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Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members.
This position has the option to work virtually. Must reside in the state of WA, OR, ID, WI, FL, MT, TX, AZ, VA, AL, TN. The CDS is responsible for facilitating a thorough, complete and accurate patient health record which will secure the correct reimbursement for resource utilization, the highest quality measures and outcomes, superior communication between providers, and ultimately high patient satisfaction. Travel may be required to outlying clinics. Work is conducted remotely, in the hospital and/or in the clinic. Position Reports To: Director of Quality Analytics
Required: Recent 2 years acute care experience, preferably ICU, PCU or strong Med/Surg. Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499). Must successfully pass an on-line clinical knowledge assessment (provided by Confluence Health) with 70% or greater. Extensive knowledge of pathophysiology, disease processes and associated care-pathways. Basic computer skills; familiarity with Microsoft software programs. Desired: BSN. 5 years acute care experience Experience in organizational, analytical, and writing skills. ACDIS or other national CDI certification. Knowledge of CMS and regulatory environment.
Ability to learn and develop the skills necessary to perform clinical documentation reviews using the tools provided. Perform accurate and timely record review. Recognize opportunities for documentation improvement. Formulate clinically credible documentation clarifications. Effectively communicate opportunities for clarification to providers in a way that secures complete and accurate documentation. Effective and appropriate communication with providers, the clinical documentation and coding teams, and others that fosters collaboration and trust. Timely follow-up on all clarification requests. Participate in Task Force meetings. Manage multiple priorities. Adhere to established clinical documentation rules, processes and workflows. Apply critical thinking, problem solving, and deductive reasoning skills to complex clinical and interpersonal situations. Understand and communicate differences between IPPS and OPPS and how they impact DRGs and ICD-10 code assignment. Able to process multiple sources of information simultaneously while maintaining clarity of thought and purpose. Required to maintain active Basic Life Support (CPR) certification. Performs other duties as assigned.
Mercy, one of the 15 largest U.S. health systems and named the top large system in the U.S. for excellent patient experience by NRC Health, serves millions annually with nationally recognized care and one of the nation’s largest and highest performing Accountable Care Organizations in quality and cost. Mercy is a highly integrated, multi-state health care system including 55 acute care and specialty (heart, children’s, orthopedic and rehab) hospitals, convenient and urgent care locations, imaging centers and pharmacies. Mercy has over 1,000 physician practice locations and outpatient facilities, more than 5,000 physicians and advanced practitioners and more than 50,000 caregivers serving patients and families across Arkansas, Illinois, Kansas, Missouri and Oklahoma. Mercy also has clinics, outpatient services and outreach ministries in Arkansas, Louisiana, Mississippi and Texas. In fiscal year 2025 alone, Mercy provided more than half a billion dollars of free care and other community benefits, including traditional charity care and unreimbursed Medicaid.
Utilization Management for the assigned inpatient Care Management population. This position is designed to facilitate an effective process of the Mercy Care Management model; supporting quality patient care, safety and financial components; promoting integration of a seamless care model; assisting with patient throughput; collaborating to include coordination as evidenced by metrics, optimizing performance and adoption of best practice
Education: Graduate of an accredited school of nursing. Licensure: Current license in the state of residence and/or employment, Minimum Required Experience: 2-3 years acute care hospital setting, Minimum Required Other: Must have the ability to work independently and meet deadlines, giving attention to detail and follow up, Minimum Required Excellent time management skills, organizational skills, able to coordinate multiple tasks and prioritize work, Minimum Required Must have a good understanding of medical terminology with the ability to read, discuss and understand patient medical information, Minimum Required Excellent verbal and written communication skills, particularly telephone, Minimum Required Advanced computer skills, Minimum Required Must have ability to interact effectively with a variety of people and situations at all levels of the organization, Minimum Required Preferred Experience: Care Management or Utilization Review experience, Preferred Certifications: Case Management or Utilization Review, Preferred
Tia is a full-stack women's healthcare business that builds products, tools and clinical services virtually and in person to help every woman be her own patient advocate and get meaningfully better healthcare. We’re putting the soul back in medicine, one patient and one provider at a time through a care philosophy that is reimagined to listen to and empower women to actively take control of their healthcare. The care philosophy that supports our patients is also built to support clinicians who are the heart and soul of the care Tia is able to provide. In order to do that - we need YOU!
As a Virtual RN, you will be part of the Care Connect team at Tia, working with teams across the company to empower providers to focus on patient care and support overall business needs. You will also be every Tia member’s partner in their health and wellness journey- helping them navigate both the healthcare system and ensuring that they are getting a concierge-level experience at Tia. REPORTS TO: Associate Manager - RN Team
Graduate from an accredited nursing program- BSN preferred Active Registered Nurse state licensure in CA or in progress of obtaining. Additional licensure in NY & AZ preferred Flexibility to work evening, weekend, and holiday hours Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency 1-3 years of experience in a healthcare or related field. Previous leadership experience is preferred. Comfortable with a fast-paced environment and frequent change and energized by metrics Understanding of healthcare processes, medical terminology, and member engagement in a healthcare context. Should possess excellent communication, teamwork and management skills, be empathic but resolute in your decision-making, and be attentive to detail Knowledge in using Electronic Medical Record (EMR) systems, clinical messaging platforms, and Google Workspace. Good problem-solving skills and the ability to remain composed in high-pressure situations. Solution-oriented: Will seek answers to your questions, whether through SOPs or through other team members. Adherence to strict confidentiality standards and understanding of healthcare data privacy regulations, such as HIPAA. Physical Demands Prolonged periods of sitting or standing at a desk and working on a computer. Extensive use of a keyboard, mouse, and multiple monitors for high-volume clinical documentation. Ability to maintain focused visual attention to digital medical records and patient communications for extended periods. Requires high-speed, reliable internet connectivity and a quiet, secure workspace conducive to handling sensitive HIPAA-protected information. Work Environment This is a 100% remote, virtual position. You are responsible for maintaining a secure, HIPAA-compliant home office with a high-speed internet connection that meets the minimum technical specifications listed above.
Day-to-day patient communications: Triage member communications appropriately Manage inbound members messages, ensuring proper prioritization across various types of messages Ensure if we cannot answer the members' needs that we connect them to someone who can i.e. urgent needs, clinical needs, etc. When performing any handoffs to another team member, do so by providing both the members and other Tia team members full context. Answer phone calls and call patients Ensure each member's message is responded in a personal, empathetic way while adding context and informing members about their options in their healthcare. Solution-oriented mindset -- will work to ensure Tia can support all members requests, no matter how difficult. Maintains extreme ownership of the RN queues, prioritizing urgent clinical needs and working toward 'Inbox Zero' through efficient task management and protocol-driven care. Ensuring members needs get met and ensuring that if a member expresses concerns, that we follow internal processes to ensure they get addressed. Answering clinical questions in chat and escalating as appropriate Responding to clinical questions in chat that arise within agreed-upon Turn Around Time while using Tia’s Tone of Voice Principles Providing patients with full context behind treatment recommendations Escalating patients to providers or urgent care using designed protocols Performing Other Nurse Tasks like:Medication refills Executing medication refills and bridges via established clinical standing orders and protocols Reporting lab results Management of lab and imaging results (including BI-RADS and complex screening panels) to provide patients with immediate, actionable context. Work collaboratively with care team members to facilitate careAct as a team when it comes to a patient’s care, working together to ensure we can provide a high quality patient experience. Assist in the execution of clinical protocols and support quality improvement initiatives across care journeys for both patients and providers. Support providers in everyday tasks to advance the patient needs Support the day-to-day needs of providers, including managing provider inboxes, prescription refills, and other clinical tasks. Build strong, collaborative relationships with providers, and act as the RN resource for our market teams
We're looking for experts to help train better AI. At Alignerr, we offer paid, flexible projects for writers, coders, and subject matter experts to refine and align advanced artificial intelligence. Work when you want, where you want. Apply today at Alignerr.com or through our open Job Postings.
Your clinical knowledge is more valuable than you think — beyond the bedside. We're looking for experienced nurses and clinical informatics professionals to help evaluate and improve AI systems designed for healthcare environments. Your real-world perspective on nursing workflows, EHR systems, and patient documentation will directly shape how AI understands and supports clinical practice. This is a unique opportunity to influence the future of healthcare technology while working fully remotely on your own schedule. Organization: Alignerr Type: Hourly Contract Location: Remote Commitment: 10–40 hours/week
Registered Nurse (RN) or equivalent clinical background with hands-on experience in nursing informatics or health IT Familiar with EHR platforms such as Epic, Cerner, or similar systems Strong understanding of clinical documentation workflows and nursing care processes Able to critically evaluate content and communicate feedback clearly in writing Detail-oriented, self-motivated, and comfortable working independently No prior AI experience required — your clinical expertise is what matters Nice to Have: Experience with data annotation, quality assurance, or clinical evaluation systems Background in nursing education, clinical training, or health informatics consulting Familiarity with interoperability standards such as HL7 or FHIR
Evaluate AI-generated clinical content, nursing workflows, and health informatics outputs for accuracy, safety, and real-world applicability Identify gaps, errors, or unrealistic scenarios in AI responses related to EHR systems, clinical documentation, and patient care processes Provide structured, expert feedback on how well AI models reflect actual nursing practice and informatics standards Review and annotate clinical data scenarios, flagging inaccuracies or workflow misrepresentations Suggest improvements that align AI outputs with evidence-based nursing and informatics best practices Work independently and asynchronously on task-based assignments
Community Health Systems is one of the nation's leading healthcare providers. With healthcare delivery systems in 36 distinct markets across 14 states, CHS operates 69 affiliated hospitals with more than 10,000 beds and approximately 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, imaging centers, cancer centers, and ambulatory surgery centers.
