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Rock Medical Group
Rock Medical Group
WellSky
WellSky is one of America’s largest and most innovative healthcare technology companies leading the movement for intelligent, coordinated care. Our proven software, analytics, and services power better outcomes and lower costs for stakeholders across the health and community care continuum. In today’s value-based care environment, WellSky helps providers, payers, health systems, and community organizations scale processes, improve collaboration for growth, harness the power of data analytics, and achieve better outcomes by further connecting clinical and social care. WellSky serves more than 20,000 client sites — including the largest hospital systems, blood banks, cell therapy labs, home health and hospice franchises, post-acute providers, government agencies, and human services organizations. Informed by more than 40 years of providing software and expertise, WellSky anticipates clients’ needs and innovates relentlessly to build healthy, thriving communities. For more information, visit wellsky.com.
The Utilization Review Clinician is responsible for reviewing medical records to determine medical necessity. This includes conducting patient evaluations, managing admissions and informational visits, and ensuring timely post-discharge follow-ups with completed assessments to help prevent acute care readmissions. In this role, you will also review requests for post-acute services promptly, using established clinical guidelines and coverage criteria to assess appropriateness. You’ll collaborate with physicians, healthcare providers, and both internal and external stakeholders to support improved health outcomes. By applying clinical expertise, you’ll coordinate care with facilities and providers, follow standard operating procedures and organizational policies, and consult with peer reviewers, Medical Directors, or delegated clinical reviewers to ensure care is medically appropriate, high-quality, and cost-effective throughout the medical management process. The ideal candidate will have working knowledge of Microsoft Office applications (e.g., Word, Excel) and be comfortable using clinical decision support tools and operational software.
Required Qualifications: Bachelor's degree or equivalent work experience 4-6 years of clinical nursing or therapy experience Active RN, OT, or PT license Preferred Qualifications: 1-2 years' experience in utilization review, case management and/or managed care regulations Experience with MCG Guidelines, InterQual or other clinical decision support tools, especially in utilization management and prior authorization processes Job Expectations: Willing to travel up to 30% based on business needs Willing to work additional or irregular hours as needed Must work in accordance with applicable security policies and procedures to safeguard company and client information Must be able to sit and view a computer screen for extended periods of time
Conduct prior authorization reviews and/or continued stay reviews for post-acute care services by applying clinical guidelines and escalating cases to medical directors as needed Approve services in compliance with health plan guidelines, contractual agreements, and medical necessity criteria Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care and seamless care transitions Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and professional growth Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes Support all payer programs and initiatives related to the post-acute space Make benefit determinations about appropriate levels of care using clinical guidelines Coordinate benefits and transitions between various areas of care Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively Perform other job duties as assigned
Optimal Care
Optimal Care is where your dedication meets a rewarding career. As a clinician owned and operated company, we create the opportunity and environment for each employee to realize their highest potential while maintaining a personalized focus on our Patients and Families every day. We are the Midwest's premier provider of Physician Services, Home Health, and Hospice Care. Our integrated care delivery model incorporates technology, innovation and best practices. We produce value based outcomes by managing chronic disease process, rehabilitation and end of life care. We live a simple Mission: Serve Together, Provide Value, and Deliver Exceptional Quality Care. What does this mean for you? At Optimal Care, you have our resolute commitment to being an exceptional place to work. Your expertise, passion and commitment to exceptional quality care will continue to thrive. With you we can build a remarkable place to work.
As a Hospice After Hours Registered Nurse, you'll work three 12-hour shifts consecutive nights (7am-7pm, Friday-Sunday). No additional on-call requirements, no schedule surprises - just a predictable schedule that lets you plan your life with confidence. You'll be the compassionate presence that patients and families need during their most vulnerable hours, providing critical skilled nursing care and emotional support to terminally ill patients. This specialized role is perfect for an experienced RN who thrives in autonomous settings, thinks critically under pressure, and finds deep fulfillment in hospice care while valuing an exceptional work-life balance. Here's what makes this role exceptional: Start and finish at home: No commuting to an office - begin and end your on-call shifts from home No additional on-call: Unlike many nursing roles, your schedule is set with no surprise call-ins or extended shifts Optimized territories: Manageable drive times between patients ensure you can provide quality care without excessive travel This schedule is designed for nurses who want to make a meaningful impact in hospice care while having dedicated, uninterrupted time for their personal lives.
Required Qualifications: Graduate of an accredited Diploma, Associate, or Baccalaureate School of Nursing Current Registered Nurse (RN) license in state of practice Minimum 1 year of nursing experience in a clinical care setting Reliable transportation with valid driver's license and automobile insurance Ability to work evenings, nights, weekends, and holidays Preferred Qualifications: Bachelor of Science in Nursing (BSN) Experience in hospice or home health environment Previous after-hours or on-call experience Essential Skills and Competencies: Strong clinical assessment and critical thinking abilities Excellent autonomous decision-making skills with good judgment Emotional resilience and ability to support families facing end-of-life issues Outstanding communication and crisis management skills Comfort working independently during non-business hours Ability to remain calm and focused in urgent or emotionally intense situations Strong time management with ability to prioritize multiple urgent needs Cultural sensitivity and respect for diverse beliefs about death and dying
Provide Urgent Hospice Care: Respond promptly to after-hours patient and family needs with clinical expertise and compassion Conduct admissions, routine visits, respite care, or continuous care as required Assess and manage urgent symptoms including pain, anxiety, respiratory distress, and other comfort needs Make critical clinical decisions independently while collaborating with on-call physicians and team members Deliver Expert Clinical Nursing: Perform comprehensive nursing assessments and continuously re-evaluate patient needs Demonstrate proficiency in medication administration across all routes (IM, SQ, SL, TD, PO, enteral tube, IV) Use durable medical equipment and devices safely and effectively Provide skilled interventions requiring specialized nursing expertise Perform phlebotomy with proper implementation of universal precautions Support Families Through Crisis: Provide appropriate support and guidance at time of death Conduct bereavement assessments when requested Offer reassurance and education to anxious families during nighttime hours Help families navigate difficult decisions with empathy and clinical expertise Coordinate After-Hours Care: Verify and follow plans of care according to physician orders and IDG assessments Communicate significant findings and changes to physicians, supervisors, and facility staff Assist with hospital discharges to home or facility settings during evening/overnight hours Supervise home health aide and LPN care delivery per organizational policy Report unsafe conditions promptly to appropriate parties Maintain Clinical Excellence: Complete all documentation within 24 hours of visits Document medication regimens and update profiles according to procedures Ensure clinical notes reflect ongoing communication and care coordination Demonstrate knowledge of Conditions of Participation and payor requirements Maintain compliance with hospice regulatory standards
NYU Langone Health
NYU Langone Health is a fully integrated health system that consistently achieves the best patient outcomes through a rigorous focus on quality that has resulted in some of the lowest mortality rates in the nation. Vizient, Inc., has ranked NYU Langone No. 1 out of 118 comprehensive academic medical centers across the nation for four years in a row, and U.S. News & World Report recently ranked four of its clinical specialties No. 1 in the nation. NYU Langone offers a comprehensive range of medical services with one high standard of care across seven inpatient locations, its Perlmutter Cancer Center, and more than 320 outpatient locations in the New York area and Florida. The system also includes two tuition-free medical schools, in Manhattan and on Long Island, and a vast research enterprise. For more information, go to nyulangone.org and interact with us on LinkedIn, Glassdoor, and Indeed.
We have an exciting opportunity to join our team as a Telehealth Nurse - Access Center - Boynton Beach, Florida. In this role, the successful candidate carries out remote patient care responsibilities with emphasis on decision-making. Provides competent, safe and compassionate care based on established NYUHC Patient Care and Nursing Standards and program policies. As a member of the interdisciplinary healthcare team, collaborates with the provider and local site to implement a comprehensive patient-centered plan of care to achieve expected outcomes; utilizes principles of assignment and delegation consistent with the NY State Nurse Practice Act.
To qualify you must have a Bachelor of Science in Nursing 3-5 years of clinical experience, preferably in an ambulatory office setting or emergency department, including telephone triage and patient education Must obtain unrestricted Registered Professional Nursing license in New York and Florida State upon hire Comfortable with providing patient education related to chronic conditions such as but not limited to diabetes, hypertension, asthma, COPD and heart failure, Ability to demonstrate critical thinking and independent thinking Ability to ask open ended questions, identify significant from insignificant responses, ask about other diagnoses, probe for additional information, and redirect as necessary Excellent communication skills written, interpersonal and the ability to communicate effectively via telephone and electronically Strong computer skills including Microsoft Office suite and Electronic Medical Records, preferably Epic Excellent customer service skills. Required Licenses: Registered Nurse Lic- Florida, Registered Nurse License-NYS Preferred Qualifications Bilingual: Spanish or Russian/Greek Telephonic care management experience
Review physicians messages received from patients though the electronic medical record as per accepted policy and procedure Participate in regular debrief meetings with local sites to identify issues or opportunities for improvement Document provider and patient interactions accurately and in a timely manner using the electronic medical record systems per policy and accepted nursing standards Provide telephonic patient education regarding results and understanding condition management as per provider instruction and nursing scope of practice Assist providers in contacting patients regarding test results as per provider instruction Communicate effectively with local site pool, staff or provider via telephone or electronic message as appropriate Determine proper handling or routing of non-urgent messages based on established guidelines or in accordance with sound judgement Assess messages for urgent situations or needs, and contact patient telephonically for further evaluation and referral to the local site or emergency/urgent care services as appropriate
Help at Home
In our 50 year history, Help at Home has provided care for individuals, helping them to remain independent and able to live their best lives in their own homes. Our clients have always been like family. As the leading national provider of high-quality, relationship-based home care for seniors and people living with disabilities, we’re uniquely positioned as the home care company of choice. Our person-centered home care services create Great Days and Meaningful Moments for individuals, while also driving high-quality, low-cost outcomes. We provide in-home, community-based care in 11 states and 200+ locations with the help of 60,000 highly trained, compassionate caregivers who have relationships with 70,000+ clients.
As the nation’s leading provider of high-quality home care services, we empower our clients to live independently, safely, and with dignity in their own homes. The home is more than a place – it’s the center of health, care coordination, and Meaningful Moments that transform lives. We’re seeking a **Registered Nurse (RN) Case Manager** who is passionate about making a difference and driving impact. This role offers an opportunity to contribute to meaningful work and help shape the future of care in communities across the country.
What You'll Bring: Ability to exercise initiative and independent judgment Ability to work independently and leverage community resources to benefit clients Excellent interpersonal, written and verbal communication skills Ability to thrive in a fast-paced and ever-changing environment Energetic team player with a positive attitude and curious mindset Education And Experience: Graduate of an accredited nursing school Minimum of one (1) year clinical nursing experience, preferably in home health/home care setting State of Georgia or multistate RN licensure Experience working with medically fragile clients, addressing medical, social and behavioral components of care Management Authority: Trains other associates Directs work of other associates Travel Requirements: Regular travel on a daily or weekly basis throughout an assigned territory
Provides services in accordance with the plan of care Makes the initial evaluation visit and regularly reevaluates the patient’s nursing needs Initiates the plan of care and necessary revisions Initiates appropriate preventive and rehabilitative nursing procedures Prepares clinical and progress notes for each patient visit and summaries of care conferences on his/her patients in a timely manner as per Agency policy Coordinates services Informs personnel of changes in the condition and needs of the patient Counsels the patient and family/significant others in meeting nursing and related needs Processes orders and notifies physician of patient needs and changes in condition Completes certification/recertification orders and discharge summaries Determines the amount and type of nursing needed by each individual patient Supervises and teaches other nursing personnel Conducts patient care conferences on patients assigned to his/her care Participates in peer review and Quality Assessment and Performance Improvement as assigned Completes and submits OASIS assessments, reassessments, transfers, resumptions of care, discharges and significant change in condition in accordance with Agency defined time frames Appropriately utilizes ICD-10 codes Performs other related duties as assigned
ConcertoCare
ConcertoCare is a tech-enabled, value-based provider of at-home, comprehensive care for seniors and other adults with unmet health and social needs. ConcertoCare deploys physician-led interdisciplinary teams— supported by its proprietary population health platform, Patient3D®, and clinical decision support tools — to manage the country's most medically and socially complex and costly patients in ways that keep them in their homes and out of the hospital. The results are better health outcomes, reduced costs, and a more personalized and integrated experience for patients and their families. ConcertoCare works with a wide variety of payers and can partner with a patient’s current primary care physician or serve as the provider of record. Led by a world-class team of home-based care physicians, population health technology experts, former policymakers, and senior health plan executives, ConcertoCare serves seniors across the country. For more information, visit www.concertocare.com.
The ConcertoCare Case Manager coordinates all aspects of a patient’s care (medical, behavioral, functional, and social) and serves as a patient advocate across the continuum of care in partnership with the patient’s providers and extended care team. This is a unique Case Management role that is intimately integrated with a larger care team. This role requires a high level of interaction to successfully engage patients and foster positive, trusting relationships to help them achieve their goals. The ideal Case Manager has excellent communication skills, takes initiative, works well with other members of the care team, and creatively solves problems to address a patient’s needs holistically. This position is part of the Population Health Team, reports to the Vice President of Case Management, and works closely with other Population Health team members as well as market-based care teams. This is an ideal position for a registered nurse who seeks an opportunity to contribute to the health and well-being being of highly complex patients, enjoys a collaborative multidisciplinary team-based approach to care, and is excited to engage in developing and nurturing our innovative, value-based clinical model focused on caring for patients with complex and social support needs that the current health system does not serve well.
Current RN License in good standing in the state of practice required. Bachelor's degree in nursing required, or associates in nursing with other clinical or business bachelor’s degree Minimum of 4 years experience working in a clinical setting, with at least 2 years of case management experience in home health care, ambulatory care, community public health, and/or the insurance setting Certified Case Manager (CCM) certification or commitment to complete when eligible Geriatric care experience is highly desired 2 years of discharge planning, utilization management, case management, performance improvement, and/or managed care preferred. Knowledge of Medicare and Medicaid regulations and insurance benefits preferred Strong knowledge of clinical best practices as they relate to case management, discharge planning, utilization management, performance improvement, and/or managed care Strong clinical skills and ability to implement evidenced-based care. Ability to manage patient complexity and multiple clients with diverse needs Demonstrated ability to triage patient-reported symptoms and issues that require escalation to our field-based team and to apply critical thinking skills in unexpected circumstances. Ability to communicate effectively in writing and verbally. Demonstrated ability to perform multiple concurrent tasks with minimal supervision and meet deadlines. Ability to work in a fast-paced, dynamic environment and work well with others on a team. Proficient computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) as well as clinical systems/ EMR competency Knowledge and ability to navigate internet-based tools and applications, and proficiency in computer documentation Demonstrates a high level of professionalism.
Conduct initial intake calls as well as scheduled and urgent patient outreach based on individual patient’s needs and risk levels to review and update the care plan, monitor progress, ensure needs are met, and identify new areas of concern. Provide ongoing care coordination for an assigned panel of complex patients. Conduct needs assessments and develop plans of care in partnership with the rest of the patient’s care team. Ensure care is coordinated, patient-centered, and aligned with the needs and wishes of the patient. Support patients during care transitions, including outreach and assessment during and post hospitalization to ensure discharge needs are addressed, to facilitate provider follow-up, and to perform medication reconciliation. Identify and implement interventions and collaborate closely with ConcertoCare’s multidisciplinary team (providers, Director of Clinical Care, social work, behavioral health, and clinical pharmacy), external providers, and social service organizations to: (1) address gaps in care, (2) mitigate the risk of inpatient admissions, readmissions, emergency room visits and movement to an institutional setting, (3) and keep patients safely living in their desired and appropriate home environment. Identify and verify appropriate utilization of resources across the continuum of care. Actively participate in interdisciplinary care team huddles, and other clinical meetings. Participate in quality improvement and evaluation processes. Adhere to compliance policies, procedures, and standards of conduct including all applicable laws and regulations. Serve as a mentor for new hires and existing case management team members Other duties as assigned
LifeStyle Options - an Addus Homecare Company
LifeStyle Options specializes in customized companion and nursing services and is a member of the Addus Family of Companies. For over 40 years, Addus HomeCare has been one of the nation’s top providers of personal home care and support services and is committed to providing high-quality, cost-effective care that gives people the freedom to remain in their homes.
