Nurse works closely with the Admissions Team and clinical leaders to support timely decisions and facilitate safe and efficient transitions to dialysis care. This is a remote role. Weekly Schedule: Alternates every week between the following shifts: Shift A: Monday to Friday, 7:00 AM – 3:30 PM central Shift B: Monday to Friday, 10:30 AM – 7:00 PM central Weekend Coverage: 1–2 Saturdays per month, 8:00 AM – 4:30 PM central

Active, unrestricted RN or LVN license Minimum of 3 years of dialysis experience, preferably in an outpatient chronic setting Previous experience reviewing medical records for new dialysis admissions or clinical triage Strong clinical judgment and understanding of ESRD, dialysis modalities, and patient readiness Excellent written communication skills and attention to detail Proficient in using electronic systems to document reviews and manage workflows Comfortable working independently in a fast-paced, virtual environment

Review medical records for new dialysis referrals, focusing on identifying high acuity conditions, missing information, and clinical red flags. Complete clinical triage documentation within the internal referral management platform, clearly noting referral concerns, comorbidities, and readiness indicators. Communicate effectively within the internal referral management application to notify the Admissions Team when a clinical review is complete and chair time can be released. Apply clinical judgment to determine whether the patient is suitable for acceptance into a USRC or SHC facility, based on medical history, current status, and dialysis modality. Ensure medical record reviews are completed within the target timeframe of 30 minutes per referral. Escalate high-risk or unclear referrals to the appropriate clinical or operational leaders for further review. Collaborate with Admissions and field staff to support efficient handoffs and strong communication across departments. Maintain current knowledge of internal admission criteria, clinical protocols, and dialysis best practices. Participate in training, workflow updates, and quality assurance initiatives as needed. Perform other duties as assigned. Actively promotes GUEST customer service standards; develops effective relationships at all levels of the organization. Participates in team concepts and promote a team effort; performs duties in accordance with company policies and procedures. Regular and reliable attendance is required for the job.