The Appeal Specialist II reviews, analyzes, and resolves insurance denials to ensure accurate reimbursement and regulatory compliance. This role logs and reviews denials for trend reporting, provides feedback to facilities, and communicates payer updates to relevant stakeholders. The Appeal Specialist II collaborates with internal teams to ensure timely and thorough appeal resolution and supports initiatives that improve denial prevention and recovery processes.
H.S. Diploma or GED required Bachelor's Degree in Nursing preferred 2-4 years of experience in healthcare revenue cycle or business office required 1-3 years of experience in healthcare insurance or medical billing preferred Knowledge, Skills And Abilities: Proficiency in word processing, spreadsheet, and database applications. Working knowledge of billing, coding, and reimbursement principles. Strong analytical, research, and problem-solving skills. Ability to communicate effectively with payers, facility staff, and leadership. Strong organizational and documentation skills with attention to detail. Ability to work independently and manage multiple priorities in a fast-paced environment. Understanding of insurance claims processing and denial management workflows. Licenses and Certifications RN - Registered Nurse - State Licensure and/or Compact State Licensure required
Reviews and resolves pre-payment insurance denials in collaboration with follow-up teams. Coordinates with Denial Coordinators, Facility Denial Liaisons, and Managed Care Coordinators to ensure payer accountability and identify education opportunities. Provides feedback to facilities regarding denials resulting in retractions or reimbursement impacts. Monitors payer billing and coding updates and communicates changes to SSC and ancillary departments. Tracks and logs denials and appeal activity according to established documentation and reporting guidelines. Prepares and distributes reports summarizing appeal trends, project updates, and payer response activity. Recommends process improvements to enhance appeal efficiency and reduce recurring denials. Maintains up-to-date knowledge of payer policies, billing and coding practices, and reimbursement regulations. Utilizes practice management systems and maintains documentation of appeal activity in compliance with departmental standards. Performs other duties as assigned. Maintains regular and reliable attendance. Complies with all policies and standards.
Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
The Utilization Management Registered Nurse uses clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. You will report to the Manager of Utilization Management and serve as a member of the One Home/Home Solutions Utilization Management team. This team manages post-acute care services. These services include Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). The team's goal is to ensure members receive the appropriate level of care in the most appropriate setting.
Required Qualifications: Must hold Compact Registered Nurse (RN) license in your state of residence Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting. Must be passionate about contributing to an organization focused on improving consumer experiences Preferred Qualifications: Previous experience in utilization management/utilization review for a health plan or acute care setting Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual. Experience working in a fully remote, metrics-focused role Experience as an MDS Coordinator or discharge planner in an acute care setting Experience as an RN for a Medicare Certified Home Health agency Health Plan or Medicare / Medicaid Experience Call center or triage experience BSN or bachelor's degree in a related field Additional Information Work-at-Home Information: 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. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers You will complete request determinations within established processing time frames. (i.e. 10 reviews per day?) You will communicate with providers, members, or other parties to facilitate care and treatment. You will help deliver coordinated care for our members You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.
First: we are Pioneers Transforming healthcare requires divergent thinking, bias for action, disciplined experimentation, and consistent grit and determination to maintain momentum. This journey is as challenging as it is rewarding. Second: we are Platform-Builders We’re always building foundations that allow us to achieve tomorrow more than we did today. We never lose sight of what’s ahead – in a mindset of ownership and duty to our mission. Above all: we are Patients We could all be the next person who walks through our very doors, seeking clarity or peace of mind. We are proud of our impact on our patients’ lives, and we won’t stop till everyone can benefit from our work. What We Offer An avenue to make a positive impact on people's lives and their health We believe in preventative healthcare for everyone, including our team - Prenuvo provides free, whole-body scans to each team member Growth opportunities are at the heart of our people journey, we’re doing big things with bright minds - there is no single path to success, it can be shaped along the way Building strong relationships is at the core of everything we do - our team gets together each week to connect, share, and socialize Recognizing time away to restore is vital to our wellbeing - we have a flexible vacation policy and we will encourage you to use it We now offer the Prenuvo’s Commuter Benefits Plan to help cover your transit and parking costs. Whether you ride, drive, or park, we’ve got you covered—making your commute easier and more affordable! Prenuvo offers a 401(k) retirement savings plan to eligible employees, allowing team members to make pre-tax contributions toward their retirement. While Prenuvo facilitates access to the plan, the company does not currently offer matching contributions. We offer a comprehensive benefits package including health, dental, vision, including Mental Health coverage, to support you and your family The base salary for this role ranges from $80,000 - $95,000 in local currency, depending upon experience
The Registered Nurse Navigator is a hybrid clinical and operational role that blends patient-facing communication with cross-functional collaboration. You'll provide high-touch support to patients undergoing imaging procedures, while working alongside internal teams to continuously improve how care is delivered. In this role, the Registered Nurse Navigator will function independently to conduct comprehensive nursing assessments of a patient's intention and understanding of Prenuvo services, to provide evidence-based guidance that prioritizes safety and satisfaction. The Flex Nurse Navigator will be responsible for inbound triage of patient questions and pre-scan counseling in addition to medical history review as it pertains to Prenuvo imaging and add on services. The ideal candidate will present with strong collaboration and communication skills while being able to function autonomously during flex hours to help manage a high volume patient load and clinical requests. The Nurse Navigator will work collectively with the Preventative Medicine Team to deliver timely, high-quality patient care through telephone triage, EMR management, and clinical support across multiple states. This role is fully remote. Candidates must be located in the US within registered Prenuvo locations and be able to work the following shift: 10:30 AM – 6:30 PM PST, Thursday–Monday. Help reshape the world through proactive healthcare while working with cutting-edge technology and high performing teams with deep expertise - join us to make a difference in people’s lives!
Active compact state RN license Located in Pacific or Eastern Time Zone and available to work full-time flex hours Thursday - Monday Minimum 3 years of clinical experience, preferably in ambulatory care, radiology, oncology, or concierge settings Minimum 2 years of remote nursing experience in addition to the 3 years of clinical experience Certifications in radiology-related and/or oncology-related nursing Strong background in patient communication, education, and relationship-building over the phone and video Experience working cross-functionally within healthcare or digital health teams Ability to thrive in a fast-paced, startup environment—comfortable with ambiguity, pivots, and iterative work Clear, professional written and verbal communication skills Confidence using clinical software, telehealth platforms, and productivity tools Demonstrated systems thinking and eagerness to contribute to continuous improvement A warm, calm presence and a commitment to patient-centered care Passion for Prenuvo’s mission and excitement to build something new
Inbound Call Triage and Patient Navigation Conduct thorough and real-time chart review of patients who are returning calls from our nurse navigator team Support patients in understanding what to expect, how to prepare, and what their next steps may be Provide counseling as it relates to patient specific concern and answer patient questions with clarity and empathy Complete medication requests per standing order protocol Screen patient for appropriateness and safety for add on services Follow up with patients to promote comprehensive care coordination before, during, and after their journey Internal Collaboration & Influence Contribute to internal process improvements by sharing insights and identifying workflow gaps Participate in quality improvement initiatives, knowledge sharing, and feedback loops Collaborate with nursing and non-clinical team members via communication platforms to ensure closed-looped patient care Clinical Documentation & Coordination Maintain accurate and timely documentation of all patient interactions Ensure compliance with privacy standards and clinical protocols Coordinate with other members of the medical group to ensure seamless patient care
Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.
Position: Medical Expert - Sanctum Type: Contract Compensation: $180–$300/hour Location: Remote Duration: Ongoing Commitment: 20 hours/week Start Date: Saturday 4/25/2026 Compensation & Legal Remote, 100% asynchronous. Paid weekly via Mercor.
Must-Have: MD / DO / RN practicing in the United States or Canada. Actively practicing, board-certified or board-eligible in one of the listed specialties. Comfortable reading literature and translating evidence into structured feedback. 6+ hours per week of availability, flexible schedule.