Are you looking for a job with flexibility AND variety? At LifeStyle Options you can do exactly that! Our RNs enjoy keep their skills sharp and help reduce burnout by working private duty one-on-one with a client in their home (low acuity). Starting wage is $35 per hour. You pick when, what and where you work! We offer weekly pay and 24/7 support. This position delivers professional nursing care to clients in accordance with the established plan of care and Company policies and procedures. Provides care consistent with all relevant professional standards and state and federal requirements
Graduate from an accredited registered nursing program Licensed as a RN in the state of practice (NEW GRADS WELCOME!) CPR certification. (NOTE: we offer classes if you need to renew) Home care or home health experience preferred Ability to provide nursing care in the home environment Ability to complete necessary documentation appropriately, legibly and timely Interpersonal, verbal, and written communication skills necessary to complete job responsibilities
Observe and report any signs or symptoms indicative of changes in condition of the client and family situation. Document such reports and observations in the clinical record and notify supervisor. Perform assigned nursing procedures, including the administration of treatments and medications in the care of the patient, in accordance with the State Nurse Practice Act and the plan of care. Teach the client appropriate self-care techniques. Notify the Supervisor, Case Manager, physicians, or families of changes in the client’s condition. Communicate potential risk management issues and report abuse or unsafe/illegal practice as required by law. Work with client, family and health care team members effectively to coordinate patient care. Maintain a high degree of confidentiality at all times due to access to sensitive information. Follow HIPAA regulations and requirements. Abide by all regulations, policies, procedures and standards. Performs other duties as assigned.
Paradigm
Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm’s business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs. We’re proud to be recognized—again! For the fourth year in a row, we’ve been certified by Great Place to Work®, and for the third consecutive year, we’ve earned a spot on Fortune's Best Workplaces in Health Care™ list. These honors reflect our unwavering commitment to fostering a positive, inclusive, and employee-centric culture where people thrive.
The Clinical Coordinator (LPN or RN) plays a critical role in coordinating and managing medical and healthcare-related services for injured workers, partnering closely with patients, employers, providers, adjusters, and internal teams to support appropriate treatment plans and timely return-to-work outcomes. This role requires strong clinical judgment, organization, and communication skills, along with the ability to independently analyze medical information and collaborate across disciplines to drive quality, compliant case management. This is a full-time, fully remote position, offering the opportunity to make a meaningful impact while working from home. The schedule for this role is Monday through Friday, 11:00 AM – 7:30 PM Eastern Time. Ideal candidates bring a nursing background (LPN or RN), experience in workers’ compensation or related clinical settings, and a commitment to service excellence, ethical practice, and continuous improvement.
Qualifications: Education/Training: Current RN or LPN state licensure in good standing with the State Board of Nursing. Experience: Previous Work Comp Case Management experience with at least three (3) years hospital/clinical experience in Orthopedics, Neurology, Occupational Health, Med/Surg or other comparable clinical discipline. Knowledgeable of injured worker’s rights and ability to ensure an atmosphere which to promote the privacy, dignity, and well-being of injured workers. Maintain confidentiality of all data, including injured workers’ Protected Health Information (PHI), employee, and operations data. Skills: Excellent verbal and written communication, cooperation, service excellence, and effective conflict resolution skills; Able to promptly address concerns with tact and provide appropriate follow up; proficient reading, writing, grammar, and mathematics skills; strong knowledge of medical terminology; Excellent organizational, prioritization, and multi-tasking skills; Excellent computer skills (e.g., Outlook, Teams, to be trained on proprietary software). Comply with all regulatory requirements, current laws and policies which protect workers from harassment and all illegal and discriminatory behavior. Comply with applicable Quality Assurance initiatives. Complete requirements for required training, demonstrate acceptable attendance, and appropriate personal appearance. Equipment/Machinery Used: Standard office equipment including phones, scanners, fax, laptop/PC, copiers, various computer programs, etc.
Support the Mission, Values and Vision of Paradigm, promoting positive public relation and demonstrating service excellence, respect for customers, coworkers, and management. Consistently maintain a high level of ethical and professional standards, continuously striving to improve healthcare services. Provide appropriate follow up with supervisor, co-workers, case managers, and providers regarding updates, reported complaints and concerns. Collaborate effectively with all departments through interdepartmental referrals and communication. Support and participate in common teamwork to achieve departmental and organizational goals, cooperating and working together with team as well as other internal and external partners. Actively participate in the QA process and departmental improvement efforts, identifying clinical areas for improvement Plan and complete job duties, organizing individual caseload to meet jurisdictional and Best Practice Standards for timeliness, notification, and documentation requirements. Independently approaches problem resolution by appropriate use of research and resources. Appropriately research, review, analyze and prepare medical information, document pertinent information in the case file notes, apply evidence based established guidelines to support case management interventions and facilitate the case management process, collaborating objectively with case managers, adjusters, and internal departments for case resolution. Utilize appropriate desktop resources to perform the case management process. Identify any concerns within the department and bring to the attention of the Clinical Nursing Supervisor and if needed, the Vice President of Operations. Identify quality assurance and risk management issues and bring to the attention of the appropriate management. Precept new staff within the department as requested. Assist with on-call duties on assigned weeknights or weekends and is compensated accordingly. Maintain reliable and predictable attendance during scheduled work hours.
Paradigm
Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm’s business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs. We’re proud to be recognized—again! For the fourth year in a row, we’ve been certified by Great Place to Work®, and for the third consecutive year, we’ve earned a spot on Fortune's Best Workplaces in Health Care™ list. These honors reflect our unwavering commitment to fostering a positive, inclusive, and employee-centric culture where people thrive.
We are seeking a Telephonic Nurse Case Manager with compact RN license and CCM to work Monday - Friday, 8 AM to 5 PM Eastern time zone. NCIC registry and GA Rehab Supplier required upon hire. It's more than a job. It's a passion. Work at Paradigm, and you’ll find deep satisfaction knowing you’re making a profound difference in people’s lives. Meaningful work: better outcomes for all isn’t just our tagline. It’s what guides us to do our best—every day. At Paradigm, you’ll find an authentic connection between the work you do and your passion for making a difference in the world. Exceptional people: You'll work alongside smart people who share a commitment to excellence and a dedication to service. We're not here just for a "job." We're here to transform lives. Collaborative culture: At Paradigm, a spirit of collaboration and care is evident in everything we do. We promote a culture of inclusivity and value diversity of all kinds including thought, knowledge, and experience. No matter the team, everyone works together toward a common goal to deliver exceptional outcomes.
Unrestricted compact RN required CCM required NCIC Registry and GA Rehab Supplier List required upon hire Bilingual (Spanish speaking) preferred Worker’s compensation case management experience strongly preferred ICU/ER experience experience will be considered Case Managers may also need regional or national certifications and must adhere to the standards of practice outlined by the specific national certifying body or the jurisdictionally accepted standards of practice. Professional licenses or certifications required to meet qualifications for this position must be current, unrestricted and allow for practice within a state or territory of the United States.
The Telephonic Case Manager provides remote medical case management services to injured individuals, many of whom were industrially injured. A Telephonic Case Manager assists consumers in their recovery so that they may return to the highest level of function as possible. Medical services are coordinated and assessed frequently, vocational options are explored with the injured worker and their employers, and pre-injury employment or alternate employment is secured. The Telephonic Case Manager works with all parties to the claim including: the injured person, the claim’s examiner, employer, attorneys (plaintiff and defense) and medical providers.
TEKsystems
We’re TEKsystems and TEKsystems Global Services. We accelerate business transformation for our customers, so they can capitalize on change and master the momentum of technology. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. We’re building tomorrow by delivering business outcomes and making positive impacts in our global communities. TEKsystems and TEKsystems Global Services are Allegis Group companies.
Clinical Quality Assurance Coordinator – SIU Division Location: Remote Experience Level: Intermediate Overview We are seeking detail‑oriented and clinically strong Registered Nurses (RNs) or Licensed Vocational/Practical Nurses (LVNs/LPNs) to join our client’s Special Investigative Unit (SIU) as Clinical Quality Assurance Coordinators . In this role, you will support the review of medical services, validate accuracy, and ensure compliance with policies, criteria, and fraud‑waste‑abuse (FWA) standards. You will partner closely with Client Coordinators who process applications and referrals, then rely on you to complete the clinical quality review and communicate findings back to clients.
SIU Division Requirements: Experience in Group Health SIU or similar investigative environments. Strong understanding of Fraud, Waste, and Abuse (FWA) detection and investigative methods. Solid working knowledge of CPT, HCPCS, ICD‑10 codes and billing/payment policies. Ability to identify clinical and billing irregularities with precision. Required Skills: Quality assurance and clinical analysis Nursing documentation software Understanding of insurance policies and clinical documentation Strong written and verbal communication Ability to interpret clinical information and apply criteria accurately
Conduct detailed quality assurance reviews of processed referrals and applications. Verify accuracy of surgeon selection, specialty alignment, and State Insurance usage. Confirm that requested services were completed exactly as ordered—no more, no less. Assess whether services met clinical policies, criteria, and medical necessity. Identify irregularities such as upcoding, unbundling, incorrect modifier usage, or unusual billing patterns. Prepare clear, grammatically accurate reports summarizing findings and clinical rationale. Communicate results to clients via phone and email with professionalism and clarity. Manage quick‑turnaround cases and prioritize workload effectively.
Thyme Care
We exist to create a more connected, compassionate, and confident experience for people with cancer and those who care for them. We make it easier to get answers, access high-quality care quickly, and feel supported throughout treatment and beyond. Today, Thyme Care is a market-leading value-based oncology care enabler, partnering with national and regional health plans, providers, and employers to deliver better outcomes and lower costs for thousands of people across the country. Our model combines high-touch human support with powerful technology and AI to bring together everyone involved in a person’s cancer journey: caregivers, oncologists, health plans, and employers. As a tech-native organization, we believe technology should strengthen the human connection at the center of care. Through data science, automation, and AI, we simplify complexity, improve collaboration, and help care teams focus on what matters most: supporting people through cancer. Looking ahead, our vision is bold: to become a household name in cancer care, where every person diagnosed asks for Thyme Care by name. If you’re inspired to make cancer care more human and to help reimagine what’s possible, we’d love to meet you. Together, we can build a future where every person with cancer feels truly cared for, in every moment that matters.
Thyme Care Inc., the management company to Thyme Care Medical PLLC, is the employing entity with your duties to be performed for Thyme Care Medical PLLC, a medical practice, and its patients. As a Thyme Care Oncology Nurse Navigator, you'll be a vital clinical resource for our members and their care network, offering triage, support, and education throughout their cancer journey via phone and email. Under the guidance of our Nurse Team Lead, you'll conduct comprehensive clinical assessments, oversee member health, and facilitate end-of-life care discussions. Your main objective will involve actively engaging with members, addressing clinical issues, and efficiently managing any escalations that arise. In contrast to TOC and Complex Oncology Nurse roles, this position focuses on symptom management and care coordination, rather than on coordinating admissions, discharges, and post-discharge needs to prevent readmission. The shift for this position is 11:30 AM - 8 PM EST.
Member-Centric Approach: You prioritize the member experience and demonstrate a deep commitment to Thyme Care's mission. Action-Oriented: You proactively identify and prioritize initiatives, taking prompt action to address urgent needs. Organizational Skills: You excel at multitasking and thrive in fast-paced environments while maintaining meticulous organization in communications and documentation. Communication Skills: You are an effective listener and communicator, skilled at building rapport and fostering strong working relationships with members and colleagues. Adaptability: You are comfortable with change and ambiguity and have a proven track record of success in dynamic environments. Qualifications: A Bachelor of Science Degree in Nursing and a compact unrestricted registered nurse (RN) license are required. Compact + single state licensure in New York and/or Illinois licensure is preferred. Additionally, you have at least 5 years of nursing experience, including 3 years in solid tumor oncology nursing. Certifications: Oncology-related certifications such as Oncology Certified Nurse (OCN), Advanced Oncology Certified Nurse (AOCN), Advanced Oncology Certified Nurse Specialist (AOCNS), or Certified Case Manager (CCM) are required or obtained within 2 years of hire.
Familiarize yourself with Thyme Care systems, tools, technology, and partners, conducting a minimum of 20 member calls per day. Collaborate closely with Nurse leaders and Medical Directors to ensure alignment with clinical protocols and best practices. Establish trusting relationships with members and their care network, prioritizing empathy and active listening in every interaction. Adhere to Care Team policies, procedures, and documentation standards, contributing to efficient operations and maintaining quality standards. Support members throughout the oncology care continuum, from screening to survivorship or end-of-life care, coordinating care and providing clinical support as needed. Identify and address member needs promptly, offering assistance with care coordination, symptom management, nutritional support, discharge planning, and provider referrals. Participate in case conferences to monitor member progress, provide updates, and collaborate on targeted support plans with the healthcare team. Foster strong partnerships with payers and providers to optimize care delivery and minimize readmissions. Collaborate with non-clinical Care Team members to address social determinants of health needs, such as food resources and transportation access. Be available for urgent clinical escalations and provide clinical consult support as required Performs other projects and duties as assigned and as related to department business needs and objectives.
Imagine360
Imagine360 is an integrated health plan addressing one of the greatest challenges on behalf of self-funded employers: healthcare costs are harming the bottom line, they're increasingly unaffordable for employees, and the experience remains poor. We help businesses and their employees navigate through clutter and chaos and bring deep cost savings that protect everyone’s well-being and budgets. It’s way more than a health plan. It’s a promise. We’ve helped hundreds of self-funded clients. Our solutions are ready to be implemented. The results are proven and impactful. Imagine360’s innovative payment model includes preferential contracting with providers and health systems, and additional price protection through reference-based pricing, saving employers 15-30% on average compared to the national carriers. With more than 17 years’ experience, and 25-million-months of member data, Imagine360 offers care coordination and medical management to proactively guide members through the complexities of healthcare. We bring employers a reimagined health plan solution, created to provide the flexibility, service and support employers need to take good care of employees, their families and business. We do this through: Assistance with plan design and expert administration with integrated third-party administration Built-in price protection from the #1 reference-based pricing solution in healthcare Provider contracts with Imagine Health’s top-rated providers and health systems Comprehensive member support throughout their healthcare journey It’s more than a health plan. It’s our promise to deliver a better health plan experience.
Imagine360 is seeking a Disease Management Care Coach, Behavioral Health RN to join the team! The Behavioral Health RN Care Coach is responsible for providing telephonic coaching and educational resources to people with chronic health conditions. The RN serves patients with medical, behavioral health, mental health, and/or neurodevelopmental disorder needs. Coaching topics include medication compliance, nutrition, physical activity, and care coordination. Responsibilities include assessment, coordination, planning, monitoring, and evaluation. The RN will receive member referrals from non-Behavioral Health Case Managers and Disease Management clinicians to support the Behavioral Health needs of those members. Position Location: 100% remote
Required Experience/Education: Nursing Degree from an accredited college or university 3+ years' experience working with Behavioral/Mental Health patients or programs Skills and Abilities: Must have intermediate knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software License and Certifications: Active and unrestricted Compact Registered Nurse License required
Provide telephonic coaching, and information and referral services to program participants managing various chronic health conditions with clinical oversight assistance Assess participant needs using scripted assessments Communicate, as needed, with service delivery partners, physicians, and other health professionals to provide care coordination Review pertinent medical history, current diagnosis, and pharmaceutical data via information database system with clinical oversight Assist participant in forming realistic goals related to overall health Determine and provide relevant community and/or healthcare resources that help support participant's goals Promote wellness and provide education regarding preventative care measures Effectively assess, coach and graduate clients from care, resulting in appropriately managed caseloads Document participant activities and coaching/counseling sessions in established format in the case tracking software In addition to performing standard Care Coach roles, Registered Nurses are involved in clinical decision-making and patient education. The scope of practice for nursing work includes, but is not limited to: Rationale for the effects of medications and treatments Implement measures to promote a safe environment for clients and others Accurately report: Administration of medication and treatments Client response Contact with other health care team members The client's status including signs and symptoms Nursing care (education) rendered Respect the client's right to privacy by protecting confidential information Promote and participate in education and counseling to a participant based on health needs Clarify any treatment that is believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner Know, recognize, and maintain professional boundaries of the nurse-client relationship
Imagine360
Imagine360 is an integrated health plan addressing one of the greatest challenges on behalf of self-funded employers: healthcare costs are harming the bottom line, they're increasingly unaffordable for employees, and the experience remains poor. We help businesses and their employees navigate through clutter and chaos and bring deep cost savings that protect everyone’s well-being and budgets. It’s way more than a health plan. It’s a promise. We’ve helped hundreds of self-funded clients. Our solutions are ready to be implemented. The results are proven and impactful. Imagine360’s innovative payment model includes preferential contracting with providers and health systems, and additional price protection through reference-based pricing, saving employers 15-30% on average compared to the national carriers. With more than 17 years’ experience, and 25-million-months of member data, Imagine360 offers care coordination and medical management to proactively guide members through the complexities of healthcare. We bring employers a reimagined health plan solution, created to provide the flexibility, service and support employers need to take good care of employees, their families and business. We do this through: Assistance with plan design and expert administration with integrated third-party administration Built-in price protection from the #1 reference-based pricing solution in healthcare Provider contracts with Imagine Health’s top-rated providers and health systems Comprehensive member support throughout their healthcare journey It’s more than a health plan. It’s our promise to deliver a better health plan experience.