Design clinically realistic prompts and scenarios in specialties like Internal Medicine, Emergency Medicine, and Cardiology. Write "golden" reference responses at attending-level quality for diagnostic reasoning and treatment planning. Grade AI-generated responses using structured rubrics to ensure adherence to evidence-based standards. Provide written feedback to the research team to improve model behavior and patient care reasoning. Participate in weekly office hours and specialty calibration sessions for continuous improvement.
SSM Health is a Catholic, not-for-profit, fully integrated health system dedicated to advancing innovative, sustainable, and compassionate care for patients and communities throughout the Midwest and beyond. The organization’s 40,000 team members and 13,900 providers are committed to fulfilling SSM Health’s Mission: “Through our exceptional health care services, we reveal the healing presence of God.” With care delivery sites in Illinois, Missouri, Oklahoma and Wisconsin, SSM Health includes hospitals, physician offices, outpatient and virtual care services, comprehensive home care and hospice services, a fully transparent pharmacy benefit company, a health insurance company and an accountable care organization. It is one of the largest employers in every community it serves. For more information, visit ssmhealth.com
It's more than a career, it's a calling WI-REMOTE Worker Type: Regular Job Highlights: We are looking for a candidate with tenured CDS experience and excellent Clinical experience. This is a fully remote role for candidates living in our four state footprint. Eligible states are MO, IL, WI and OK. Schedule - M-F 8 Hour Shifts between 0500 and 1800. Job Summary: Performs duties of a clinical documentation specialist and serves as a mentor and resource to the clinical documentation improvement team. Assists team managers with the query escalation report, mismatch escalations, reconciliation, query impact, and precepting new hires.
EDUCATION: Graduate of accredited school of nursing or education equivalency for licensing EXPERIENCE: Two years' acute care experience and three years' clinical documentation specialist experience PHYSICAL REQUIREMENTS: Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. Frequent keyboard use/data entry. Occasional bending, stooping, kneeling, squatting, twisting and gripping. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Rare climbing. REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS State of Work Location: Illinois Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) State of Work Location: Missouri Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration State of Work Location: Oklahoma Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) State of Work Location: Wisconsin Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services
Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate Diagnosis Review Group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI). Maintains appropriate productivity level. Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary. Reconciles reviews and ensures correct query impact. Generates and distributes query escalation reports to physician advisors. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Identifies issues with reporting of diagnostic testing proactively. Assists with provider education as needed. Educates physicians and key healthcare providers regarding clinical documentation improvement (CDI) and the need for accurate and complete documentation in the health record. Attends department meetings to review documentation related issues. Trains and mentors new CDI staff on CDI strategy, workflows, and software. Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM. Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, SOI, and/or ROM. Troubleshoots documentation or communication problems proactively and appropriately escalates. Serves as first line of escalation in the mismatch process. Acts as a resource and first point of contact for front-line clinical documentation staff for workflow or case reconciliation matters. Assists in the mortality review and risk adjustment process utilizing third-party models. Demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record. Imparts knowledge to providers and other members of the healthcare team. Maintains a level of expertise by attending continuing education programs. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's Scope of Service. As an SSM Health nurse, I will demonstrate the professional nursing standards defined in the professional practice model. Uses the ANA Code of Ethics for Nurses to guide his/her response to the current and evolving health and nursing needs of our patients and our patient populations. Works in a constant state of alertness and safe manner. Performs other duties as assigned.
Pager Health℠ is a leading AI-powered care navigation platform empowering health plans to deliver high-engagement and simplified, intelligent health experiences for their members and teams. Our solutions help people get the right care at the right time in the right place and stay healthy, while simultaneously reducing system friction and fragmentation, powering engagement, and orchestrating the enterprise. Pager Health partners with leading payers, providers and employers representing more than 26 million individuals across the United States and Latin America.
This position is for a full-time, remote Registered Nurse who is willing to think creatively and utilize their clinical skills in the field of Telehealth! We are seeking motivated Registered Nurses with 2+ years of clinical hospital experience to work in Pager Health's Command Center. The shift for this role is overnight (10:45pm - 9:45am Eastern Time). 4 days a week (rotating days). Every other weekend required. An active compact unencumbered RN license is required for this position. We have a variety of shifts available, which will be determined during the interview process. Working every other weekend is required. The core objective of the Triage RN, Nurse Navigator is to use technology to build trust and triage patients to the right care at the right time while providing an exceptional virtual care experience through empathic communication.
2+ years of clinical hospital experience; within the ICU or ER highly preferred An active compact unencumbered RN license Minimum of Associates Degree in Nursing (ADN) Bilingual and able to communicate in both English and Spanish is a major plus Ability to give and receive actionable feedback Passionate about patient care and triage Enjoy helping others Ability to use critical thinking when presented with new and challenging situations Relish solving problems, seeking out answers, and trying new things Kind, empathetic and possess a strong social perceptiveness Positive, energetic, and fun! Outstanding multitasking skills Enthusiasm and savviness for new technology Mastery of oral and written language along with strong typing skills Ability to assess and communicate with patients via a text-based platform Flexible and fast learner, comfortable in a fast-paced and changing environment Eager to challenge the status quo of traditional healthcare Detail oriented and an organized self-starter with outstanding interpersonal skills
Provide exceptional customer service and virtual care by communicating with patients via live messaging, video, phone, and/or email Document within EMR Follow and apply clinically validated triage protocols Ensure the highest quality customer service for patients and providers Complete basic nursing responsibilities, outpatient testing, medications, etc. Troubleshoot technology with patients Work to ensure a seamless patient call center experience Coordinate lab orders, prescription orders, radiology tests, and any aspect of patient care Work on projects that will optimize operational efficiency and improve the patient’s telemedicine experience Assist in identifying technology needs that improve patient experience Additional projects as assigned
Boulder Care is an award-winning digital clinic transforming addiction medicine. We provide fully virtual, evidence-based care — delivered by a multidisciplinary team of clinicians and peer recovery professionals. Named by Fortune as one of the Best Workplaces in Healthcare, Boulder fosters a culture of kindness, respect, and meaningful work that delivers outstanding patient outcomes and moves the addiction medicine industry forward. Our Philosophy At Boulder, our care model is rooted in harm reduction with a low-barrier, compassionate approach that prioritizes patient autonomy and choice. We meet people where they are, and our clinicians empower patients to reduce harm and build stability on their own terms through nonjudgmental, non-coercive, non-punitive support. We work with patients to identify their own recovery goals and support them over time through shared decision-making.
Boulder Care is hiring experienced Nurse Practitioners aligned with harm reduction principles. In this position, you will work directly with patients to deliver medication for opioid use disorder (MOUD) in a fully remote outpatient setting. Clinicians in this role independently initiate and manage buprenorphine treatment within a structured, team-supported model of care. This is a 100% remote, full-time, W2 position. If you are interested in part-time opportunities, please visit our careers page to view current openings. Schedule & Work Structure Full-time: 30–40 hours per week Full-time Monday through Friday schedules are fixed and may be structured as 3x10s, 4x8s, 4x10s, or 5x8s Paid Break Allotments: 8+ hour shift = one 30-minute break and one 10-minute break (40 minutes) 10+ hour shift = one 30-minute and two 10-minute breaks (50 minutes)
Reside in one of the following states: AK, AZ, CO, FL, ID, IL, KS, MA, MD, MN, NC, NH, NM, NV, NY, OH, OR, VA, WA, WY Have an active Nurse Practitioner license in your state of residence (Note: we are currently unable to hire PA-Cs or CNSs) NOTE: candidates who reside in Florida, Illinois, Massachusetts, Minnesota, or Virginia must hold the designation or licensure required to practice independently without physician supervision in their state. Have at least 1 year of experience in an independent, outpatient setting where you regularly prescribed buprenorphine-based medications — including initiating care, not just continuing existing prescriptions — as a core part of your daily practice Are interested in full-time work: 30-40 hours/week, with various shift options (see below for details) Active NP license and reside in one of these states: AK, AZ, CO, FL, ID, IL, KS, MA, MD, MN, NC, NH, NM, NV, NY, OH, OR, VA, WA, WY Note: Candidates who reside in Florida, Illinois, Massachusetts, Minnesota, or Virginia must hold the designation or licensure required to practice independently without physician supervision in their state. 1 year of experience in an independent, outpatient setting where you regularly prescribed buprenorphine-based medications — including initiating care, not just continuing existing prescriptions — as a core part of your daily practice Strong patient-centered practice and ability to work autonomously Private workspace with HIPAA-compliant setup
Telehealth addiction treatment on your terms and timeline - grounded in kindness, respect, and unconditional support. At Boulder Care, we help people with substance use disorders reach their goals through judgement-free recovery support and evidence-based addiction treatment, rooted in the principles of harm reduction. Patients can access their Care Team — a Clinician, a Care Advocate, and a Peer Recovery Specialist — through secure messaging, video visits, and phone support from an app on their phone. By championing low-threshold access to medications for addiction treatment, Boulder improves clinical and functional outcomes — sharing in the cost savings with health plan and employer partners under a value-based model. We are proud to offer millions of Americans access to Boulder as an affordable in-network provider and affordable self-pay options to those who need it.