Imagine360 is currently seeking a Case Manager RN to join the team! The RN is responsible to providing case management for individuals under the group health plans administered by Imagine360 by utilizing nursing education, clinical and professional experience. Position Location: 100% Remote
Required Experience / Education: Nursing degree from an accredited college, university, or nursing school Must maintain active, current, and unrestricted Registered Nurse license and CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization 1+ year in Utilization Management, Case Management or transferable skills Pediatrics and or NICU experience is a plus. Must be a Certified Case Manager or eligible to sit for the Certified Case Management Exam within 3 years of starting employment with i360. Must have intermediate knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software Licenses and Certifications: Must maintain active, current, and unrestricted Registered Nurse license and CEU's as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization
Identify, collect, process and manage data to perform the Case Management process by utilization Imagine360 approved clinical guidelines and following Medical Management Policy and Procedures Completes clinical assessments per P&P to identify and deliver indicated medical service coordination Completes medical necessity, utilization management reviews, and review of benefits as part of the pre-determination process Identify and refer cases for Physician Advisor reviews Utilize clinical knowledge, expertise and educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment Assess the need for and collaborate with community resources for members in case management Perform negotiations with providers Uses assigned software accurately to document to complete and document all steps of review of medical necessity and case management process, including time slips Facilitate the Patient Satisfaction Surveys Assess for cost savings and document the cost saving in assigned software platform Appropriately refer complex cases to Manager, Case Management Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and Medical Management Policy and Procedure Participate in the Quality Management Program via collecting and adhering to performance metrics per Case Management Policy
CVS Health
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary: The Transition of Care Coach is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. The TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by: Complete post-discharge questionnaire, which may be market specific. Providing comprehensive discharge planning Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications. Benefit education Provides clinical assistance to determine appropriate services and supports due to member's health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports) Evaluation of health and social indicators Identifies and engages barriers to achieving optimal member health. Uses discretion to apply strategies to reduce member risk. Presents cases at case conferences for multidisciplinary focus to benefit overall member management. Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member's condition(s) and abilities to self-manage. Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up. Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel. Updates the Care Plan for any change in condition or behavioral health status. Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality.
Required Qualifications: 2+ years’ work experience as a Licensed Practical Nurse (LPN) Candidate must be a Licensed Practical Nurse (LPN) with active and unrestricted status Discharge planning experience Advanced proficiency in Microsoft Word, Excel, and Outlook Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care Effective verbal and written communication skills Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses Preferred Qualifications: Bilingual Education: High School Diploma OR Equivalent Experience (REQUIRED) Associate's Degree (PREFERRED) Bachelor's Degree (PREFERRED) License: Active and unrestricted Licensed Practical Nurse (LPN)
Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines. Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions. Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community. Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions
UVA Health
Based in Charlottesville, Va., UVA Health embodies the leadership and inventiveness personified by its founder, Thomas Jefferson. In 1825, Jefferson established the nation’s 10th medical school, which has since grown into a nationally renowned academic medical center. UVA Health includes a 612-bed hospital, level I trauma center, children's hospital and primary and specialty clinics throughout Central Virginia. Ranked among the best hospitals by U.S. News & World Report, UVA has doctors, nurses and other healthcare professionals recognized as leaders in their fields and who make every effort to push the envelope of medicine.
Capable clinician, focused on expanding knowledge and skills. Consistently provides effective direct care, as part of the interdisciplinary team, to a variety of complex patients. Manages care and implements treatment plans at a refined skill level in collaboration with patients, their families, physicians, and other members of the health care team. Seeks as well as provides feedback for improved clinical practice. Assumes a beginning leadership role but seeks mentoring in this process. This job description integrates the AAACN Scope and Standards of Practice for Professional Ambulatory Care Nursing, the ANA Nursing: Scope and Standards of Practice, and the ANA Code of Ethics for Nurses with Interpretive Statements, with the UVA Nursing Professional Practice Model. ANA Scope and Standards of Practice definition of nursing: Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities and populations.
Education: Graduate of an accredited nursing program required. Bachelor of Science in Nursing required within 5 years of hire. Experience: 1 year of relevant experience. Licensure: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia. American Heart Association (AHA) Healthcare Provider BLS certification required. PHYSICAL DEMANDS: Job requires standing for prolonged periods, frequently traveling, bending/stooping. Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly; Ability to lift/push/pull 20 - 50lbs. May be exposed to chemicals, blood/body fluids and infectious disease
Relationship Based Care - Self and Colleagues: reflects the influence of the nurse's relationship with self, colleagues, and patient/family on the patient's experience. Relationship Based Care - Patients and Families: reflects the influence of the nurse's relationship with self, colleagues, and patient/family on the patient's experience. Expert Caring: encompasses clinical assessment, planning, prioritizing, coordinating, and implementation of care. Empowered Leaders: demonstrate knowledge of and actively participate in shared governance. Lifelong Learners: encompasses professional development through formal education, professional certification, and internal and external learning opportunities and recognizes the value of external professional organizations. Supports onboarding of new team members and precepts as applicable. Quality Achievement: includes adherence to clinical documentation guidelines, comprehension of outcomes data, engagement in performance improvement activities, and commitment to standard work. Innovation: is demonstrated by the application of technologies that support patient care, actively seeking to implement evidence-based practice and new knowledge generated by nursing research. In addition to the above job responsibilities, other duties may be assigned.
Evolent
Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture.
Technical Requirements: We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.
Evolent
Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture.
Technical Requirements: We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.
To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration.
Within Health
Within Health is revolutionizing eating disorder treatment through our innovative telehealth platform. We provide remote clinical services at the Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) levels of care. Our mission is to transform lives by increasing access to quality eating disorder treatment, improving patient outcomes, and fostering healing in a compassionate, stigma-free environment. We combine clinical expertise with cutting-edge technology to address the complex needs of individuals with eating disorders, creating a future where effective treatment is accessible to all who need it.
The Registered Nurse (RN) Team Lead will function as the Lead of a larger multidisciplinary treatment team. They will work closely with clients and monitor providers in order to provide the best care possible to our eating disorder clients. They will be responsible for assessing clients, contributing to the multidisciplinary treatment plan, providing weekly coaching to parents/loved ones, completing concurrent utilization review, and evaluating a client’s overall care in order to ensure they are progressing towards their treatment goals. They will also interface with clients by facilitating, and co-facilitating groups throughout the week. They will also serve as a liaison with clients, families, providers, community organizations and other health related service agencies to provide quality care to our clients. The RN specializes in working with clients with eating disorders, is thoughtful, sensitive, respectful, flexible, and brings a loving, positive attitude to our expert Clinical Team. Shift times will vary and may include on-call hours at night and on weekends.
An RN with an active, unrestricted, unsupervised RN license, with willingness to obtain additional RN licenses or Compact license in multiple states. 3+ years experience as an RN in an eating disorder or behavioral health setting. Minimum 1 year of supervisory experience. Strong communicator, both verbally and in writing. Ability to foster teamwork and create a cohesive work environment in a virtual setting. Experience treating clients with eating disorders and Disordered Eating preferred. Ability to demonstrate understanding of a variety of models and theories of eating disorders, trauma, mental illness, and related issues. Knowledge of philosophies, practices, policies and outcomes of models of treatment, recovery, relapse prevention, and continuing care for dually diagnosed populations. Understanding of diagnostic criteria for co-occurring conditions and ability to conceptualize modalities and placement criteria within the continuum of care. Understanding of diverse cultures and gender specific issues and ability to incorporate needs of gender and culturally diverse groups into practice settings. Excellent organizational and time management skills. Ability to prioritize workload and work independently. Physical & Environmental Requirements Must have reliable internet connection. Must be comfortable operating a computer and smart-phone and navigate applications within macOS and iOS. Must be comfortable communicating with colleagues and patients via chat, telephone, and video calls. Must be able to sit for the majority of the shift. This is a work-from-home position. Work should be performed in a private, quiet space with minimal background noise.
Perform focused nursing assessments utilizing remote patient monitoring devices. Oversee a team of therapists, dietitians, and care partners providing recommended treatments for clients. Document all client interactions appropriately and within designated timeframes. Conduct weekly family coaching calls. Coordinate care and program services with patient, family, treatment team, and outpatient team. Educate clients, and family members when appropriate, regarding medical complications of eating disorders. Educate clients, and family members when appropriate, regarding psychiatric medications. Provide in-the-moment feedback by utilizing between-session messaging to motivate and support clients and families. Alert medical and clinical professionals to intervene during emergencies. Maintain strict client confidentiality. Participate in Staff meetings. Participate in scheduled Partnership Meetings. Participate in scheduled Family Partnership Meetings. Facilitate or co-facilitate groups as appropriate. Attend supervision and department meetings. Participate in initial and ongoing training. Provide case management for clients, ensuring effective communication with those involved in the recovery process, including school administrators, law enforcement, attorneys, etc. Communicate with clients, family members, team members, & outpatient teams in a timely and consistent manner. Give direction and direct feedback to different team members. Other related duties as assigned based on need.
Thyme Care
We exist to create a more connected, compassionate, and confident experience for people with cancer and those who care for them. We make it easier to get answers, access high-quality care quickly, and feel supported throughout treatment and beyond. Today, Thyme Care is a market-leading value-based oncology care enabler, partnering with national and regional health plans, providers, and employers to deliver better outcomes and lower costs for thousands of people across the country. Our model combines high-touch human support with powerful technology and AI to bring together everyone involved in a person's cancer journey: caregivers, oncologists, health plans, and employers. As a tech-native organization, we believe technology should strengthen the human connection at the center of care. Through data science, automation, and AI, we simplify complexity, improve collaboration, and help care teams focus on what matters most: supporting people through cancer. Looking ahead, our vision is bold: to become a household name in cancer care, where every person diagnosed asks for Thyme Care by name. If you're inspired to make cancer care more human and to help reimagine what's possible, we'd love to meet you. Together, we can build a future where every person with cancer feels truly cared for, in every moment that matters.
As an Oncology Nurse Team Lead, you will oversee and manage one or more of our frontline nurse teams, ensuring their ability to deliver the highest standards of clinical care and operational efficiency as they advocate, coach, and provide members with clinical guidance throughout their care journey. Reporting to the Nurse Manager, you will manage clinical escalations, provide ongoing training, coaching, and mentoring to your teams, drive the productivity and performance of your team, and foster cross-team collaboration. This role is pivotal in driving individual and team performance, identifying opportunities for quality improvement initiatives and enhancing Thyme Care's service offerings by effectively communicating feedback to our clinical leadership from members, providers, and your teams. To excel in this role, you must demonstrate strong leadership and mentorship capabilities, with a proven track record of managing hourly staff and high-performing nurse teams. You are a proactive problem solver who views challenges as opportunities for growth and is committed to continuous improvement. Experience in healthcare, particularly in oncology, as a nurse navigator or case manager is essential. Knowledge and an understanding of provider and health plan operations are also beneficial.
A BSN. You must have a Bachelor of Science Degree in Nursing, a multi-state, unrestricted Registered Nurse (RN) compact license, and a willingness to obtain additional state licenses, as needed. Experience. You have at least 8 years of nursing experience, with 2 years as a people manager in oncology and/or case management. Additionally, you are certified as an Oncology Certified Nurse (OCN), Advanced Oncology Certified Nurse (AOCN), Advanced Oncology Certified Nurse Specialist (AOCNS), or Certified Case Manager (CCM). Team player. You're a strong collaborator who understands what it's like to lead a team in a growing and evolving environment. You'll ensure your team meets and exceeds the standards set while collaborating with the rest of the organization. Effective listener and communicator. You are winsome and articulate, but you always start with listening and hearing what may not be voiced because you listen intently to others. You build rapport and excellent working relationships with your team, leadership, and stakeholders. Comfort with ambiguity. You have a proven track record of success within scaling businesses, fast-paced environments, and startups. You understand that rapid changes to the business, strategy, organization, and priorities is par for the course… and part of the adventure. Coach. You know your team's strengths and what motivates them, and you strive to keep morale high while constantly challenging them to beat their best and never lose sight of the goal. Grit. You're never afraid to get your hands dirty, but you can also take a step back and connect the company's strategy to your team's performance and execution. A desire to learn how to use new technologies. We are a technology company focused on interacting with folks during the season when they need it most. Experience with video chatting, Google Suite, Slack, electronic health records or comfort in learning new technology is essential. Identify priorities and take action. You know how to identify and prioritize your team's needs and do what it takes to address urgent and essential needs immediately. Bias to action. You're a self-starter and don't need anyone to tell you when to do something. You're always solving problems and going the extra mile for others.
Have completed Nurse training and demonstrated competencies in a Nurse role. Know our Care Team policies and procedures, escalation pathways, communications best practices, and documentation standards backward and forward, and actively share ideas on improving them. Be on the path to becoming an expert on our Thyme Care systems, tools, technology, partners, and expectations. Directly manage and serve as an escalation point to a team of Oncology Nurses, including but not limited to escalated member or caregiver interactions and process-related questions or issues. Have built strong, trusting relationships with your team and leadership, where listening and empathy are the foundation for every interaction. Lead team meetings such as weekly team huddles to drive queue management, prioritization, and performance, and ultimately establish targeted support plans. Act as an air traffic controller by monitoring assignments and ensuring queues are effectively and efficiently managed. Understand the performance of your direct team members, both quality and productivity and address issues and challenges through coaching, mentorship, and performance improvement plans. Understand the skills, qualities, and experience that set a candidate up for success and participate in the oncology nurse interview loop. Support our nurses in identifying and prioritizing member needs and assisting them with care coordination and clinical support such as symptom management, nutritional support, discharge coordination, connecting members to high-quality providers, and preventing readmissions. Provide clinical expertise in medical, behavioral, and crisis management. Provide support on building and maintaining resources, optimizing schedules, and contributing to updating staffing requirements, project initiatives, and policies and procedures. Provide support in conducting root-cause analyses to identify knowledge, data, or procedure gaps. Drive engagement and promote the Thyme Care vision and strategy. Be available for urgent clinical escalations and clinical consult support. Provide Nurse overflow, holiday, and on-call coverage support as needed. Develop strategies to promote culturally competent care and close the health literacy gap.
Alignment Health
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.