Boulder Care is looking for Registered Nurses who are aligned with Harm Reduction principles and have experience supporting patients receiving buprenorphine-based treatment for opioid use disorder in an outpatient setting. This is a 100% remote, full-time, W2 position. We are looking for RNs who: Have an active, unrestricted RN license in your state of residency Have a minimum of 2 years of specialized nursing experience in outpatient substance use disorder treatment. Are interested in full-time work (40 hours a week) with a Monday-Friday schedule: 1pm - 9pm EST (10am - 6pm Pacific Time) If this sounds like you, please continue applying. About the role This position is 100% remote but you must reside in one of the following states: AL, AK, AZ, CO, FL, GA, ID, IN, KS, MD, MI, NH, NM, NY, NC, OH, OR, PA, TN, TX, WA, WY The Registered Nurse works directly with patients to deliver medication-assisted recovery for substance use disorder (SUD) and empowers patients in their recovery journeys in coordination with the Care Team (primarily Nurse Practitioners, Medical Assistants and Peer Recovery Specialists) Our team delivers compassionate and empathetic telephonic, text-based, and video-based (telehealth) patient engagement and monitoring Boulder Care recognizes the value that lived experience can provide to our organization, community, and patients. Applicants with lived experience and/or training as a peer recovery specialist are encouraged to apply
Bachelor’s Degree in Nursing, preferred Preference given to candidates with 2+ years specialized nursing experience in outpatient substance use disorder treatment Embrace a harm reduction philosophical approach to care Compassion, empathy, and deep dedication to patient care Excellent written and verbal communication Extraordinary customer service skills, computer skills and record keeping Ability to handle multiple tasks simultaneously and prioritize based on severity of need, while working independently with minimal supervision Ability to achieve specified outcomes in collaboration with all members of the leadership team Demonstrates quality in clinical performance as evidenced by creativity in problem solving and interdisciplinary communications Ability to work collaboratively with medical staff including Clinicians, Care Advocates , Peers, Case Managers and colleagues in all aspects of care provision Experience in office-based nursing preferred Knowledge of Hepatitis C, HIV preferred Membership in a relevant professional nursing organization (e.g. International Nurses Society on Addiction) or specialty certification (e.g. CARN) preferred A dedicated, private workspace with a lockable door and high-speed internet to maintain a secure, distraction-free environment, ensuring compliance with HIPAA and confidentiality standards Due to privacy protocols, we are unable to employ individuals who are or have previously been patients at Boulder Care Expected hours of work 40 hours per week (salaried) Shift Options: Monday-Friday 1pm - 9pm EST (10am - 6pm Pacific Time) Compensation Pay range: $80,000 - $95,000 (determined by several factors including your relevant skills, education, and experience)
Essential Functions - Patient Care (50%) Provide compassionate, empathetic telephonic, text based & video-based (Telehealth) patient engagement and monitoring, assisted by clinical decision support tools Provide support to patients within the Boulder application to ensure successful engagement and initiation of treatment Educate patients about addiction, medications, and available support services; answer questions regarding treatment and program protocols, and provide guidance to patients and providers within scope of practice Provide opioid overdose prevention, education, and reversal, safer consumption education, and safer sex education and testing Access Prescription Drug Monitoring Program information, facilitate patient adherence monitoring protocols, for each assigned patient Assess progress, patient functioning, and stage in recovery; in collaboration with other care team members and the patient, develop and update treatment care plans for each individual Assess and advocate for acute withdrawal management Assess for pain and collaborate findings with Clinician Provide Buprenorphine initiation education and follow up Maintain effective, proactive, and superior follow-up communication with patients, providers and care team Maintain an accurate and updated medical record of individual patient progress during all clinical interactions Identify and provide crisis intervention, within scope of practice If applicable: facilitate placement for adjunctive or higher level of care; maintain contact with these placements to provide continuity of care and to streamline transitions of care Obtain and review drug testing results and recommend further testing as appropriate, guided by clinical decision support tools Essential Functions - Care Coordination (30%) Coordinate with multidisciplinary care teams via telehealth to guide treatment planning and delivery including the following functions; Collaborate with pharmacies to facilitate medication refills and support patients with medication-related concerns Collaborate with outside providers and community care agencies to maintain accurate and timely data exchanges between all organizations and individuals involved in patient care Assist with the management of patient appointments with other care team members and referrals outside of Boulder Report patient change in status (e.g. high risk for returning to use) and potential support services to prescribing clinicians in a timely manner Provide patient updates and outcomes reports to the prescribing provider in alignment with Boulder Care goals Essential Functions - Administrative (20%) Meetings (department, company-wide, ECHO, meetings with your manager) Maintain HIPAA and 42 CFR Part 2 compliance and all levels of required patient confidentiality Manage and maintain individual schedule of assigned patients Chart prep
Community Health Systems is one of the nation's leading healthcare providers. With healthcare delivery systems in 36 distinct markets across 14 states, CHS operates 69 affiliated hospitals with more than 10,000 beds and approximately 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, imaging centers, cancer centers, and ambulatory surgery centers.
Benefits Comprehensive Health Coverage – Medical, dental, and vision plans to keep you and your family healthy. Future Security: 401(k) with matching Student Loan Support – Up to $10,000 repayment assistance, because we invest in your future. Educational Tuition Assistance Competitive Pay & Full Benefits – A salary and package designed to reward your expertise and dedication. Job Summary: The Appeal Specialist II reviews, analyzes, and resolves insurance denials to ensure accurate reimbursement and regulatory compliance. This role logs and reviews denials for trend reporting, provides feedback to facilities, and communicates payer updates to relevant stakeholders. The Appeal Specialist II collaborates with internal teams to ensure timely and thorough appeal resolution and supports initiatives that improve denial prevention and recovery processes.
Qualifications: H.S. Diploma or GED required Bachelor's Degree in Nursing preferred 2-4 years of experience in healthcare revenue cycle or business office required 1-3 years of experience in healthcare insurance or medical billing preferred Knowledge, Skills And Abilities: Proficiency in word processing, spreadsheet, and database applications. Working knowledge of billing, coding, and reimbursement principles. Strong analytical, research, and problem-solving skills. Ability to communicate effectively with payers, facility staff, and leadership. Strong organizational and documentation skills with attention to detail. Ability to work independently and manage multiple priorities in a fast-paced environment. Understanding of insurance claims processing and denial management workflows. Licenses and Certifications RN - Registered Nurse - State Licensure and/or Compact State Licensure required
Reviews and resolves pre-payment insurance denials in collaboration with follow-up teams. Coordinates with Denial Coordinators, Facility Denial Liaisons, and Managed Care Coordinators to ensure payer accountability and identify education opportunities. Provides feedback to facilities regarding denials resulting in retractions or reimbursement impacts. Monitors payer billing and coding updates and communicates changes to SSC and ancillary departments. Tracks and logs denials and appeal activity according to established documentation and reporting guidelines. Prepares and distributes reports summarizing appeal trends, project updates, and payer response activity. Recommends process improvements to enhance appeal efficiency and reduce recurring denials. Maintains up-to-date knowledge of payer policies, billing and coding practices, and reimbursement regulations. Utilizes practice management systems and maintains documentation of appeal activity in compliance with departmental standards. Performs other duties as assigned. Maintains regular and reliable attendance. Complies with all policies and standards.
WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries, including Banking and Financial Services, Healthcare, Insurance, Shipping and Logistics, and Travel and Hospitality. We bring together deep domain excellence - WNS’ core differentiator - with AI-powered platforms and analytics to help businesses innovate, scale, adapt and build resilience in a world defined by disruption. Our purpose is clear: to enable lasting business value by designing intelligent, human-led solutions that deliver sustainable outcomes and a differentiated impact. With three global headquarters across four continents, operations in 13 countries, 65 delivery centers and more than 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact.
Start Date: 06/22/2026 Training Schedule (First 6 Weeks): Monday to Friday, 8:00 AM – 4:30 PM (CST) Regular Schedule After Training: 10:30am CST - 7:00pm CST Location: Remote Compensation Disclosure The base salary for this position is $65,000 [LVN/LPN], $75,000 [RN] annually. This represents the base pay range that we reasonably expect to offer for this position. In addition to base pay, this role may be eligible for performance-based bonuses, incentive pay, or commissions, which are not included in the listed base salary range. WNS complies with all applicable federal, state, and local pay transparency laws, including those in California, Colorado, New York, Washington, and Illinois. Note: For complete compensation information, please refer to the job posting on our official careers page.
RN, LPN/LVN graduate from an accredited school of nursing Current, active unrestricted RN, LPN/LVN license in the state or territory of the U.S. Minimum of two (2) years experience in utilization review, case management, or clinical quality improvement Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint) and ability to adapt to new healthcare specific software and systems, required Experience working with state and federal regulatory and compliance standards, preferred Working knowledge of National Coverage Determination (NCD) and Local Coverage Determination (LCD) Knowledge of insurance terminology Good organizational and time management skills Excellent written and verbal communication skills Ability to utilize critical thinking skills Highly motivated, self-starter who can work efficiently and independently, or as a team member
Performs utilization review of cases to determine if the request meets medical necessity criteria in accordance with medical policies agreed upon with the Client and any applicable governing body. Facilitates resolution of escalated cases that may require special handling. Performs clinical reviews according to the policies and procedures of HealthHelp within the identified State and Federal or Client agreed upon timeframes. Collaborates with client personnel to resolve customer concerns. Appropriately identifies and refers quality issues to UM Leadership. Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes. Maintains written documentation according to HealthHelp’s documentation policy. Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management. Keeps current with regulation changes as provided by Compliance Department and Nursing Management. Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs. Provides quality customer service through interaction with providers, administrative staff, and others. Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others. Engages in phone conversations with ordering providers, members, internal staff, primary care physicians (PCPs), and rendering providers as necessary to facilitate the clinical review process and ensure appropriate care decisions. Effectively utilizes various computer systems and software to manage cases and document reviews. Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy. Participates in the HealthHelp Quality Management Program, as required. Adheres to both URAC & NCQA standards pertinent to their job description. Ability to prioritize projects, work independently under pressure, and meet critical deadlines. Capable of communicating clinical concepts to providers and staff based on guidelines. Performs other related duties and projects as assigned to meet business needs.
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together.
The Registered Nurse Clinical Annotator plays a critical role in supporting the development of artificial intelligence models designed to streamline and automate prior authorization processes in healthcare. This position leverages clinical expertise to interpret, annotate, and validate medical documentation, ensuring that AI systems are trained on accurate, contextually relevant, and policy-compliant data. General Job Profile Reviews the work of others Develops innovative approaches Sought out as expert Serves as a leader/ mentor You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Active, unrestricted RN license: 3+ years of recent clinical experience in acute care, case management, utilization management, or a related clinical specialty Solid understanding of clinical documentation, medical terminology, and evidence based practice Experience applying guideline based criteria (e.g., InterQual, MCG) in clinical review or UM workflows Ability to interpret medical records and determine clinical appropriateness using structured criteria Proficiency with electronic medical records (EMR) and comfort navigating multiple clinical systems Familiarity with HIPAA requirements, data privacy standards, and safe handling of patient information Demonstrated experience performing clinical prior authorization reviews across diverse service categories, including medical/surgical procedures, diagnostic imaging, DME and related supplies, specialty therapies/devices, and other utilization management areas aligned to health plan medical policy Ability to work independently while maintaining productivity, quality, and adherence to annotation guidelines Curiosity and willingness to learn emerging technologies, AI supported workflows, and evolving guidelines Preferred Qualifications: BSN Experience collaborating with cross functional teams (clinical, data science, operations) Experience with data labeling, clinical data annotation, or AI/ML workflows High level of accuracy, attention to detail, and commitment to consistent, high quality annotations Solid analytical thinking, clinical reasoning, and ability to identify gaps or inconsistencies in documentation Effective written communication skills, with the ability to clearly document annotation decisions and rationales
Review medical records and interpret clinical documentation with accuracy and clinical judgment Apply guideline based criteria to annotate, categorize, and label case data used for AI model training Ensure annotations are clinically sound, consistent, and aligned with established utilization management (UM) guidelines Contribute to the development of high quality training datasets that support safe and effective AI model performance Identify gaps, ambiguities, or inconsistencies in documentation and escalate issues as needed Participate in refinement and continuous improvement of annotation guidelines, clinical rules, and workflows Collaborate with cross functional teams including data science, clinical operations, and product teams to ensure clinical accuracy and operational relevance of labeled data Support testing, validation, and quality review activities for AI supported UM tools and workflows Maintain detailed documentation of annotation decisions, rationales, and guideline interpretations Uphold clinical, ethical, and regulatory standards in all aspects of data handling, patient information, and annotation workflows You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
At Amedisys whether we’re caring for patients directly or supporting those who do, each of us is a caregiver at heart. From home health to hospice to personal care, every team member contributes to our mission of providing exceptional, clinically distinct care in the home to more than 415,000 patients every year. We know that every life tells an incredible story, and we celebrate that each day by honoring our patients with genuine, personal attention. Everything we do, from the boardroom to our nationwide network of care centers, is centered on the best care possible for those who have entrusted us with their well-being and comfort. We work closely with doctors and other healthcare providers to coordinate services, and every patient has an individual plan of care that meets their specific needs. Amedisys recognizes that nothing we do is possible without our incredible team. For all employees, whether they’re on the front lines delivering direct care or supporting our clinical team, this isn’t just a job – it’s a higher calling. We’re committed to finding passionate, qualified caregivers for our team and investing in them with the best resources, training and professional development opportunities to nurture their talents in order to empower them to make a real difference. At Amedisys, we know that the unique skills and experiences all service members and military spouses have lead to outstanding, dedicated caregivers, and that is why we are proud to partner with organizations such as Hiring our Heroes, TAOnline.com, and Military Spouses Employment Partnership to recruit and employ veterans and military spouses across our company. Together, we will lead the future of healthcare in the home, establishing ourselves as the premier innovative choice for aging in place wherever patients call home. Visit our website at www.amedisys.com/careers to learn how to join a team of committed professionals who are dedicated to a culture of delivering excellent patient care.
PT Benefitted 30-32 hours a weekly Hourly Position/Remote Position Most Holidays required annually Every weekend required-Day Time Hours (Schedule/Hours direct to Triage Leadership) Hours may be variable depending on licensure (No Overnights shifts available) Compact Licensure with ability to pick up additional licensure including CA, MA, and OR Bilingual Needed, Not Required Hospice Experience 1-2 years preferred Compact Licensure Required, and fall under NCL guidance Are you looking for a rewarding career in homecare? If so, we invite you to join our team at Amedisys, one of the largest and most trusted home health and hospice companies in the U.S. Attractive pay $34.00-$36.00 What's in it for you A full benefits package with choice of affordable PPO or HSA medical plans. Paid time off. Up to $1,000 in free healthcare services paid by Amedisys yearly, when enrolled in an Amedisys HSA medical plan. Up to $500 in wellness rewards for completing activities during the year. Use these rewards to support your wellbeing with spa services, gym memberships, sports, hobbies, pets and more.* Mental health support, including up to five free counseling sessions per year through the Amedisys Employee Assistance program. 401(k) with a company match. Family support with infertility treatment coverage*, adoption reimbursement, paid parental and family caregiver leave. Fleet vehicle program (restrictions apply) and mileage reimbursement. And more. Please note: Benefit eligibility can vary by position depending on shift status. *To participate, you must be enrolled in an Amedisys medical plan.
Qualifications: Current, unencumbered license to practice as a registered nurse in the state you are assigned to work. One year of experience as a registered nurse. Current CPR certification. Knowledge of physical, psychosocial, and spiritual needs of terminally ill patients and their caregivers. Must be comfortable with technology. Must be willing and eligible to obtain additional RN licenses in other states (reimbursed). Preferred: Previous hospice experience. Telephone triage experience. Spanish speaking.
Assesses physical, environmental, and emotional factors telephonically to determine hospice needs. Utilizes EHR, including the patient's plan of care to develop recommendations. Provides recommendations, patient/caregiver education/instructions and hospice support telephonically based on the situation and the plan of care. Collaborates with pharmacies, DME vendors and other agencies for effective patient management. Facilitates delivery or maintenance of provided medical equipment to meet patient needs. Assigns all visits, admissions and follow-up calls to on-call field staff (RN, LPN, HA, CH, SW) as needed. Submits accurate and detailed documentation in real-time to promote continuity of care. Utilizes a combination of agency resources and nationally recognized standards of practice to achieve excellent pain and symptom management and high-quality end-of-life care. Participates in agency performance improvement initiatives. Performs other duties as assigned.
Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.