The Remote Inpatient Review Nurse assists patients through the continuum of care in collaboration with the patient’s primary care physician, facility case manager, discharge planner and employing contracted ancillary service providers and community resources as needed. Assures that services are provided at the most appropriate, cost effective level of care needed to meet the patient’s medical needs while maintaining safety and quality. Schedule: Monday - Friday, 8:00 AM - 5:00 PM Pacific Time (Required)
Experience Required: Minimum 3 years of general case management skills. Minimum of two years of experience utilizing Milliman Care Guidelines to justify Inpatient versus Observation Length of stay: including review of diagnosis and length of stay. Two consecutive years related experience in a managed care setting as an inpatient case manager Preferred: Experience with a Senior population. Education Required: Successful completion of an accredited Licensed Vocational Nursing Program Preferred: Associates or Bachelors Degree Specialized Skills Required: Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others. Excellent critical thinking skills related to nursing utilization review Knowledge of Medicare Managed Care Plans Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors; Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. Report Analysis Skills: Comprehend and analyze statistical reports. Preferred: Knowledge and experience in complex/catastrophic case management preferred Licensure: Must have and maintain an active, valid, and unrestricted LVN or 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. The noise level in the work environment is usually moderate. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this fully remote job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, hand, or feel and talk or hear. The employee is frequently required to reach with hands and arms The employee is occasionally required to climb or balance and stoop, or kneel The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.
Performs reviews of inpatients with complex medical and social problems. Generates referrals to contracted ancillary service providers and community agencies with the agreement of the patient’s primary care physician. Performs follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting. Reviews inpatient admissions timely and identifies appropriate level of care and continued stay based on acceptable evidence-based guidelines used by AHC. Effectively communicates with patients, their families and or support systems, and collaborates with physicians and ancillary service providers to coordinate care activities. Identifies Members who may need complex or chronic case management post discharge and warm handoff to appropriate staff for ambulatory follow up, as necessary. Communicates and collaborates with IPA/MG as necessary for effective management of Members. Assigns and provides daily oversight of the activities and tasks of the CCIP Coordinator. Records communications in EZ-Cap and/or case management database. Arranges and participates in multi-disciplinary patient care conferences or rounds. Monitors, documents, and reports pertinent clinical criteria as established per UM policy and procedure. Monitors for any over utilization or underutilization activities. Generates referrals as appropriate to the QM department. Enters data as necessary for the generation of reports related to case management. Reports the progress of all open cases to the Medical Director, Director of Healthcare Services and Manager of Utilization Management. Performs other duties as assigned.
Alignment Health
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 an organized, detail-oriented, and customer service oriented telehealth coordinator (bilingual Spanish, medical assistant with front- and back-office, and remote experience) to join the remote Virtual Care Center (VCC). As a telehealth coordinator, you will support patients and providers in the Virtual Care Center. This includes, but is not limited to, answering calls in the phone queue, scheduling telephonic and virtual appointments, following up on referrals and authorizations, supporting outbound follow up calls, providing systems trainings for new hires, and completing administrative tasks. You will also be responsible for managing inbound and outbound calls in the phone queue while collaborating with cross-functional teams such as Clinical Operations, Member Services, AVA Product team, and DTS Help Desk support to successfully manage the program. As a telehealth coordinator, you will be focused on assisting Alignment Health staff and patients with resolving issues in a timely manner. This role reports to the Director of Virtual Health. Individuals with front and back office medical assistant experience in PCP, clinic, and / or urgent care settings, and remote experience are highly encouraged to apply! Schedule: - Option A: Monday / Tuesday / Wednesday / Friday / Saturday 9:00 AM – 6:00 PM Pacific Time (Thursdays and Sundays off) - Option B: Sunday / Monday / Tuesday / Wednesday / Thursday 11:00AM – 8:00 PM Pacific Time (Fridays and Saturdays off)
Required: Experience with providing high quality customer service Experience providing technical assistance Minimum 1 year experience in a primary care or medical office setting using phones and scheduling appointments Education Required: High school diploma or general education degree (GED). Preferred: Completion of medical assistant program from an accredited school of training. Training Preferred: Medical Terminology Specialized Skills Required: Able to use multiple systems simultaneously Basic understanding in current mobile device technology and ability to learn and adapt to Alignment specific applications and protocols Proficiency in Microsoft Suite programs (Outlook, Teams, Work, Excel) Basic math skills required for data analyzation Able to trouble-shoot and research issues effectively Willingness and capability to learn new technologies and adapt to dynamic environment Strong customer service skills Technology and automated solutions oriented Well organized with strong attention to detail and analytical skills while maintaining speed in completing work Efficient working style with strict adherence to deadlines Preferred: Bilingual Spanish Licensure Required: None Preferred: Medical assistant certificate Medical terminology certificate 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.
Answer inbound calls on the Virtual Care Center queue Collect appropriate patient information for scheduling virtual appointments with providers Screen patients for appropriate telehealth platform use for virtual appointments Support providers with requests for referrals and authorizations including submission, review, and follow up of requests Contact partnered medical offices to support patient requests as necessary (ie. IPA groups, PCP offices, pharmacies, DME companies) Complete outreach calls for various patients’ groups as applicable (ie. ER admits, Teladoc follow ups, Annual assessments) Support new hire onboarding by completing training or shadowing sessions of systems used in VCC Complete other job duties as assigned Participate in team meetings Note: The Virtual Care Center provides 24-hour member support, and team schedules rotate to maintain coverage. Because there is no single time when all team members are consistently on shift, team meetings are mandatory and are scheduled with advance notice (approximately 2× per month for 30 minutes). Team members are expected to attend these meetings even if they occur during a non-scheduled work hour or meal break. Attendance is clocked and paid, and camera use is optional — phone participation is acceptable. Supervisory Responsibilities: N/A
Alignment Health
Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.
Location: Fully Remote (Must be licensed in California) (HIPAA compliant work space) Schedule: Monday–Friday, 8:00 AM – 5:00 PM PT Language: Bilingual candidates strongly preferred (Spanish and Vietnamese) Join the Team That’s Redefining Healthcare! Are you a compassionate Registered Nurse with a passion for improving the lives of seniors and complex care patients? Join Alignment Health as a Telephonic RN Case Manager for our Special Needs Plan (SNP) members — all from the comfort of your home! This is a fully remote, phone-based position where you'll play a vital role in helping members navigate their care journeys, close gaps in care, and overcome barriers to better health. (HIPAA compliant work space)
Must-Haves: Active, unrestricted RN license in California (Non-Compact) Minimum 2 years of clinical nursing experience At least 1 year of case management experience Proficiency with Microsoft Office (Word, Excel, Outlook) Nice-to-Haves: Bilingual (Spanish, Korean, Mandarin, etc.) Previous health plan or IPA experience Bachelor's Degree in Nursing (BSN) Licensure Requirement Upon Hire: Must be willing to obtain RN licensure in Nevada, Arizona, North Carolina, and Texas (company reimburses costs) Work Environment Fully remote — work from anywhere in the U.S., but must work Pacific Time hours All communication is conducted via phone, email and Teams. Company-provided equipment and IT support included
As a Fully Remote RN Case Manager (SNP), you will: Provide telephonic case management to medically complex and chronically ill members Conduct comprehensive health assessments and create individualized care plans Coordinate care with internal and external partners, including physicians and specialists Educate members and caregivers on disease management and preventive care Monitor member progress and advocate for timely, appropriate interventions Identify and help resolve service or access issues impacting care quality
BioMatrix Infusion Pharmacy
BioMatrix is a nationwide, independently-owned infusion pharmacy with decades of experience supporting patients on specialty medication. Our compassionate care team helps patients navigate the often-challenging healthcare environment. We treat our patients like family and get them started on therapy quickly. We work closely with them as well as their family and their healthcare providers throughout the patient journey, staying focused on optimal clinical outcomes.
GENERAL DESCRIPTION The Nursing Learning and Development Specialist supports Nursing by delivering ongoing education and reinforcing practice, with a strong emphasis on learning and adoption related to nursing software and system changes. This role is embedded early in Nursing IT and software initiatives to support learning, training, and adoption from start to finish. The role sits within the L&D team and partners closely with Nursing leadership to ensure education aligns with real-world nursing workflows and evolving technology.
MINIMUM REQUIREMENTS Active or previous work experience as a licensed RN 3+ years' experience in nursing education, clinical education, or practice-based training Strong understanding of nursing workflows and clinical practice environments KNOWLEDEGE, SKILLS AND ABILITIES REQUIREMENTS Computer Skills Become and remain proficient is all programs necessary for execution. Strong facilitation and presentation skills Effective verbal and written communication skills Ability to collaborate cross-functionally with Nursing, IT, and L&D teams Strong interpersonal skills and ability to influence without direct authority
Be embedded early in Nursing IT and software initiatives to support learning and adoption end-to-end Partner with Nursing leadership, IT, and L&D to ensure education and training are addressed throughout system changes Support identification of learning needs related to software updates, system changes, and workflow impacts Plan and deliver ongoing nursing education, including quarterly in-services and targeted learning initiatives Reinforce nursing practice through timely, relevant education aligned to how work is performed Support professional development and continuous learning for Nursing teams Practice, Process & Gap Identification Apply a systems and process lens to understand why gaps occur Bring insights back to L&D to inform learning strategies and support solutions Evaluate nursing workflows to identify opportunities for improvement in processes, system access, and staff understanding to enhance clinical practice. Collaboration & Partnership Ability to think in workflows, processes, and implement such Partner closely with Nursing leadership to align education priorities to operational needs Work within the L&D team to support learning solutions and adoption efforts Provide input and validation on training content to ensure clinical accuracy and relevance NON-ESSENTIAL FUNCTIONS & RESPONSIBILITIES Participate in special projects as assigned Support additional L&D initiatives outside of core nursing education when needed Attend team meetings, organizational training sessions, and professional development activities.
BioMatrix Infusion Pharmacy
BioMatrix is a nationwide, independently-owned infusion pharmacy with decades of experience supporting patients on specialty medication. Our compassionate care team helps patients navigate the often-challenging healthcare environment. We treat our patients like family and get them started on therapy quickly. We work closely with them as well as their family and their healthcare providers throughout the patient journey, staying focused on optimal clinical outcomes.
The Clinical Liaison assists in supporting patient management activities. This role serves as a clinical partner to Sales, Intake, and Operations, supporting the referral process from initial receipt through clinical approval and transition into the patient care workflow. While not directly responsible for conducting clinical reviews or completing patient assessments or care plans, the Clinical Liaison maintains a strong understanding of these processes to effectively coordinate across teams. Responsibilities include reviewing patient charts and clinical documentation for completeness, coordinating timely follow-up with physicians’ offices, nursing staff, and sales representatives, providing status updates, and resolving barriers to progression. The role also includes completing welcome and educational calls with patients, supporting patient engagement, assisting with compiling patient reports, and performing related administrative tasks as needed. This position requires an active RN license and is primarily remote, with the ability to work on-site at a BioMatrix location as needed.
Bachelor’s Degree in Nursing Valid RN license in good standing- preferrable compact RN license. 3 + years related work experience in specialty infusion therapy patient care Proficient level computer and internet skills (e.g. Microsoft Office, etc). Willing to travel for business purposes (when necessary to attend meetings, conferences, seminars, etc.) Master’s Degree in Nursing preferred, but not required. Solid Organ/Transplant experience and management of patients background preferred, but not required. Knowledge of all Transplant software (UNOS, SRTR) preferred. Knowledge of pharmacy software a plus. KNOWLEDEGE, SKILLS AND ABILITIES REQUIREMENTS: Able to function independently under remote supervision Excellent written and verbal skills Attention to detail and high level of accuracy in work Excellent patient engagement and clinical assessment skills Demonstrates sound judgement consistent with evidence based medicine Demonstrates critical thinking and excellent problem solving
Assists intake and pharmacy staff in searching and coordinating with home health nursing agencies in the care of patients (if applicable). Also provides training for nurses contracted by home health nursing agencies in infusion therapies and protocols. Provide clinical review of new referrals to ensure completeness, accuracy and appropriate diagnosis. Maintain and report active patient lists for high-volume centers and facilitate recurring virtual meetings to address issues, improve coordination, and enhance patient care Assists in data collection and monitoring of all clinical trials and protocols as assigned. Assists pharmacists with BioMatrix regulatory compliance program including the implementation of tracking systems and audits to ensure compliance with federal, state and pharmacy regulatory standards including HIPAA, and health and safety codes (i.e. risk management, medication - use safety, fire safety and infection control). Maintains a working knowledge and is up-to-date on federal, state and pharmacy laws and regulations as applied to operations. Provides HIPAA compliance and Medicare’s Fraud, Waste, and Abuse training to employees, annually and ongoing as needed. Maintains patient confidentiality in remote work environment as per HIPAA Privacy Rule standards. Maintain and review a list of active patients with current issues that requires attention, and partner with various internal teams to solution and resolve. Coordinate with field team to resolve any issues, pressing concerns, MD communication coordination support needs, and office visit schedule in order to provide status updates for both pending and active patients (post start of care/first infusion follow up). Support all PA submission activities including case evaluation for completeness of diagnosis, appropriate DX, conformance to payor medical policy prior to PA submission, creation of LMN, support Peer to Peer when necessary. Work with Operations to establish a clinical review for each new referral. Function as main POC (in collaboration with Transplant Services Program Manager) for referred patients, MD/MDO for order verification, clinical questions, general question regarding care process. Partner with field nursing team on care of active patients including next infusion schedule/scheduling, and MD visit schedule. NON-ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Participation in membership in professional societies and organizations. Ability to prioritize and handle multiple tasks and projects concurrently. Careful attention to detail. Performs related duties as requested. Participates in quality assurance activities and audits as directed.
Walker Healthforce
Walker Healthforce is known as the dominant force of performance, precision, expertise, and integrity in the healthcare consulting community! As a certified WMBE, we provide end-to-end healthcare IT and clinical solutions to hospitals, health systems, and payer organizations, including Fortune 100 firms nationwide. We are healthcare experts, we’re custom not commodity and we’ve been exceeding expectations for nearly 20 years. Join forces with us to experience unparalleled results today!
Appeals Nurse | 2 years’ experience | Remote | Contract Walker Healthforce is seeking a Appeals Nurse with 2 years of experience to support a healthcare client based out of New Jersey. This is a 3-month contract opportunity. MUST BE A RESIDENT OF THE FOLLOWING STATES: NJ, NY, DE,CT, PA. START DATE: ASAP HOURS/SCHEDULE: 8am-5pm EST Monday- Friday WORKER TYPE: W2
CORE REQUIREMENTS: Requires an active Compact Licensure - NJ, NY, DE,CT, PA 2 Years of Clinical Experience Proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes 3 - 5 years of experience with a background in either Utilization Management, Prior Authorization – Medical Surgical (Inpatient or Outpatient), Complex Case Management w/ exposure to UM, Concurrent or Retrospective Medical Policy Review. Familiarity interpreting Milliman Care Guidelines MCG guidelines and CareRadius platform exposure is also desirable. May be required to reach out to providers via phone and fax Ability to make sound clinical judgements quickly to maintain turnaround time while being accurate. Strong computer proficiency with general navigation, typing, copy/paste, etc. Relevant tools include: CareRadius, Outlook, Teams, OneNote, Excel Requires an associate’s or bachelor’s degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school. ADDITIONAL REQUIREMENTS: Health Insurance Payer experience preferred, however will accept Health System UM related experience. Must be located New Jersey, New York, Pennsylvania, Delaware, or Connecticut Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications. Prefers working knowledge of case/care management principles. Prefers working knowledge of principles of utilization management. Prefers basic knowledge of health care contracts and benefit eligibility requirements. Prefers knowledge of hospital structures and payment systems. WE CONSIDER IT A BONUS IF YOU ALSO HAVE: Experience with Medicare, Medicaid and/or DSNP programs Familiarity interpreting Milliman Care Guidelines MCG guidelines, CMS Guidelines and Care Radius platform exposure
Appeal Analyst RN who will train new hire in the clinical role to complete Utilization Management Appeals and act as an RN II on the team Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. Coordinates and assists in implementation of plan for members. Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care. Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness. Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided. Encourages member participation and compliance in the case/disease management program efforts. Documents accurately and comprehensively based on the standards of practice and current organization policies. Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care. Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. Completes other assigned functions as requested by management.
COPE Health Solutions
COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit CopeHealthSolutions.com.
The Care Manager (CM) RN will lead a multidisciplinary healthcare team in a primary care / telephonic setting, focusing on coaching and coordination of care for patients needing navigation, addressing nursing care needs and follow up after clinical events. The CM RN will identify the needs of patients at risk and assist the providers to develop processes for managing the patient’s preventative care, transitions of care, and or chronic disease management using defined protocols as well as their own sound clinical judgement. This person will promote patient-centered care, working with primary care providers and medical home team members. The CM RN is a key role in the care coordination of patients attributed to value based contracts. Position Description: The Care Manager (CM) RN will lead a multidisciplinary healthcare team in a primary care / telephonic setting, focusing on coaching and coordination of care for patients needing navigation, addressing nursing care needs and follow up after clinical events. The CM RN will identify the needs of patients at risk and assist the providers to develop processes for managing the patient’s preventative care, transitions of care, and or chronic disease management using defined protocols as well as their own sound clinical judgement. This person will promote patient-centered care, working with primary care providers and medical home team members. The CM RN is a key role in the care coordination of patients attributed to value based contracts.
Qualifications or Education, Training and Experience Compact RN License – California and NY Licensure preferred in addition Bachelor’s degree in nursing preferred; Associate degree in nursing is minimum requirement. 1-2 years’ experience in acute inpatient, rehabilitation, sub-acute, skilled facility, home care, ambulatory care management, or managed health plan. Preferred: Certified Case Management (CCM) certification Preferred: Care/Case Management experience Working knowledge of the following required: Principles of utilization management; care management principles; basic knowledge of health plan contracts and benefit eligibility requirements; Hospital structures, Managed Care and payment systems Timely and accurate documentation of day-to-day activities in designated technology platform Adaptable to new technologies and software Proficiency in EMR system(s), Outlook and data entry experience preferred Basic PC skills (MS Word/Outlook/PPT/Excel) Examples of Competencies: Ability to use independent judgment and to manage and impart confidential information. Ability to analyze and solve problems; requires details, data and facts that must be analyzed and challenged prior to making decisions. Strong communication and interpersonal skills. Ability to clearly communicate medical information to professional practitioners and/or the public. Excellent organization, prioritization, follow up, analytical and time management skills with ability to handle multiple priorities and deadlines. Good interpersonal skills, sense of urgency, being proactive and ownership for one’s work. Dependable, with strong work ethic and extremely high degree personal integrity. Ability to deal with multiple interruptions on a continual basis that must be met with a friendly exchange with others. Ability to develop and implement new approaches to improve processes, procedures, or the general work environment. Ability to review critical issues, effectively solve problems and create action plans.
Evaluates patients for care management services, determines appropriate level of care coordination management for the patient Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing clinical expertise and judgement to evaluate needs for alternative services as needed Work collaboratively with physicians and in-house resources including pharmacists, registered dieticians, social workers and other disciplines to create a person-centered care plan with measurable SMART goals Monitor and update care plan to include progress towards achieving established goals and self-management activities Interact with patient, family and providers and multidisciplinary care team to assess the options of care including use of benefits ad community resources to update care plan. Utilize developed systems, processes, and initiatives to engage patients in relevant case management activities necessary to promote wellness and care at the right place and time. Work collaboratively with physicians and in-house resources including pharmacists, registered dieticians, social workers and other disciplines to support patient adherence to medical plan of care. Supervise and act as a resource for non-clinical staff [i.e. care coordinators, social workers]. Verify that appropriate home care, hospice care, and other ancillary services (DME, infusion services etc.) are in place and are being delivered as directed by the care team Coordinate necessary referrals and authorizations within care management areas Facilitate the information flow between hospital, long-term care, specialists and home health representatives and the care team Use available data and work with physician and office staff to help identify high risk, high need, and potentially high-cost patients Coordinate care and communicate with multiple providers, internal and external to the practice. Identify and utilize cultural and community resources and align with the patient’s cultural preferences as much as possible Verify that members are screened for behavioral health concerns (depression / substance abuse) and are receiving appropriate screening and behavioral health interventions. Facilitate any necessary follow-up behavioral health needs with local behavioral health providers. Attend required training and collaboration sessions [i.e., learning sessions, care management meetings, and practice team meetings] as scheduled. Provide and facilitate open communication, regarding patient status, with physicians and office staff. Obtain records from other physicians/labs/diagnostic centers as requested by the physicians and as needed for care coordination efforts. Develop constructive relationships with internal population health team members, participating providers, and community resources. Other job-related duties as assigned
COPE Health Solutions
COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit CopeHealthSolutions.com.
Resolves grievances, appeals and external reviews for one Health Plan LOBs. Ensures regulatory compliance, timeliness requirements set by regulatory agencies, and accuracy standards are met. Coordinates efficient functioning of day-to-day operations according to defined processes and procedures. Creates and maintains accurate records documenting the actions and rationale for each grievance or appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Completes responsibilities within defined deadlines, so as to avoid negatively impacting Operations. Assists with collecting and reporting data. FLSA Status: Exempt Salary Range : $85,000-$95,000 Reports To: Utilization Management Director Direct Reports : None Location : Remote Travel : Up to 10% Work Type : Regular Schedule : Full Time
Qualifications or Education, Training and Experience: Compact Licensed RN required - California and New York State licensure preferred Bachelor’s degree in nursing preferred; Associate degree in nursing is minimum requirement. Knowledge of Medicare and Medicaid regulations Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills. Working knowledge of Microsoft Excel, Power-Point, and Word and strong typing skills Knowledge of Medicaid and/or Medicare regulations Knowledge of Milliman criteria (MCG) For UM Only: Previous Managed Care Organization or Health Plan experience. 3 years previous experience working in Appeals and Grievances Experience working with community-based organizations in underserved communities Working knowledge of the following required: Principles of utilization management; care management principles; basic knowledge of health plan contracts and benefit eligibility requirements; Hospital structures, Managed Care and payment systems Timely and accurate documentation of day-to-day activities in designated technology platform Adaptable to new technologies and software Proficiency in EMR system(s), Outlook and data entry experience preferred Basic PC skills (MS Word/Outlook/PPT/Excel)
Develops and maintains current knowledge of state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, managed long term care as well as contractual requirements. Investigates and reviews routine and complex situations and underlying issues, analyzes and solves problems, focusing primarily on issues of medical necessity, quality of care, long term services and supports, etc.. Consults with the member, family, providers and health plan departments as necessary. Identifies and communicates key points from details. Investigates and coordinates the resolution of routine and complex grievances and appeals according to defined processes and procedures ensuring that required timeframes and regulatory requirements are met, accurate and timely follow up is completed and activities are documented as required. Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure appropriate appeal resolution and execution of the plan’s fiduciary responsibilities. Prepares records for physician review as needed. Conducts review of requests for prior authorization of health services, as required in certain product lines, and prepares written responses consistent with regulatory requirements. Coordinates external case reviews requested by enrollees, including preparing and submitting documentation according to regulatory requirements and tracking external reviews throughout the process. External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services (CMS), Independent Review Entities and Quality Improvement Organizations. Collaborates with professionals, health plan departments such as Claims and Medical Management, and the third party administrator staff and legal, as necessary, to investigate and facilitate resolution of individual grievances and appeals. Consults with enrollees, providers and the Medical Director, as appropriate. Provides input and recommendations for design and development of policies, processes and procedures for improved department operations and customer service. Reviews information available from Medicaid, Medicare, other payers, and/or professional medical organizations regarding benefit levels and medical necessity criteria. Enters data and assists with compiling reports and analysis on the grievance and appeals process. Provides timely case completion with strict adherence to required regulatory and department timeframes, which may require after hours and weekend scheduled work. Works outside of regularly scheduled hours, as needed for timely case resolution, or as scheduled for coverage purposes by department management.
BRG
BRG combines world-leading academic credentials with world-tested business expertise purpose-built for agility and connectivity, which sets us apart—and gets you ahead. At BRG, our top-tier professionals include specialist consultants, industry experts, renowned academics, and leading-edge data scientists. Together, they bring a diversity of proven real-world experience to economics, disputes, and investigations; corporate finance; and performance improvement services that address the most complex challenges for organizations across the globe. Our unique structure nurtures the interdisciplinary relationships that give us the edge, laying the groundwork for more informed insights and more original, incisive thinking from diverse perspectives that, when paired with our global reach and resources, make us uniquely capable to address our clients’ challenges. We get results because we know how to apply our thinking to your world. At BRG, we don’t just show you what’s possible. We’re built to help you make it happen.
Clinical and Quality Transformation (CQT) helps providers improve care for their patients by implementing evidence-based leading practices to enhance clinical quality, operational efficiency, and care delivery. CQT’s broad-based engagements help providers transform how they deliver care through a combination of reduced complications and mortality, optimizing surgery quality and operations, improved throughput and length-of-stay reduction, improved emergency department performance, quality infrastructure enhancements, and more accurate clinical coding and documentation—helping organizations deliver better patient care and outcomes while most effectively utilizing their clinical resources and infrastructure.
Support Project Workstream(s) Under The Direction Of The Project Workstream/pilar Subject Matter Expert (SME), Or Serve As The SME If It Is In The Individuals Core-knowledge Area Supporting SME in non-core knowledge area: Support CPI SME in the workstream assessment and/or implementation deliverables. Assists CPI SMEs in establishing client processes/policies that maximize the quality and efficiency of client operations Monitors implemented workstreams and provides timely feedback to CPI SMEs as directed. Ability to independently meet with clients and executives to advance project deliverables Ability to independently create client facing materials including but not limited to slide decks and other materials Acting as SME in core-area of knowledge: Ability to develop project plan and client deliverables for smaller-scale projects Ability to independently implement client deliverables created by self or a SME Ability to lead performance improvement work teams towards developing future-state processes Ability to independently meet with clients and executives to advance project deliverables Ability to independently create client facing materials including but not limited to slide decks and other materials Submits complete, accurate, and on-time expense reports and time entry Contributes internally to advancement of the firm through participation on work teams, task forces, etc. Actively notifies superiors when bandwidth for additional utilization exists Effectively utilizes non-productive time towards professional continuing education, and/or advancement of the firm Willingness to work in other service lines as directed/assigned Following 1 year of employment, ability to effectively serve as a “buddy” for summer associates and/or other new hire employees at the associate, senior associate, and consultant level Other duties as assigned. Qualifications: Either 3+ years of experience in clinical performance improvement consulting or 5-10 years of industry experience in a relevant role with relevant licensure/certification(s) and at least two years of industry experience in a relevant leadership role, such as a nurse manager (e.g. Registered Nurse, Social Worker, or experience in a health system performance improvement department with Lean Six Sigma Black Belt Certification or Certification as a Project Management Professional (PMP)) Bachelor's Degree required in health or related field from an accredited college/university, or equivalent training/experience; Masters Degree in a relevant field is preferred. Candidates without a Masters Degree must enroll in a Masters program and earn their degree within three years of being hired into the role. Proficient in Microsoft Excel, PowerPoint, and Word. Experience with Tableau preferred but not required. Understanding of labor productivity concepts, practices, verbiage, and benchmarking. Analytical skills as they relate to the project and/or supporting the SME Time management skills that enable supporting multiple engagements. Resource management skills. Expanded operational knowledge of inpatient nursing, including care models, standards of care across varying inpatient levels and effective resource utilization. Strong expertise in workforce and productivity infrastructure including census and workload variability management, skill-mix methodologies, workforce planning tools and staffing to demand strategies. Applies proven change management skills to guide stakeholders through process redesign workflow transformation, and adoption of sustainable operational improvement. Able to interface effectively with the client’s nursing and labor initiative leaders. Actively participate in inpatient nursing initiatives and independently lead smaller initiatives to drive process efficiencies and operational excellence.
Learn and subsequently execute Project Manager Office (PMO) responsibilities under the direction of the project’s Client Services Executive and project Engagement Director. Responsibilities include but are not limited to: Developing project travel logistics file Developing/negotiating project hotel room rates under direction of project engagement director Developing, monitoring, and coordinating project travel arrangements among multiple team members, and communicating on-site schedules to the client per project specifications Reviewing and approving travel expense reports Supporting the engagement director in coordinating/scheduling client meetings Developing/coordinating client-facing materials including but not limited to assessment slide decks, executive steering committee slide decks, etc. Other duties as assigned by the project engagement director
Sentara Health
Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees. Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals. We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health. Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.
Sentara Health Plans is hiring an Integrated Nurse Case Manager/Registered Nurse/RN for Chronic/Complex Condition in Virginia Beach, Norfolk, VA and the surrounding areas! This is a full-time, work-from-home position that requires travel to conduct face-to-face home visits for chronic/complex condition members (asthma, diabetes, heart failure, cancer, heart disease, COPD) Virginia Beach, Norfolk, VA and the surrounding areas! Status: Full-time, permanent position (40 hours) Standard working hours: 8am to 5pm EST, M-F Location: Applicants must reside in Virginia Beach, Norfolk, VA and the surrounding areas!
Target Member Population Includes: High Emergency Room (ER) utilizers Recent hospital discharges Members diagnosed with heart failure, COPD, asthma or diabetes Education: Associate or Bachelors Degree in Nursing REQUIRED Certification/Licensure: Registered Nurse (RN) License (Compact or Virginia) REQUIRED Experience: 3 years experience in Nursing REQUIRED Case Management experience preferred Managed Care or Health Plan experience preferred Experience working with chronic/complex condition members (Asthma, diabetes, heart failure, cancer, heart disease, COPD), home health experience, inpatient case management experience, hospice experience preferred Strong knowledge of physical, psychological, socio-cultural, and cognitive patient needs. Excellent communication skills, both oral and written, as well as strong problem-solving and analytical
Responsible for case management services within the scope of licensure; develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum Performs telephonic or face-to-face clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical and behavioral health, social services and long-term services Identifies members for high-risk complications and coordinates care in conjunction with the member and health care team Manages chronic illnesses, co-morbidities, and/or disabilities ensuring cost effective and efficient utilization of health benefits; conducts gap in care management for quality programs Assists with the implementation of member care plans by facilitating authorizations/referrals within benefits structure or extra-contractual arrangements, as permissible Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on care management treatment plans Presents cases at case conferences for multidisciplinary focus. Ensures compliance with regulatory, accrediting and company policies and procedures May assist in problem solving with provider, claims or service issues.
CalvertHealth
CalvertHealth (CH) is a private, not-for-profit hospital. Founded in 1919, CH has been taking care of Southern Maryland families for more than 100 years. Our hospital is accredited by The Joint Commission, licensed by the Maryland Department of Health and Mental Hygiene and certified for Medicare and Medicaid. You can feel confident that you will receive only the highest-quality care at CH. There are 267 active and consulting physicians representing over 40 different specialties. Nearly 1200 dedicated employees help CH provide the very best for our patients. An additional 176 volunteers help add those "special touches" you will notice during your stay here. CH is governed by a community board of directors who volunteer their service to the hospital. They represent our community and take an active role in the operation of our facility. You can find out more about our board members at www.CalvertHealthMedicine.org. In addition to our main hospital campus, satellite medical office buildings in Dunkirk, Solomons, Twin Beaches and Prince Frederick ensure that quality care is no more than 15 minutes from anywhere in Calvert County. We are dedicated to the seamless delivery of high-quality medical services for each of our patients. This means supplying everything you may need, from acute, critical care to rehabilitation and home health services, all in the same continuum. It also means providing community health education, wellness programs and reaching out to our neighbors through community partnerships.
To assess, plan, implement the nursing care to meet the patients’ needs, by following the appropriate policy and procedures of the assigned department.
Education:Position requires completion of a Diploma Nursing Program or an Associate Degree in Nursing (AA) or higher. Registration/Certification/Licensure: Unexpired state licensure from Maryland Board of Nursing or compact state board of nursing Registered Nurse Certification in specialty, preferred Experience: Position requires 6 months to 1 year related experience
Maintains unit-specific and hospital competencies, mandatory learning, and any clinical certifications required in accordance with the Staff Education and Training policy GA-057 and/or any other department requirements. Successful completion of a Telemetry training program. Successful completion of a Chemotherapy program relevant to current Inpatient care, if applicable. Stroke Training required within 30 days of hire. Maintain unit specific and hospital competencies in accordance with policy requirements Demonstrated proficiency of computer skills necessary to effectively complete position requirements to include Microsoft Office applications with an emphasis on Excel, Access, Word and Outlook. Previous experience and demonstrated professionalism in effectively communicating with internal and external customers, both verbally and in writing, and in promoting a positive work atmosphere. Ability to work independently, prioritize concurrent projects, meet deadlines, follow through with deliverables, and produce quality work. Effectively communicates with all patient populations and staff by implementing organization-wide communication techniques as a daily practice. Effectively advocates for quality patient safety and satisfaction as a daily practice.