Imagine360 is seeking a Disease Management Care Coach, Behavioral Health, RN to join the team! The Care Coach is responsible for providing telephonic coaching and educational resources to people with chronic health conditions. Coaching topics include medication compliance, nutrition, physical activity, and care coordination. Responsibilities include assessment, coordination, planning, monitoring, and evaluation. Position Location: 100% remote
Required Experience/Education: Nursing Degree from an accredited college or university. 2+ years of experience in direct participant coaching. Skills and Abilities: Must have intermediate knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software License and Certifications: Active and unrestricted Compact Registered Nurse License required
Provide telephonic coaching, and information and referral services to program participants managing various chronic health conditions with clinical oversight assistance Assess participant needs using scripted assessments Communicate, as needed, with service delivery partners, physicians, and other health professionals to provide care coordination Review pertinent medical history, current diagnosis, and pharmaceutical data via information database system with clinical oversight Assist participant in forming realistic goals related to overall health Determine and provide relevant community and/or healthcare resources that help support participant's goals Promote wellness and provide education regarding preventative care measures Effectively assess, coach and graduate clients from care, resulting in appropriately managed caseloads Document participant activities and coaching/counseling sessions in established format in the case tracking software In addition to performing standard Care Coach roles, Registered Nurses are involved in clinical decision-making and patient education. The scope of practice for nursing work includes, but is not limited to: Rationale for the effects of medications and treatments Implement measures to promote a safe environment for clients and others Accurately report: Administration of medication and treatments Client response Contact with other health care team members The client's status including signs and symptoms Nursing care (education) rendered Respect the client's right to privacy by protecting confidential information Promote and participate in education and counseling to a participant based on health needs Clarify any treatment that is believed to be inaccurate, non-effacious, or contraindicated by consulting with appropriate practitioner Know, recognize, and maintain professional boundaries of the nurse-client relationship
Peraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the world’s leading mission capability integrator and transformative enterprise IT provider, we deliver trusted, highly differentiated solutions and technologies to protect our nation and allies. Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace. The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces. Each day, our employees solve the most daunting challenges that our customers face. Visit peraton.com to learn how we’re keeping people around the world safe and secure.
Program Overview: Performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse in Medicare and Medicaid programs. About The Role: SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse. We are looking to add a Nurse Reviewer to our SGS team of talented professionals.
Basic Qualifications: 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD Proven experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity. Current nursing license. Strong investigative skills Strong communication and organization skills Ability to apply Federal, State and Managed Care Organization (MCO) regulations to claims under review Strong PC knowledge and skills US citizenship required The most competitive candidates will have: Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases Have experience involving review of services performed for Medicaid Have a CPC (Certified Professional Coder) certificate. Essential Functions: This position may require the incumbent to appear in court to testify to work findings. Ability to compose correspondence, reports, and referral summary letters. Ability to communicate effectively, internally and externally Ability to handle confidential material. Ability to report work activity on a timely basis. Ability to work independently and as a member of a team to deliver high quality work Ability to attend meetings, training, and conferences, overnight travel required
The position requires the individual to conduct medical record reviews and to apply sound clinical judgment to claim payment decisions. Responsibilities may include additional research on medical claims data and other sources of information to identify problems, review sophisticated data model output, and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. The incumbent will use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, and overpayment recovery. Will work with external agencies to develop cases and corrective actions as well as respond to requests for data and support. Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government Research regulations and cite violations. Conduct self-directed research to uncover problems in Medicaid payments made to institutional and non-institutional providers. Make claim payment decisions based on clinical knowledge Telework available in the contiguous United States
Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
Knowledge, Skills, and Abilities: N/A Education: Bachelor's of Nursing or higher in a healthcare related field [Required]• Master's or higher in a healthcare related field [Preferred] Field of Study: N/A Work Experience: 3+ of recent cdi experience [Required]• 5+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required]• Experience in outpatient clinical documentation reviews and improvement processes [Preferred]• Experience with, modeling, and report development [Preferred] Additional Information: An equivalent combination of education ad relevant work experience may be considered in lieu of the stated degree requirement: Bachelors degree and 3+ years of experience OR Associates degree and 5+ years of experience OR High School Grad or Equivalent and 7+ years of experience. Licenses and Certifications: Certified Cardiac Device Specialist (CCDS) [Required] OR Certified Documentation Improvement Practitioner (CDIP) [Required]• Certified Documentation Expert Outpatient (CDEO) [Preferred] Physical Requirements: (Please click the link below to view work requirements) Physical Requirements – https://tinyurl.com/23km2677
Reviews concurrent medical records for compliance, completeness, and accuracy regarding severity of illness, risk of mortality, and quality. Completes accurate and timely record reviews to ensure the integrity of documentation compliance. Inputs data into CDI software accurately and concisely, resulting in precise metrics obtained through the reconciliation process. Understands and supports CDI documentation strategies and continues to educate self and team members through mandated education sessions and provided webinars. Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision-making, balancing quality considerations with regulatory compliance. Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to clinical team members. Transcribes documentation clarifications as appropriate to ensure documentation compliance is accomplished. Educates members of the patient-care team regarding documentation regulations and guidelines, including quarterly and annual compliance updates from Medicare. Communicates effectively and appropriately with physicians and other healthcare providers to ensure accurate and complete clinical documentation. Collaborates with HIM staff to resolve discrepancies with DRG assignments and other coding issues. Completes timely follow-up case reviews on all concurrent cases, prioritizing resolution of those with clinical documentation clarifications. Performs other duties as assigned.
Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
Knowledge, Skills, and Abilities: Bilingual proficiency in English and another language [Preferred] Education: Associate's of Nursing [Required] Bachelor's of Nursing [Preferred] Field of Study: N/A Work Experience: 1+ years acute care experience [Required] 1+ years of experience in clinical nurse telephone [Preferred] 1+ years of experience in outpatient practices [Preferred] Additional Information: N/A Licenses and Certifications: Basic Life Support – CPR Cert (BLS) [Required] Registered Nurse (RN) [Required] Physical Requirements: (Please click the link below to view work requirements) Physical Requirements – https://tinyurl.com/msy4mja2
Training is in-person at Tampa office, then transitioned to fully remote Shift: Monday through Friday from 8AM to 5PM Follows established nursing protocols and guidelines for triage to ensure safe, evidence-based care. Participates in continuous learning and skill development opportunities. Assesses patient symptoms via phone, utilizing clinical protocols to determine the appropriate course of action. Provides guidance and education on common health concerns and home care advice. Facilitates referrals and appointment scheduling to ensure continuity of care. Documents patient interactions, including symptoms, advice provided, and follow-up plans, in the electronic medical record (EMR). Monitors patient progress and promotes early intervention in acute care situations. Demonstrates professional qualities in time management, problem-solving, decision-making, and communication. Acts as an advocate for patients, addressing their needs and concerns with empathy and professionalism. Operates within applicable accrediting body protocols to deliver safe patient care. Integrates evidence-based clinical guidelines and protocols in the development of patient-centric treatment plans. Collaborates with healthcare team members to ensure cohesive care management. Other duties as assigned
We’re building partnerships and transforming care. Alternate Solutions Health Network was founded in 1999 by David and Tessie Ganzsarto. We collaborate with health systems in joint venture partnerships to create a post-acute care solution, delivering efficient centralized operations and utilizing a best-in-class software platform. ASHN will never ask, nor require a candidate to provide money for work equipment and network access during the application process. If you become aware of any instances where you as a candidate are asked to provide information and do not believe it is a legitimate request from ASHN or affiliate, please contact jennifer.sanchez@ashealthnet.com to validate the request. Our Vision Story: Inspiring Care at Home At Alternate Solutions Health Network, we’re not just delivering care—we’re building bridges. Bridges between health systems and home health, between clinicians and their passion for caregiving, and between patients and the lives they long to lead. At ASHN, our purpose is simple yet profound: Inspiring care at home. We believe on the power of people, and you are the heart of our mission. Culture of Care At ASHN, you're part of a team that truly cares. We support your growth with mentorship, leadership development, and a sense of belonging. Care with a Purpose As a leader in the home health industry, you'll deliver dignity, independence, and hope to those who need it most. Your work inspires and transforms lives. Care that Connects By caring for patients in their homes, you create meaningful connections and provide deeply personal, heartfelt care. Caring Made Flexible: Your Career, Your Way Life is unpredictable and we get that. With flexible schedules, pay-per-visit earnings, and room to grow, your career works for you.
Our culture and people are what set us apart from other post-acute care providers. We’re dedicated to the growth and development of our team to set them up for success. We CARE for our patients like they are our own FAMILY. Registered Nurse (RN) Clinical Field Staff Liaison Monday - Friday, 8:00am - 4:30pm, rotating remote on-call. Agency: Redcrest Home Health, LLC Location: Bloomington, IN Schedule: SUMMARY: The RN Clinical Field Staff Liaison - Hospice (CFSL) provides support for personnel and patient care services. The CFSL is responsible for reviewing compliance, quality and safe delivery of services by following clinical processes. The company adopts the Nursing scope of practice as outlined by the State for its licensed nursing personnel. Provides backup to the Clinical Manager and Program Assistants as needed.