Acentra Health
Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact. Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes - making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.
Acentra Health is looking for a Clinical, Supervisor - RN - Full-time to join our growing team. Job Summary: As the Clinical Supervisor - RN - Full-time, this individual plays a pivotal role in overseeing and managing the Utilization Management (UM) activities within the organization. With a strong clinical foundation and leadership acumen, the Clinical Supervisor ensures that UM processes are executed efficiently, consistently, and in alignment with regulatory and contractual standards. A key focus of the role is to uphold excellence in clinical programs, fostering continuous improvement and innovation in care management practices. Additionally, the Clinical Supervisor is instrumental in cultivating and maintaining strong relationships with customers and stakeholders, ensuring that service delivery meets or exceeds expectations and contractual obligations. The Clinical Supervisor will also have oversight of direct reports. The Clinical Supervisor and direct reports are expected to work Monday through Friday, with participation in a rotating schedule that includes weekends and holidays. This position is remote U.S.*** Working hours between 8:00 a.m. and 6:00 p.m. EST, with rotational evenings, weekends, and holidays as required***
Active, unrestricted Registered Nurse (RN) license in the state of Indiana or a valid compact state license. Associate degree or equivalent experience directly applicable to clinical practice. A minimum of 5+ years of experience as a practicing RN. A minimum of 5+ years of supervisory experience in a healthcare setting with a minimum of 2+ years in Utilization Management. A minimum of 2+ years of experience applying InterQual and/or MCG clinical criteria in utilization review processes. Strong verbal and written communication skills, with the ability to convey complex information clearly and professionally. Demonstrated customer-centric approach with a focus on achieving results and fostering positive relationships with internal and external stakeholders. Excellent organizational and time management skills, with the ability to prioritize multiple tasks effectively. Proven ability to work both independently and collaboratively within a team environment. Proficiency in Microsoft Office Suite and other relevant software applications essential to the role. Working hours between 8:00 a.m. and 6:00 p.m. EST, with rotational evenings, weekends, and holidays as required Preferred Qualifications/Experience: Bachelor's degree. Ability to provide technical guidance and leadership support to management and clinical teams
Lead and oversee all Utilization Management (UM) activities including prior authorization and retrospective reviews, ensuring accuracy, consistency, and timely completion. Conduct utilization reviews as needed to support workload demands and program requirements. Monitor daily work queues and adjust staffing schedules to align with departmental demands. Evaluate productivity and performance metrics of nurse reviewers to maintain high standards of efficiency and quality. Identify onboarding and ongoing learning needs for Clinical Reviewers; collaborate with leadership to design and implement effective development plans. Actively participate in leadership meetings, committees, and cross-functional workgroups to promote shared decision-making and continuous improvement. Oversee quality assurance activities such as audits, Quality Improvement Plans (QIPs), database management, and Inter-Rater Reliability (IRR) support. Identify areas for process and clinical improvements; develop and execute action plans to enhance outcomes. Serve as a liaison to customers and providers, ensuring timely resolution of issues and promoting service excellence. Stay current with clinical best practices and UM protocols, act as the primary resource for nurse reviewers regarding clinical review inquiries. Support departmental and organizational goals by performing additional duties as assigned. Read, understand, and adhere to all corporate policies, including policies related to HIPAA and its Privacy and Security Rules. The above list of responsibilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary.
CVS Health
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Must reside in Louisiana** Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Identify trends and emerging issues and report and recommend solutions. In particular responsible for the review and resolution of clinical documentation, clinical complaints and appeals. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an unrestricted active nursing license. Reviews complaint/appeal requests of all clinical and benefit documentation. Considers all previous information as well as any additional records/data presented to render a recommendation/review.
Required Qualifications: Experience in reading or researching benefit language. Excellent verbal and written communication skills. Excellent customer service skills 3-5 years of clinical experience required Preferred Qualifications: Managed Care experience preferred Education: RN with current unrestricted state licensure required.
Data gathering requires navigation through multiple system applications. Contacts the provider of record, vendors or internal Aetna departments to obtain additional information. Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR). Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure and regulatory requirements are required to support the appeals review. Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals are processed within requirements. Condenses complex information into a clear and precise clinical picture while working independently. -Coordinates appeal process, in collaboration with members and their authorized representatives, providers, regulators, internal/external consultants and participants (e.g. fair hearing, state mandated reviews, chairs appeal panel hearings) in compliance with state regulation and benefit plan designs. ---Reports findings to team leader/supervisors, responds to rebuttal issues and makes recommendations for improvement as indicated. Identifies trends and emerging issues and reports on and gives input on potential solutions.
Included Health
Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included. Learn more at includedhealth.com.
We’re looking for a Pediatric Behavioral Health Nurse Care Manager to join our Care and Case Management team—someone passionate about supporting children, adolescents, and their families holistically through their healthcare journey with deep focus around behavioral health. This role is ideal for a nurse who brings both clinical expertise and deep compassion to their work, ensuring the unique behavioral health needs of pediatric members are met with innovative, evidence-based interventions. The telephonic Nurse Care Manager will support members navigating complex behavioral and medical health challenges. You’ll collaborate with a multidisciplinary team of healthcare professionals, care coordinators, and records specialists to deliver integrated, remote care in a virtual-first environment. The ideal candidate enjoys spending time on the phone with families, listening deeply, answering questions, and advocating for their needs. You should excel in creating and managing care plans, navigating behavioral health resources, and offering clinical guidance that supports both short- and long-term outcomes. Schedule: Monday-Friday 9am-6pm PST
Bachelor of Science in Nursing (BSN) required Must reside in a compact NLC state Active Compact RN license in good standing with the nursing board of their state Active California Nursing License Willingness to become licensed in multiple states Current CCM Certification preferred 5+ years Nursing experience 2+ years experience working in Behavioral Health Pediatric setting Be able and willing to work until shift schedule: Monday- Friday, 9am- 6pm PST Comfortable managing a wide range of pediatric behavioral health conditions including anxiety, depression, ADHD, autism spectrum disorders, and trauma-related diagnoses. Ability to manage volume while maintaining quality and a high standard of care. Flexible and adaptable in a fast-paced, rapidly evolving care delivery model. Familiar with HIPAA and committed to upholding the privacy and security of patient information. Excellent verbal and written communication skills; able to explain clinical concepts in parent-friendly language. Technologically competent and able to work across multiple electronic systems. Demonstrated success working in multidisciplinary teams to coordinate care. Deep understanding of cultural and socioeconomic factors influencing pediatric behavioral health. Exceptional attention to detail and documentation quality.
Deliver coordinated, family-centered virtual Care Management by phone that improves behavioral health outcomes for pediatric members. Develop personalized, goal-oriented care plans in collaboration with families and our multidisciplinary team. Support members through behavioral health treatment plans, transitions of care, and episodes of acute behavioral health crises. Help families navigate behavioral health systems, treatment options, benefits, and community-based resources. Partner with local pediatricians, behavioral health specialists, schools, and other care team members to ensure aligned, coordinated care. Provide compassionate, longitudinal support to families through continuous engagement and advocacy. Coordinate resources that address clinical, behavioral, and social determinants of health impacting the child and family.
Included Health
Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included. Learn more at includedhealth.com.
We're looking for Oncology Nurse Care Managers for our Care and Case Management team, who are passionate about caring for members holistically through their healthcare journey and ensuring needs are met with industry-leading interventions. As a telephonic Nurse Care Manager you will report to the Manager, Care and Case Management and will guide members through complex medical and behavioral Health situations, partnering with a diverse clinical team that includes a variety of healthcare professionals, care coordinators, and records specialists, to deliver integrated remote care in a creative way. The Nurse Care Manager should enjoy spending time on the phone, listening to members' needs, answering questions, and serving as an advocate. You will excel at creating cohesive care plans, and have the clinical skills to guide members clinically and navigate available benefits and resources. Nurse Care Managers will support members through complex care management, disease management, and acute case management, ensuring they receive longitudinal care that results in excellent health outcomes. #LI-Remote
Bachelor of Science in Nursing (BSN) required Oncology experience highly preferred 5+ years of experience in nursing 2+ years experience working in care management Must reside in a compact NLC state. Active Compact RN license in good standing with the nursing board of their state. Willingness to become (and maintain) licensure in multiple states. Work until 9-6PM PST Be comfortable discussing several medical conditions and experience with populations across the age ranges Spanish speaking desirable Experience working remotely, and strong competence and ability to use multiple computer/medical record systems. Be empathetic. We work with patients and their families who are going through challenging times. You practice empathy and reassure patients that we are available to help them. We are a fast-growing company and we are busy. Our team will meet volume goals without sacrificing quality. Strictly follow security and HIPAA regulations to protect our patients' medical information. Be pleasant, responsive, and willing to work with and learn from our team. A lot of time is spent on the phone with patients and families, and a lot of time communicating with colleagues. Therefore, the ability to gather a clinical history, answer questions at a patient level, and summarize findings is critical. Efficient at writing medical information in easy-to-understand, patient-centric language. Physical/Cognitive Requirements Prompt and regular attendance at assigned work location. Capability to remain seated in a stationary position for prolonged periods. Eye-hand coordination and manual dexterity to operate keyboard, computer and other office-related equipment. No heavy lifting is expected, though occasional exertion of about 20 lbs of force (e.g., lifting a computer \/ laptop) may be required. Capability to work with leadership, employees, and members in an appropriate manner.
Deliver coordinated, patient-centered virtual Care Management by telephone or video that improves members' health outcomes. Create impactful care plans together with members and our diverse care team, and help members achieve the desired goals. Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general. Partner with the members' local providers to ensure coordinated care. Provide compassionate, longitudinal follow-up care, building supportive relationships. Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family. Coordinate necessary resources that holistically address members' problems, whether clinical or social
ChenMed
We’re unique. You should be, too. We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.
The Registered Nurse 1, CareLine, is responsible for providing telephonic triage directional patient care advice for general and specific illnesses, health related issues, client counseling, patient advocacy, health education and referral and resource management to ChenMed patients and their families. Providing on-call coverage, the incumbent in this role provides remote clinical advice and assessments within license and as possible given technology and medium. The registered nurse collaborates with primary caregivers and others on the interdisciplinary care plan team to provide a team approach of care. The Schedule For This Position Is As Follows Tues, Thurs, Fri 0530-0830 & Saturdays 0530-1430
Knowledge, Skills And Abilities: Knowledge and understanding of general/core Nursing-related functions, practices, processes, procedures, techniques and methods Broad nursing knowledge and understanding Ability and willingness to provide extraordinary customer service and professionalism to all customers Maintains current nursing knowledge and competency to stay abreast of budding nursing trends and best practices Excellent written and verbal communication skills through a variety of formats, tools and technologies Capable of building trust and professional relationships to deliver VIP care across the continuum Ability to demonstrate excellent clinical judgment Ability to problem solve Ability to prioritize work under pressure Ability to provide constructive feedback Ability to effectively collaborate with a multidisciplinary team Proficient skill in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook; competent in other systems required for the position Ability and willingness to travel locally, within South Florida to attend meetings and trainings up to 10% of the time; required availability to work evening, weekends and/or holidays Minimum requirement to work 4 holidays in the calendar year Spoken and written fluency in English; bilingual (Spanish/Creole) preferred This job requires use and exercise of clinical judgement Education And Experience Criteria: Associate Degree in Nursing required, Bachelor’s Degree in Nursing preferred Nurse Licensure Compact multistate license required Michigan and Illinois Nurse Licensure required within 90 days of hire, ability to obtain additional licenses as requested by the organization within 90 days of hire Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required Minimum of 3 years acute clinical nursing work experience working in emergency services, urgent care, or geriatric care required Minimum of 1 year virtual care experience highly preferred Must reside within the Continental United states within a state where company is established as a legal entity
Connects with patients via phone or video call. Interviews and questions patients to collect health history and uses a computer system to record and store comprehensive and focused data relating to the health needs of patients and families. Provides health assessment and treatment solutions, monitors patient health and at-home care, aids in emergency scenarios and promotes patient wellness. Based on technology available, monitors a patient’s blood oxygen levels, heart rate, respirations, blood pressure and blood glucose as well as other assessment measures. With the help of video chatting, identifies patient’s symptoms and conditions. Analyzes data to determine the appropriate health maintenance and identify appropriate outcomes for patient and family. Collaborate with on-call providers as needed to support expected clinical outcomes for the patient and family. Evaluates and documents progress toward the anticipated outcome. Assist in ensuring achievement of optimal patient outcomes using Telemedicine. Documents interventions in a readable, understandable language. Aids in enhancing the quality and efficacy of the organization’s telehealth practices and professional nursing practice through successful utilization and improvement of outcomes that demonstrate program efficacy. Utilizes appropriate resources to plan and provide services that are safe, effective and fiscally responsible. Performs other duties as assigned and modified at manager’s discretion.
Byte2
Connecting Tech Talent with Innovation. Specialized recruitment for AI, Health Tech, FinTech, and cutting-edge technology roles. We bridge the gap between exceptional talent and groundbreaking companies. Why Choose Byte2? We understand that technology recruitment requires deep technical knowledge and industry insight. Our team combines years of experience in tech hiring with a passion for innovation. Expert Network Access to a curated network of top-tier tech professionals Industry Focus Specialized knowledge in AI, Health Tech, FinTech, and emerging technologies Fast Delivery Quick turnaround times without compromising on quality
Our client is seeking experienced Advanced Nurse Practitioners to work with us delivering full-scope general medicine within a modern, clinician-supportive healthcare system. This is not high-volume, protocol-driven telehealth. APRNs practice as part of a broader care model that includes asynchronous and synchronous virtual care, clinical triage and synthesis, coordination of labs and imaging, rapid specialist e-consults, and referrals to in-person care when appropriate. Clinicians remain involved in guiding patients through decisions and next steps, rather than handing care off after a single interaction. The role is designed to fit naturally alongside an existing clinical career and offers flexible, meaningful work supported by exceptional tools and a white-glove operational backbone.
Required: Advanced Practice Nurse with a background in Family Medicine or Internal Medicine Minimum of 6,240 clinical practice hours (equivalent to ~3 years full-time experience) Active, unrestricted NP licensure covering at least 40% of the U.S. population, including California, Texas, Florida, and New York Eligibility to see Medicare and Medicaid patients Strong comfort with clinical triage, diagnostic ambiguity, and broad clinical synthesis Experience practicing independently within scope and collaborating closely with physicians and specialists Ability to learn and adopt new clinical tools and workflows quickly Comfort working in a virtual-first environment (prior telehealth experience helpful, not required) A clean record of practice, with no history of malpractice Strong Fit If You: Have experience overseeing clinical groups, workflows, or policies Enjoy practicing medicine across varying degrees of acuity and complexity Value continuity, follow-through, and patient partnership Appreciate tools that provide full context and reduce administrative overhead Are thoughtful, engaged, and motivated to practice high-quality medicine at scale Must have medical licenses in enough states to cover close to 40% of the US population
Provide asynchronous text-based and synchronous video-based care for adult patients across the U.S. Practice broad general medicine across a wide range of acuity and clinical complexity Perform clinical triage and synthesis for patients with unclear or evolving concerns Order and interpret labs and imaging, and coordinate rapid specialist e-consults Recommend and guide patients to appropriate in-person care when needed (operations teams handle provider identification, booking, and scheduling) Help patients identify and coordinate the next clinically relevant steps — not just address the presenting complaint Maintain clinical ownership and continuity throughout the decision-making process Contribute to clinical workflow development, policies, and quality improvement efforts as appropriate Clinical Environment & Support Advanced Nurse Practitioners work within a modern virtual care system supported by: Exceptional clinical support and technology that provide full patient context and reduce administrative burden Asynchronous chat and synchronous video visits Rapid access to specialist input and physician collaboration Expedited labs, imaging, and referrals within patients’ insurance networks Clear price visibility for insurance and cash options to support shared decision-making A dedicated operations team that handles coordination and non-clinical work All medical decisions are made by licensed clinicians. Technology exists to support clarity, alignment, and continuity — not to replace clinical judgment.