Current RN license in the state of employment 3 years experience as an RN, with at least one year in Hospice Strong critical thinking skills with the ability to problem solve clinical needs Ability to create positive impressions and communicate with a variety of people Exemplary communication skills and customer focus Ability to remain calm, have patience and be accommodating Compassionate and caring while working with patients, families, and all other customers Ability to resolve conflict using conflict management skills Knowledgeable on nursing best practices and able to make appropriate nursing judgments Detail-oriented and observant Ability to synthesize complex medical information and escalate to Clinical Management Ability to prioritize and be timely Ability to clinically support the needs of the department to ensure team goals are met timely Takes advantage of available resources (individuals, processes, departments, and tools) to complete work effectively and efficiently Applies fact-based knowledge of technical skills and business understanding Ability to follow directions and work as a team member Valid driver’s license and auto insurance. HEALTH QUALIFICATIONS: Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without reasonable accommodations. Below are minimal knowledge/physical requirements of this position. Constantly (66%-100%)Reading, Speaking, Writing English Communications Skills Computer/PDA Usage Sitting Hand/finger dexterity Hearing/Seeing Hearing in person Hearing on the phone Talking in person Talking on the phone Vision for close work Frequently (34%-66%)N/A Occasionally (2%-33%)Walking Bending Standing Driving Lifting up to 50 lbs. with or without assistance Stretching/Reaching Climbing Stooping (bend at waist)Distinguish smell/taste Rarely (1% or less)N/A
Ensure quality and safe delivery of hospice services for the patient from beginning to end of their service. Collaborates with Agency Clinical Manager and Medical Director to facilitate hospice care and ensure compliance Meet and exceed quality indicators Collaborates with intake, providing daily support, managing assignment volume based on staffing availability Completes RN Clinical Manager workflow when needed to ensure timeliness of completion as well as identify education needs for field clinicians for escalation to Clinical Managers. Focus on Key Performance Indicators as assigned Assist with implementation of quality improvement programs in the field Participates in on-call rotation, and patient staffing as needed to manage staffing needs and patient related issues Completes field visits as needed Participates in managing cost of goods working with monitoring supply costs, DME costs, medication costs Maintains positive working relationships with referral sources including physicians, hospitals, skilled facilities, assisted livings and families Assist with monthly IDG meetings when needed Reviews clinical documentation in accordance with agency protocol and Medicare/Federal guidelines Maintains active RN license in state of employment Participates in in-service program development Consistently demonstrates core values and maintains a professional appearance as a representative of the company Understands, implements and practices policies and procedures for agency operation Assists in new hire orientation when needed All other duties as assigned MANAGEMENT RESPONSIBILITY: None
We’re building partnerships and transforming care. Alternate Solutions Health Network was founded in 1999 by David and Tessie Ganzsarto. We collaborate with health systems in joint venture partnerships to create a post-acute care solution, delivering efficient centralized operations and utilizing a best-in-class software platform. ASHN will never ask, nor require a candidate to provide money for work equipment and network access during the application process. If you become aware of any instances where you as a candidate are asked to provide information and do not believe it is a legitimate request from ASHN or affiliate, please contact jennifer.sanchez@ashealthnet.com to validate the request. Our Vision Story: Inspiring Care at Home At Alternate Solutions Health Network, we’re not just delivering care—we’re building bridges. Bridges between health systems and home health, between clinicians and their passion for caregiving, and between patients and the lives they long to lead. At ASHN, our purpose is simple yet profound: Inspiring care at home. We believe on the power of people, and you are the heart of our mission. Culture of Care At ASHN, you're part of a team that truly cares. We support your growth with mentorship, leadership development, and a sense of belonging. Care with a Purpose As a leader in the home health industry, you'll deliver dignity, independence, and hope to those who need it most. Your work inspires and transforms lives. Care that Connects By caring for patients in their homes, you create meaningful connections and provide deeply personal, heartfelt care. Caring Made Flexible: Your Career, Your Way Life is unpredictable and we get that. With flexible schedules, pay-per-visit earnings, and room to grow, your career works for you.
Our culture and people are what set us apart from other post-acute care providers. We’re dedicated to the growth and development of our team to set them up for success. We CARE for our patients like they are our own FAMILY. $5000 Sign On Bonus Remote Weekend Registered Nurse (RN) Clinical Field Staff Liaison Schedule: Saturday and Sunday 8-4:30 and triaging phone calls overnight. Participates in holiday rotation. Agency: North Kansas City Hospital Home Health, LLC THIS POSITION IS REMOTE BUT YOU MUST LIVE IN THE NORTH KANSAS CITY AREA TO TRAIN IN OFFICE AND COME IN AS NECESSARY. SUMMARY: The RN Clinical Field Staff Liaison (CFSL) provides support and acts as a resource to clinicians in the field. The CFSL assists in monitoring compliance quality and safe delivery of services by following a clinical process set by clinical management. The CFSL is responsible for all practices and duties within the scope of practice as outlined by the state.
Registered Nurse with current license in the state of employment. Compact licensure, for states that participate, is required to be obtained within first 30 days of employment for additional support in all ASHN affiliated agencies. Three years of experience as an RN in an acute care setting Minimum one-year home health experience is preferred Ability to effectively communicate and create positive impressions with patients, families, physicians and co-workers Ability to remain calm, have patience and be accommodating. Compassionate and caring while working with patients Knowledgeable on nursing best practices Ability to make appropriate nursing judgments Ability to identify a situation and handle it with the best possible solution Detail-oriented and observant Disciplined style of work ethic with the ability to prioritize and be timely Ability to follow directions and work as a team member Knowledge of MS Office applications including Word, Excel, PowerPoint and Outlook Valid driver’s license and auto insurance with your name as a listed driver
Serve as a resource for field staff, referral sources, physicians, patients and their families pertaining to clinical issues and/or concerns Facilitate calls to and from Field staff; uses resources to resolve issues and reports anything of concern to manager Work in the field with staff and patients as needed Maintains positive working relationships with referral sources including physicians, hospitals, skilled facilities, assisted livings and families Assist with monthly Case Manager, Nurse and Therapy meetings Ensure Start of Care compliance Ensure quality and safe delivery of home health services Monitor Home Health Aide supervisory visits Focus on Outcome Monitors as assigned Implement quality improvement programs in the field Completes field visits as needed Participates in managing cost of good working with monitoring supply costs and visits per episode Knowledgeable of CFSS workflow Review relevant reports Reviews clinical documentation in accordance with agency protocol and Medicare/Federal guidelines Maintains active RN license in state of employment Participates in on-call, evening/weekend shifts and provides patient care, per agency needs Participates in in-service program development Maintains a professional appearance as a representative of the company Understands, implements and practices policies and procedures for agency operation Other duties as assigned HEALTH QUALIFICATIONS: Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Below are minimal knowledge/physical requirements of this position. Travel is required for this position. Constantly (66%-100%):Reading, Speaking, Writing EnglishCommunications SkillsComputer/PDA UsageHand/finger dexterityHearing/SeeingHearing in personHearing on the phoneTalking in personTalking on the phoneVision for close work Frequently (34%-66%)Sitting Occasionally (2%-33%)WalkingBendingStandingStretching/ReachingDrivingLifting up to 50 lbs. with or without assistanceClimbingStooping (bend at waist)Distinguish smell/taste Rarely (1% or less)N/A
At Chariton Valley Association (CVA), a proud partner of Center for Human Services, we EMPOWER people with disabilities to achieve their highest level of independence through high-quality, and diverse support services. Chariton Valley is a non-profit organization established by family members and parents of children with disabilities. We provide superior supports in a loving environment.
The Community RN will support the CHS mission by promoting the physical and mental health of individuals through application of nursing processes, and by ensuring qualified staff through the delivery of Level 1 Medication Administration and CPR/First Aid instruction.
Skills And Abilities: the essential functions and meet physical requirements. Accountability Attention to detail Effective written communication Ethical behavior and decision making Initiative Leadership Medical knowledge and experience Organizational skills Positivity with a collaborative attitude Professional and courteous business communication Public speaking/Teaching/Training Stress management Supervision Time management with ability to meet deadlines COMPETENCIES: Active listener Client focused Confident Creative Experienced with computers Person-centered Policy-supportive Proactive Problem solver Result-oriented Self-starter Strategic Supportive of inclusion, diversity, equity, and accessibility Qualifications REQUIRED EDUCATION and EXPERIENCE: Associate Degree in Nursing (ADN), required, Bachelor of Science in Nursing (BSN), preferred Current State License or Compact State License as a Registered Nurse. Must obtain and maintain Professional CPR certification Must obtain and maintain DHSS Approved Instructor certification Required Miscellaneous Qualifications Valid driver’s license Reliable, licensed, and insured vehicle Reliable form of communication (smart phone) Physical Requirements: Ability and strength to position/lift/transfer greater than 50 lbs. (an adult human being) regularly, including the ability to safely assist an adult human being to the ground to perform CPR Continuous ability to push and pull 100-125 lbs. of pressure consistently over extended periods as per requirements of performing CPR, as defined by the American Heart Association Continuous ability to kneel on hard or other surfaces for extended periods, as per requirements of performing CPR Type on a keyboard for long periods Vision sufficient to read medication labels and dosing instruments and/or to view computer screens for extended periods of time Drive distances of 200+ miles SHIFTS: Part Time I (0-19 hours per week) TRAVEL: This is a hybrid remote position that requires travel to multiple department locations in the state of Missouri in various counties including Jefferson. Case load is subject to change at any time.