Medix™
We are building an AI-powered care team platform designed to create infinitely scalable clinical capacity. By combining advanced AI agents with experienced clinical experts, we expand access to care and improve quality outcomes for healthcare organizations nationwide. We are a rapidly growing, venture-backed organization supported by leading healthcare and technology investors, with portfolio companies spanning digital health, value-based care, Medicare Advantage, primary care enablement, and technology-enabled clinical services.
We are seeking a passionate, versatile nurse to join as a foundational member of our Clinical Operations team. This is a broad-scope “utility player” role ideal for a clinician who thrives at the intersection of direct patient care, clinical operations, and health technology innovation. You will work across a full portfolio of AI-powered care team agents, supporting chronic condition management, care gap outreach, complex prior authorizations, and clinical documentation improvement initiatives. In this role, you will serve as an expert-in-the-loop — the clinical voice ensuring safe, compliant, and high-quality care delivery at scale.
Active Clinical Licensure: Current RN, NP, or equivalent license in good standing (Compact or multi-state licensure preferred) Clinical Experience: 5+ years of experience spanning direct patient care and virtual/telephonic care delivery Operational Exposure: Experience in care management, utilization management, prior authorization, or population health workflows Healthtech Experience: Background in a healthtech startup, venture-backed organization, health plan, or technology-enabled clinical services organization preferred Entrepreneurial Mindset: Detail-oriented, quality-driven, and energized by building new processes in early-stage environments
Deliver High-Impact Clinical Work: Conduct care management outreach and chronic condition follow-ups Support care gap closure initiatives Perform virtual and telephonic clinical activities powered by an AI platform Support Complex Clinical Operations Workflows Review and manage prior authorizations and appeals: Complete clinical-administrative tasks requiring professional judgment Ensure medical necessity and documentation accuracy Partner with Product & Engineering: Act as a clinical subject matter expert in workflow design sessions Test and refine new AI agent capabilities Identify edge cases and provide structured feedback to improve automation Provide Quality Oversight: Conduct audits of clinical workflows and care management activities Identify trends, gaps, and opportunities for improvement Develop remediation plans, quality scorecards, and clinical rubrics Develop Clinical Content & Coach Staff: Create protocols, scripts, and decision-support content that power AI agents Train and onboard clinical team members on workflows and quality standards Promote best practices in clinical documentation and compliance
Wholistic Wound Care & Wellness
Wholistic Wound Care & Wellness provides integrated healthcare services focused on preventive medicine, primary care, and specialized treatment programs. Our mission is to improve patient outcomes through comprehensive, evidence-based, and patient-centered care.
Wholistic Wound Care & Wellness Location: San Antonio, Texas Employment Type: Contract | Flexible Schedule Join a Growing Wellness-Focused Practice Wholistic Wound Care & Wellness is expanding and seeking a Texas Licensed Nurse Practitioner to provide primary care and wellness-focused services in our San Antonio clinic. This role is ideal for a provider who enjoys preventive medicine, lifestyle counseling, and long-term patient relationships while managing common primary care conditions. We offer a collaborative environment focused on patient outcomes, preventive care, and provider autonomy. Wellness-focused patient care model Flexible scheduling options Supportive and collaborative clinical environment Opportunity to build long-term patient relationships Growing practice with opportunity for professional growth
Licensed Nurse Practitioner in Texas Board Certified (FNP, AGNP, or Adult NP) Active National Provider Identifier (NPI) DEA registration preferred Experience in primary care, family medicine, or internal medicine preferred Strong communication and patient education skills
Provide comprehensive primary care visits and patient evaluations Conduct annual wellness visits and preventive health screenings Manage chronic diseases such as diabetes, hypertension, and hyperlipidemia Order and interpret laboratory and diagnostic tests Prescribe medications and adjust treatment plans Develop personalized wellness and lifestyle plans Educate patients on nutrition, weight management, and preventive health Coordinate care with specialists and other providers when needed Maintain accurate and timely clinical documentation
MyAdvisor
MyAdvisor/VetAdvisor care coordination program provides expert care for those that serve others. From behavioral health to career development, MyAdvisor will triage individual needs to find the best resources for ongoing support. With over 12 years of proven success, MyAdvisor provides support to those who are responsible for the safety and welfare of others. Three Wire delivers practice, preventative, and integrated care coordination to private and public sector employers. This care coordination, in turn, supports clinical tele-behavioral health, holistic wellness, navigational advocacy and family stability, and thus helps individuals thrive in their career and family life.
Candidate must be licensed in one (or preferably more) of the following states: AK, CO, CT, DE, HI, KS, KY, MD, NM, NY, SD, WA, WI, WY Job Summary: The Healthcare Provider will be responsible for conducting physical and mental/behavioral health assessments to military service members in Alaska. Acting as a subject matter expert regarding physical and behavioral health requirements and regulations, the Health Care Provider will perform Periodic Health Assessments (PHA), Mental Health Assessments (MHA), Pre and Post Deployment Health Assessments and Post Deployment Health Re-Assessments (PDHRA).
Must be a licensed Health Care Provider (HCP) who is a Nurse Practitioner (NP) or Physician Assistant (PA). Specialized Master’s degree or higher from accredited institution in specialty area Active Accreditation and/or licensure for specialty area Minimum 3 years’ experience providing mental and behavioral health services/assessments. Ability to work effectively in a remote setting with little supervision, while achieving program goals. Experience working with electronic health records and databases, as well as Microsoft Office Suite. Excellent organizational and multi-tasking abilities. Must have the ability to obtain SF86 Position of Trust.
Conduct Physical and Mental Health Assessments (PHA + MHA) and Post Deployment Health Re-Assessments (PDHRA) in all 50 states through telehealth portal in a remote call center environment. Triage and manage client contact including referrals to other resources if necessary. Complete required documentation associated with all PHA, MHA, and PDHRA assessments. Mission Responsibilities: Contributes to achievement of the Mission and Vision of our organization Adapting to Change-Responds to change with a positive attitude and a willingness to learn new ways to accomplish work activities and objectives Continuous Improvement-Acts to constantly improve the level of clinical and non-clinical outcomes and level of customer satisfaction in both individual and teamwork processes Client Centered Focus-Demonstrates concern for meeting or exceeding customer’s expectations/requirements in a manner that allows the client to guide rehabilitation process towards the achievement of their goal(s) and which provides satisfaction for the customer Teamwork-Accomplishes tasks through working effectively with others and appreciating the value, contributions, and commitment of every team member.
LumiMeds
LumiMeds is a fast-growing U.S.-based telehealth startup focused on weight management and long-term metabolic health. We are building the next generation of e-commerce and clinical infrastructure from the ground up. As an early-stage company, we move quickly, operate with limited layers, and expect high ownership from every team member. There is no bureaucracy here — decisions happen fast, priorities evolve, and builders thrive. We are a remote-first, globally distributed team that values clarity, accountability, and people who take initiative rather than wait for direction. Remote – United States Only Must Hold 30+ Active U.S. State Licenses
We are seeking an experienced multi-state licensed Nurse Practitioner to provide telehealth care for patients seeking evidence-based weight management treatment. You will independently evaluate patients, review clinical information, determine medical necessity, and prescribe when clinically appropriate under applicable state laws. This is an ideal role for NPs who value autonomy, flexibility, and participation in a structured but scalable telehealth model.
Required Qualifications: Active, unrestricted U.S. Nurse Practitioner license Board-certified (FNP, AGNP, or equivalent) Active licensure in 30+ U.S. states (required) Prescriptive authority in licensed states DEA registration where required Eligible to practice telemedicine in licensed states Preferred Experience: Prior telehealth experience Experience in obesity medicine, metabolic care, or GLP-1–based treatment Strong clinical documentation and compliance awareness Comfortable working independently in a remote environment
Conduct virtual patient evaluations (video and/or asynchronous review) Review intake forms, medical histories, and laboratory results Prescribe and manage treatment plans in compliance with state regulations Provide follow-up care and clinical monitoring Document encounters accurately within the EMR Maintain adherence to telehealth, prescribing, and documentation standards Collaborate with care coordination teams to support patient success
AfterQuery Experts
AfterQuery is a research lab investigating the boundaries of artificial intelligence through novel datasets and experimentation. We're backed by top investors, including Y Combinator and Box Group, and support all leading AI labs
AfterQuery is seeking Nursing Experts to create and refine healthcare reasoning challenges for our AI training modules. In this remote, flexible role, you will design and evaluate clinical scenarios that test the AI's ability to interpret and apply complex nursing principles, ensuring that our models can navigate real-world healthcare situations with precision and clinical accuracy. Your expertise will help bridge the gap between rigorous nursing practice and innovative AI solutions, making a tangible impact on the future of healthcare technology.
Required Qualifications: Active Registered Nurse (RN) license in good standing. Bachelor of Science in Nursing (BSN) or higher degree from an accredited nursing program. Proven experience in clinical practice, nursing education, or healthcare research with a robust understanding of various nursing specialties. Exceptional analytical, written, and verbal communication skills, with a keen eye for detail. Preferred Qualifications: Multiple years of clinical nursing practice or substantial healthcare experience, ideally across diverse clinical settings and patient populations. Prior involvement in nursing publications, policy work, or healthcare technology initiatives. Advanced certification (MSN, DNP, CNS, NP) or specialty certification is a plus.
Develop high-quality clinical questions and case studies that challenge AI models on topics such as patient assessment, care planning, pharmacology, pathophysiology, evidence-based practice, and more. Evaluate and validate model responses, offering detailed feedback to ensure clinical accuracy and adherence to nursing standards of practice. Collaborate with a team of healthcare and technical experts to fine-tune question difficulty and ensure content is both challenging and educational.
Personalized Health Partners
The PHP Telehealth Administrator on Call has a passion for providing remote administrative, clinical triage, and care coordination support for the PHP Telehealth provider team, as well as seniors and other residents in a variety of healthcare settings that can include, but are not limited to, skilled nursing facilities, assisted living, and independent living communities, etc. They deliver support in a high touch, person-centered care model and collaborate with the interdisciplinary team to ensure that all residents receive the right care at the right time. Personalized Health Partners (PHP) is the medical practice arm for the CommuniCare Family of Companies. The Administrator on Call would directly support both the PHP Telehealth provider group as well answering calls for triage from our other telehealth use cases outside of the Skilled Nursing and Assisted living environments. The goal of the Administrator on Call is to support the Telehealth provider team as well as our patients to increase wellness, prevent illness, improve clinical outcomes and focus on customer experience and satisfaction.
Required: Must have valid RN or LPN license Must be willing to be licensed in the 7 states served (Indiana, Ohio, Maryland, Virginia, West Virginia and Kentucky) Excellent communication and critical thinking skills Good technology aptitude Preferred Qualifications: Training or clinical experience in geriatrics, primary care/internal medicine and/or ED or urgent care 3+ years clinical experience Be open to professional development through training, obtaining certifications if necessary, and attending team meetings Experience working in a collaborative healthcare setting to drive positive outcomes and achieve goals Training or experience in outpatient primary care setting
Coordinate with telehealth providers to ensure appropriate patients receive telemedicine services. Communicate with onsite nursing teams to ensure all clinical needs are coordinated Oversee provider queue in Never Alone Support technical issues that arise for telehealth provider team Monitor EMR to triage routine clinical lab requests, routine imaging results, notifications, etc. that result after hours. Maintain timely documentation of encounters with facility nurses in the EMR Record information directly into CRM system Connect patients that need to be seen acutely by an in-house provider the next day with Central Scheduling Answer and triage calls from Never Alone use cases outside of the SNF use case Provide health education Provide an excellent customer experience to foster high customer satisfaction/retention Practice ethically and in accordance with the Scope and Standards of Practice of their profession and Board Certification. Follow all state and federal regulations, guidelines, and laws Additional duties of PHP Telehealth Administrator on Call Collaborate with telehealth provider group Participation in monthly staff meetings During downtime there may be some additional project related work related to the development of protocols, initial quality review of previous encounters, or projects to be defined as the role evolves.
CommonSpirit Health
Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 138 hospital-based locations, in addition to its home-based services and virtual care offerings.
As our Med Surg Tele Nurse at Dignity Health Yavapai Regional Medical Center, you will help provide excellent care to patients who require medical and surgical interventions. Every day, you will be responsible for assessing patients' health status, administering medications and treatments, monitoring vital signs, and providing patient education.
Required: Associate degree of Nursing or foreign equivalent. 12 months RN experience. Valid compact state or Arizona RN license. American Heart Association Advanced Cardiovascular Life Support. American Heart Association Basic Life Support for the healthcare provider. Demonstrates competency in basic EKG skills by passing EKG test or successfully completing basic EKG class/modules within six months of position. Preferred: Bachelor's degree of Nursing or foreign equivalent.
Provides assessment planning implementation and evaluation of care for patients from adolescent to geriatric. Handles patients with more complex situations with assistance and supervision. Assists with managing patient care administered by other members of the nursing staff. Assumes responsibilities of Primary Nurse and Team Leader.
UST HealthProof
UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members’ well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all. We have a strong global presence and a dedicated workforce of over 4000 people spread across the world. Our brand is built on the strong foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.
UST HealthProof is searching for a highly motivated Utilization Review RN to join our team. As a Utilization Review RN, you will perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members.
Registered Nurse with current unrestricted Registered Nurse license required. Certification in Case Management may be preferred based upon designated department assignment. Certification or progress toward certification is highly preferred and encouraged. Minimum of 2 years clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc. Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. Minimum 1 year health insurance plan experience or managed care environment preferred. Skills & Competencies: Excellent written and verbal communication skills. Excellent customer service and interpersonal skills. Working knowledge of current industry Microsoft Office Suite PC applications. Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management. Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service. Knowledge of policies and procedures, member benefits and community resources. Knowledge of applicable accreditation standards, local, state and federal regulations. Other related skills and/or abilities may be required to perform this job based upon designated department assignment.
Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols. Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards. Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities. Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc. Identify and document quality of care issues; resolve or route to appropriate area for resolution. This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
Northeast Georgia Health System
Northeast Georgia Health System (NGHS) is a non-profit on a mission of improving the health of our community in all we do. Our team cares for more than 1 million people across the region through five hospitals and a variety of outpatient locations. Northeast Georgia Medical Center (NGMC) has campuses in Gainesville, Braselton, Winder, Dahlonega and Demorest – with a total of more than 1,000 beds and more than 1,500 medical staff members representing more than 60 specialties. Learn more at www.nghs.com. NGHS includes Northeast Georgia Physicians Group (NGPG), an employed group of more than 700 talented physicians, physician assistants, nurse practitioners, midwives and other clinical staff spanning more than 40 specialties at more than 50 locations across the region. NGHS is also home to Georgia Heart Institute, the most forward-thinking heart and vascular program in the state and includes one of the largest cardiology practices in the region, including more than 120 clinicians seeing patients at more than a dozen locations. With a multi-disciplinary team of experts treating nearly every type of heart and vascular disease and participating in leading national research, we’re providing advanced care that ensures lasting heart health for generations.
Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with Physicians, Nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer (Medicare, Blue Cross, other payors as determined by CDI departmental goals). Ensures the accuracy and completeness of clinical information used for measuring and reporting Physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis.
Minimum Job Qualifications: Licensure or other certifications: Current RN Licensure in the State of Georgia. Educational Requirements: Associates Degree Minimum Experience: Five (5) years in the practice of professional nursing. Other: Preferred Job Qualifications Preferred Licensure or other certifications: CCDS or CDIP Preferred Educational Requirements: Bachelor's Degree in Nursing. Additional education in Finance, Healthcare regulations and diagnoses-procedure coding. Preferred Experience: Experience in Healthcare Utilization and Revenue Management. Other: Job Specific and Unique Knowledge, Skills and Abilities Demonstrates aptitude in critical care or medical-surgical nursing Must demonstrate excellent observation skills, analytical thinking, problem-solving abilities, and excellent written and verbal communication by organizing work priorities and following standard of work Working knowledge of DRG coding optimization strategies and clinical documentation requirements are helpful Demonstrates interpersonal skills including professionalism practicing positive approaches to the position The position requires computer skills and the ability to be self-directed Familiar with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, coding software (preferably 3M 360 Encompass) Leadership skills are required Maintains requirements contained in Remote Agreement or forfeit the opportunity
Improves the overall quality and completeness of clinical documentation by performing admission / continued stay reviews using the Compliant Documentation Program Management (CDMP) guidelines. Facilitates modifications to clinical documentation to ensure that appropriate severity of the patient is documented and to ensure appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer (Medicare, Blue Cross and others as determined by CDI program goals) Conducts on-going follow-up reviews to ensure points of clarification have been recorded in the patient's medical record using department standard work to set workflow priority and scheduling.. Works with Physicians concurrently, during the patient's stay, to educate and receive specific documentation pertinent to all requirements in question. Refers questionable quality, patient safety indicators, and utilization concerns to CDI Director, nursing and case management as indicated Writes queries to provide professional clinical inquiry about missing documentation (clinical indicators, diagnoses, or more descriptive) for conversion to codable terms following compliant, non leading format. Monitors the documentation against "core measure" quality indicators and addresses non-compliance documentation with Physicians and other appropriate staff. Interacts on a regular basis with Physician, nursing and case managers to ensure continuity of documentation. Works collaboratively with the coding staff to assign the "working" DRG to contribute for IDT Rounds. Processes all discharges by updating the DRG worksheet to reflect changes in patient status, procedures and/or treatments and concurs with the attending Physician to finalize diagnoses. Maintains a leadership role to ensure specific and compliant documentation is achieved recognizing its use in quality measures and reporting medical center and Physician outcomes. Educates various customer audiences on clinical documentation opportunities, coding, reimbursement and performance methodologies. Ensures documentation is meeting "medical necessity" for specific level of care and that services provided to the patient has a reasonably beneficial effect; refers cases to Utilization Review as indicated. Demonstrates a working knowledge of the DRG system and coding guidelines to facilitate recovery of appropriate payments for services rendered. Utilizes results of DRG analysis to have on-going dialogue with Physicians, nurses, coders, and case managers, to improve overall knowledge and performance. Participates in efforts to contain cost and/or generate revenue. Submits written ideas for reducing cost or adding revenue. Organizes and performs work effectively and efficiently by achieving daily reviews as assigned. Maintains and adjusts schedules to meet team performance and is willing to change workload or assignments as indicated. Meets assigned deadlines and departmental productivity standards. Assists with special projects as needed and all other duties as assigned. Maintains requirements in Remote Agreement in order to retain work from home opportunity. Work collaboratively with CDI team members to complete daily work of the team.
Amwell
At Amwell, we’re transforming healthcare for all—powered by technology and inspired by people. Here, your ideas don’t just matter—they drive real change, improving lives on a global scale. We marry technology and innovation with clinical excellence to provide trusted solutions that solve the healthcare industry’s biggest pain points and are on a mission to enable greater access to more convenient, affordable, and effective care. We do this through our technology-enabled care platform that is designed to help our clients achieve their digital care ambitions – today and in the future. We offer programs spanning the full care continuum, including urgent, acute and specialty care, behavioral health, and services for the treatment of chronic conditions such as heart and cardiometabolic diseases. Programs are powered by Amwell as well as our growing partner network. For almost two decades, Amwell has proudly served some of the largest and most sophisticated healthcare organizations in the U.S. and worldwide. Our team is passionate about technology’s role in transforming care delivery and making it more equitable, accessible, efficient, cost-effective and navigable for all.
This position provides quality review and support to the AmWell Medical Group (AMG). The RN candidate will be employed by American Well providing review and support to the AmWell Medical Group Practice. The AmWell Medical Group is comprised of board-certified, credentialed, qualified physicians and other allied providers and built to provide online healthcare services for American Well’s Online Care clients. The AmWell Medical Group currently provides acute care services in approximately 44 states, with the expectation of expanding to providing other medical services (e.g., chronic care management, specialty care, behavioral health) in all 50 states in the future. Care is delivered utilizing American Well’s Online Care system. Online Care allows patients and consumers to connect with physicians immediately, whenever they have a health need, from their homes or offices. The innovation uses advanced Web-based technologies and telephony to remove traditional barriers to healthcare access, including insurance coverage, geography, mobility, and time constraints.
Registered nurse with a broad range of clinical experience; minimum of 10 years in practice Experience managing clinical outcomes based on a variety of acute and chronic illnesses. Strong communication skills; ability to build professional relationships with providers to provide ongoing feedback/coaching Strong analytical skills, review and analysis of metrics, identify provider issues Strong technical and application skills to support providers/patients Interpretation and manipulation of clinical data via excel spreadsheets Experience providing remotes care/support is a plus Desire to be a part of the telehealth innovation
Participate in monthly Ongoing Professional Provider Evaluation (OPPE)- in depth provider case reviews Identify provider trends, deficits in clinical and documentation standards Participation in Provider coaching/training Participate in monthly client meeting to understand and support client expectations Initiation and management of Prior Authorizations Participation in workflow design and QA improvements Participation in risk management planning Participation in ongoing policy and procedure design and editing- including, but not limited to clinical matters, intake, emergency preparation, referral planning and documentation Participation in regulatory assessment and compliance planning Interface with providers as needed Provide clinical support to other departments as needed to support organizational initiatives Participation in department and committee meetings Participation in the development of a process that measures outcomes Participation in the quality management program, including investigation of red flag cases and adverse events Participate in root cause analysis
CenterWell Home Health
At CenterWell Home Health, we help patients manage chronic conditions or recover from injury, illness, surgery, or hospitalization – all from the comfort and safety of home. Our team of nurses and therapists provide quality care, education, and the tools needed to help patients stay independent and return to doing the things they love. As one of the nation’s largest home health providers, we serve over 355,000 patients annually across more than 350 locations in 37 states. We’re dedicated to providing a full range of home health services, including skilled nursing, physical therapy, occupational therapy, speech therapy, assistance with daily activities and social work support. When a patient needs home health, we’re here to provide a personalized care plan developed by a trained home health team. A career at CenterWell Home Health provides the stability and opportunities of a large national company—with the ability to make a positive local impact.
Shift/availability Details Part time 20 hours a week. The schedule will be 10 hour shifts, Saturday & Sunday from 10am-8:30pm EST. Required to work a rotating holiday schedule. This is a work-from-home telephonic Registered Nurse position. As a Care Manager, Telephonic Nurse, you will report directly to the Manager, Care Management. You will help to ensure optimal continuity of care for patients transitioning into and out of our services. You will be responsible to be knowledgeable regarding post-acute levels of care, and an expert regarding CenterWell Home Health services including home health, hospice, and palliative care. You will communicate with the CenterWell Home Health clinical team and help facilitate patient follow-up for patients in need of (additional) services.
Use your skills to make an impact: Associate's degree required. BSN preferred. We require a compact state RN license. Business needs may require additional state licensures be obtained. At least 3 years post-acute experience. Home health or hospice experience preferred. Nursing background working across multiple areas of post-acute care. Nursing experience in post-acute care. Current CPR certification. Knowledge of home health, hospice, and palliative care services. Ability to learn and master information related to locations and services of clients. Excellent analytical and problem-solving skills. Excellent verbal and interpersonal skills. Communicate effectively with empathy over the phone. Must read, write and speak fluent English. To Ensure Home Or Hybrid Home/Office Employees' Ability To Work Effectively, The Self-provided Internet Service Of Home Or Hybrid Home/Office Employees Must Meet The Following Criteria At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Home or Hybrid Home/Office employees will be provided with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Be a CenterWell Home Health representative in supporting patients who have been discharged from service or for those who may need post-acute services. Navigate healthcare options; care services post-acute offerings, Medicare coverage, billing issues, and accessing healthcare resources. Use a variety of tools and methods to quickly provide patient options and education including but not limited to sites of service, specialty offerings, post-acute care, and other related questions. Handle a variety of customer issues including location lookup, directions, and complaints. Make clinical level of care determination based on discussion, medical records, and any other important clinical data. Match these needs to a service site location or, if not available, look up and provide alternative services. Be a customer advocate throughout the referral process to ensure timely response and to maximize referral to admission conversion rate. Follow-up and track referral and admission outcomes. Maintain awareness and orientation to department performance objectives, meets standards, and assures patient satisfaction goals are met. Assist in the admissions process by acting as an ambassador for patients who meet the admissions requirements. Focus on placing the right patient to the right care setting at the right time Adhere to and participates in Company's mandatory training which includes but is not limited to HIPAA privacy program/practices, Business Ethics and Compliance programs/practices, and Company policies and procedures. Review and adhere to all Company policies and procedures. Provide education regarding Home Health, Hospice, and Palliative Care Services. Help with clinical eligibility review for alternate services Participate in special projects and perform other responsibilities as assigned.
Humana
Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Required Qualifications: Multi State RN license A minimum of three (3) years varied nursing experience Active RN license in the state(s) in which the nurse is required to practice Ability to be licensed in multiple states without restrictions Proficient with MS Office products including Word, Excel and Outlook Ability to work independently under general instructions and with a team Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications: Health Plan experience working with large carriers Previous Medicare/Medicaid experience a plus Previous experience in utilization management, case management, discharge planning and/or home health or rehab Experience working with MCG or Interqual guidelines Additional Information: WAH Internet Statement To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
The Pre-Authorization Nurse 2 completes medical necessity and level of care reviews for requested services using clinical judgment, and refers to internal stakeholders for review depending on case findings. Educate providers on utilization and medical management processes. Enter and maintain pertinent clinical information in various medical management systems. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follow established guidelines/procedures.
Salvo Health
Salvo is a new approach to help millions of Americans facing chronic health conditions, centered on chronic gut health and metabolic conditions from IBS to obesity. Our patients are assigned a “whole patient” care team and have seven day a week access to app-based care, using Remote Patient Monitoring (“RPM”) to bill under the patient’s insurance. This is a major step forward to go beyond episodic appointments to continuous care at home, and deliver interdisciplinary wraparound care in partnership with the patient’s existing local doctor. Salvo is backed by leading health care investors from innovators like Livongo, Ro, Ginger, Forward, Brightline, Tia, and others. Salvo care draws on expertise from Board-certified specialty physicians, registered dietitians, nurses, psychologists, and therapists who have developed our evidence-based protocols, for a personalized, multi-month journey to better health. Salvo is the first to bring a scalable and tech-enabled, more integrative approach to these chronic conditions, going beyond treating only the symptoms in order to identify and address the root causes of chronic illness. Salvo offers a competitive salary and health benefits, a remote work environment, flexible time-off, a larger sense of mission, and professional development and entrepreneurial opportunities. Working alongside a bunch of super talented and friendly people, in a culture that likes to drive constant innovation, and marked by relentless curiosity and a sense of empathy. Salvo is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.
Salvo is looking for an experienced Nurse to support our chronic disease patients. In this role, you’ll be a key contributor to the management and delivery of our care program, working closely with our patients, registered dietitians, and partner physicians to provide best-in-class care. You’ll use your medical knowledge and product expertise to help our members navigate Salvo Health, assisting in medical and administrative tasks to keep the member moving through the program. Additionally, you’ll help shape how we build and scale our product and process. Our ideal candidate is someone who enjoys the challenges of an early-stage start up, is eager to learn, process oriented, and has a patient-first mindset.
2+ year of experience as Licensed Practical Nurse or any Nursing license 2+ years of experience in patient-facing or customer-facing roles Compact state license required, additional licensing may be needed Bilingual (spanish speaking) a plus Excellent customer relation skills, as well as written and verbal communication skills Knowledge of medical terminology and proficiency of general medical office procedures Familiarity with digital applications like Slack, Coda, Google Workspace, etc. Strong analytical and proactive problem solving skills Self-motivated, results-oriented and strategic thinker Personal passion for health and wellness topics Must be authorized to work in the United States Experience working in telehealth or healthcare startup environment preferred Bonus: Experience working in GI, weight management, and/or with anti-obesity medications such as GLP-1s
Provide exceptional care, disease management and health education to patients Support goal setting for individual patients asynchronously to help them better manage their chronic conditions Create personalized action plans with guidelines to reduce or eliminate unwanted behaviors Help clients understand their motivations and create behavior change plans Conduct regular outreach to patients, based on their needs and preferences, to support engagement and elicit behavior change Coordinate with other clinical team members to provide an exceptional patient experience Develop and maintain professional, support-oriented working relationships with patients and team members Create and distribute health education materials to individual members as necessary Work with a cross-functional product team to develop and constantly improve our in-app patient experience
Reliable Home Care Providers, Inc.
Reliable Home Health Care Providers offers a variety of personalized and affordable home care services to provide elderly individuals, and/or those with disabilities or those recuperating with the special care and companionship care services they require tailored to their specific needs. We offer highly skilled caregivers, companions and certified nursing assistants on a convenient, flexible hourly, full time, or 24-hour live-in basis.
We are seeking a highly skilled and experienced QA Nurse to join our team of healthcare professionals. As a QA Nurse for Home Health, you will be responsible for ensuring that our patients receive the highest quality of care possible. You will work closely with our team of nurses and other healthcare professionals to ensure that all patient care is delivered in accordance with established standards and guidelines.
Active nursing license in the state of IL Minimum of 1 year of experience in home health nursing Strong knowledge of quality assurance and improvement processes Excellent communication and interpersonal skills Ability to work independently and as part of a team Strong attention to detail and organizational skills
Conduct regular quality assurance audits of patient care plans and documentation Complete record review according to agency-defined parameters and timeframes Identify areas for improvement and develop action plans to address deficiencies Collaborate with the nursing team to ensure that all patient care is delivered in accordance with established standards and guidelines Provide education and training to nursing staff on quality assurance and improvement processes Participate in interdisciplinary team meetings to discuss patient care and identify opportunities for improvement Maintain accurate and complete records of all quality assurance activities Fully understand current Medicare guidelines and COP's If you are a dedicated and compassionate nurse with a passion for quality patient care, we encourage you to apply for this exciting opportunity.
Crawford Thomas Recruiting
Crawford Thomas Recruiting is a nationwide recruiting and staffing firm recognized for exceeding client expectations regarding time to fill, value and quality of candidates. Our mission is to connect industry-leading companies of all sizes with experienced, vetted professionals. Our success has included the focus areas of management, sales, finance, technology, engineering, healthcare, legal and more. Crawford Thomas Recruiting is proud to service clients ranging from startups to members of the Inc. 5000 and Fortune 500.
Our client is seeking an experienced Registered Nurse (RN) to oversee its care delivery team and ensure high-quality execution of Principal Care Management (PCM) and Chronic Care Management (CCM) programs. The RN will supervise LPNs, review and sign off on care plans, maintain clinical quality standards, and ensure compliance with Medicare guidelines. This is a fully remote role.
Active, unrestricted NLC RN license, or licensed in Florida, Texas, or Colorado 2+ years of experience in chronic disease management, neurology, or care coordination. Experience supervising or mentoring clinical staff (LPNs, MAs, etc.). Excellent communication and leadership skills with a focus on patient-centered care. Proficient with EMRs and digital health tools. Detail-oriented, organized, and committed to quality assurance and compliance. Preferred: Experience with Medicare PCM/CCM documentation, neurodegenerative conditions (Alzheimer’s, Parkinson’s, dementia), telehealth care models, and prior involvement in clinical quality improvement.
Supervise and support Licensed Practical Nurses (LPNs) in care coordination, patient engagement, and documentation. Review, approve, and sign off on care plans and clinical documentation. Conduct quality assurance reviews to ensure accuracy, timeliness, and compliance with Medicare PCM/CCM standards. Serve as a clinical liaison between our client and their partner neurologists, escalating concerns as needed. Provide mentorship, training, and feedback to nursing staff to promote professional growth. Participate in workflow optimization and quality improvement initiatives. Engage patients and caregivers to assess care quality and address clinical needs. Maintain detailed, compliant time-based activity logs for CPT billing. Uphold our client’s standards of compassionate, proactive care delivery.
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