Promotes the physical and mental health of individuals served by coordinating and monitoring medical services, including health and medication services, in accordance with the requirements of regulatory agencies and in response to individual needs; providing at least 1.25 hours of service to each individual supported each month; participating in the admission of new individuals to assigned programs; clarifying medical information and advocating for individuals in hospital admissions and/or discharges, including communicating with relevant healthcare providers or pharmacists to review individual health statuses and medication plans; conducting full health assessments (including skin assessments) of individuals within 7 days of discharge from hospitalization or ER visits; coordinating ongoing care with clinics, external healthcare providers, hospitals and pharmacies; coordinating and reviewing lab work as required; traveling as needed to provide medical related support to individuals as directed; reviewing and teaching health and nutrition per individual needs; conducting Professional Assessment and Monitoring services as authorized; promoting individual empowerment and self-care activities including self-medication; and participating in on-call rotations with other community nursing staff, as directed and required by staffing and support needs; Ensures medically qualified staff by providing nursing delegations related to medical diagnoses, allergies, medication, diet and special emergency plans related to ongoing medical conditions; becoming certified to instruct Level 1 Medication Administration and CPR/First Aid training; developing instruction methods and selecting teaching aids including, but not limited to handbooks, study aids, demonstration models, visual aids, online tutorials and reference works; conducting in-person, recorded, or virtual training via diverse and appropriate instructional methods including, but not limited to individual training, group instruction, lecture, demonstration, conferences, meetings, or workshops and testing trainees to measure progress and effectiveness; reporting progress of employees in training to departmental management when advisable; and supervising Community Licensed Practical Nursing (LPN) services as required. Communicates complex medical information to individuals served, staff, and other stakeholders by developing plans to ensure that the medical needs of individuals are met; following up with health related concerns identified by the Department of Mental Health (DMH) RN; completing the medical sections of Individual Support Plans (ISPs) which address health related concerns; participating in departmental and other staff meetings to ensure alignment, and direct knowledge transfer; and answering questions about the health care and condition of individuals with staff, guardians, service coordinators, as well as the individuals, themselves. Supports regulatory compliance by documenting services in accordance with agency policy , and the requirements associated with Medicaid, DMH certification and other contractual compliance; conducting regular review of the accuracy and completion of medication administration documents at locations where individuals are supported; ensuring all CIMOR and APTS 2 referrals are completed in a timely fashion; inputting information into the state HRST system and updating monthly as needed; maintaining current and accurate knowledge of company and departmental policies and procedures; protecting confidentiality of information and following HIPAA guidelines; maintaining licensing and certifications necessary for work; participating in continuing education to remain current with modern best practices and acting as local medical advisors in matters of infectious disease control, or health crises per policy and protocols, including serving as an infectious disease control authority if so directed by the CEO, or his/her designee. Promotes a positive work culture by supporting other community nurses with a team spirit, including, but not limited to coverage for anticipated and unanticipated absences to preserve continuity of care; accepting and willingly carrying out special assignments or duties when requested; respecting the rights of individuals served, and advocating on their behalf; following CHS policies and procedures and contributing to the maintenance of medically related policies; presenting a positive attitude and demeanor when working with individuals, staff, supervisors, management, and other internal and external stakeholders; respecting all differences, similarities, and abilities while actively demonstrating cultural competence; communicating in a professional manner in all written and verbal formats; and projecting a positive image of CHS and individuals served internally and externally. To perform this job successfully, a person must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and/or abilities required to complete the essential duties and responsibilities of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform
For over 30 years, The IMA Group has been dedicated to enhancing the livelihood and productivity of individuals and organizations navigating challenging periods of health, work and disability while actively contributing to the development of new medical treatments and clinical advancements. With thousands of licensed providers and over 150 offices nationwide, IMA is able to serve national needs while maintaining a regional focus. IMA has two divisions: Evaluation Services including Government and Payer and a Clinical Research Site Network. We provide medical and psychological evaluations and other ancillary services to federal, state, and local governments and agencies, commercial insurers, TPAs and corporate clients. Our Clinical Research Division specializes in Phase II, III, and IV clinical trials in multiple therapeutic areas through our nationwide multi-site network.
The IMA Group is seeking a detail-oriented Quality Assurance Specialist to support our growing team in a fully remote capacity. This role is responsible for reviewing medical and claims-related documentation to ensure accuracy, consistency, and compliance with client and internal quality standards. This position plays an important role in supporting timely, high-quality report delivery across our physician review operations. Compensation: $25–$28 per hour, based on experience At this time, we are not considering candidates located in New York City, Chicago, California, Colorado, or Washington state.
Associate degree required; Bachelor’s degree preferred Clinical or healthcare-related background strongly preferred 1–3 years of experience in quality assurance, claims review, disability, workers’ compensation, or related areas Strong attention to detail and ability to manage multiple deadlines Comfortable learning client-specific guidelines and documentation standards Proficiency with Microsoft Word; Excel experience preferred
Review reports, addenda, peer reviews, and related documentation for quality, formatting, and completeness Identify inconsistencies, missing information, and documentation issues requiring correction Coordinate revisions and follow through to final report completion Communicate with internal teams regarding pending updates and turnaround timelines Help manage urgent requests and ensure reports are finalized within established deadlines Support a smooth, efficient experience for both internal and external stakeholders
For over 30 years, The IMA Group has been dedicated to enhancing the livelihood and productivity of individuals and organizations navigating challenging periods of health, work and disability while actively contributing to the development of new medical treatments and clinical advancements. With thousands of licensed providers and over 150 offices nationwide, IMA is able to serve national needs while maintaining a regional focus. IMA has two divisions: Evaluation Services including Government and Payer and a Clinical Research Site Network. We provide medical and psychological evaluations and other ancillary services to federal, state, and local governments and agencies, commercial insurers, TPAs and corporate clients. Our Clinical Research Division specializes in Phase II, III, and IV clinical trials in multiple therapeutic areas through our nationwide multi-site network.
Telephonic Nurse Case Manager (1099 | Remote – NJ RN License Required)We are currently seeking an experienced Telephonic Nurse Case Manager (RN) to support workers’ compensation cases through remote care coordination and telephonic case management services. This is a flexible 1099 opportunity ideal for nurses with strong clinical judgment and prior case management experience. Compensation: $35/hour Location: Remote Candidates located in New Jersey or New York are encouraged to apply. This is a contract/1099 role best suited for experienced nurses who are comfortable managing cases independently in a fast-paced environment.
Active New Jersey RN license required ASN required; BSN preferred Prior workers’ compensation case management experience required Strong clinical background preferred (ICU, ER, Trauma, Orthopedics, Neurology, or Occupational Health) Ability to work independently in a remote setting Spanish speaking is a plus
Provide telephonic nurse case management for injured workers Coordinate treatment plans with providers, employers, and claims adjusters Monitor patient progress and facilitate appropriate medical care Maintain timely and accurate documentation Communicate effectively with clients, patients, and healthcare teams
At Collabera, we bridge top talent with industry-leading companies, creating a platform for meaningful career growth. With over 30 years of global expertise, we are an AI-first, people-centric organization empowering professionals with the right opportunities, resources, and networks to grow and lead. At Collabera, it’s not just about jobs, it’s about unlocking potential and shaping success.
PAY RANGE: $42-43/hr Must hold a KY/Compact RN license Must only be in any of these states (AZ, FL, GA, ID, IA, KY, MI, MS, NE, NM, NY, OH, SC, TX, UT, WA, WI)
KY RN License OR Compact RN License Managed Care/Utilization Review InterQual
Review inpatient hospital cases Handle prior authorizations & concurrent reviews Apply medical necessity criteria
Centene Corporation is a leading healthcare enterprise committed to helping people live healthier lives. Centene offers affordable and high-quality products to more than 1 in 15 individuals across the nation, including Medicaid and Medicare members (including Medicare Prescription Drug Plans) as well as individuals and families served by the Health Insurance Marketplace. Centene believes healthcare is best delivered locally. Our local health plans provide fully integrated, high-quality, and cost-effective services to government-sponsored and commercial healthcare programs, focusing on under-insured and uninsured individuals. Centene’s hiring practices reflect the composition of the members and communities we serve, allowing us to deliver quality, culturally sensitive healthcare to millions of members. Centene employees help change the world of healthcare and transform our communities. To learn more about career opportunities with Centene, visit: https://jobs.centene.com/
You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. This is a hybrid position with about 25% local travel to provider offices in Kent, Muskegon, or Calhoun counties, MI. When not traveling, the role is remote. Ideal candidate will have an LPN or social work license. Position Purpose: Works with members and providers to close care gaps, ensure barriers to care are removed, and improve the overall member and provider experience through outreach and face-to-face interaction with members and providers at large IPA and/or group practices. Serves to collaborate with providers in the field, to improve HEDIS measures and provides education for HEDIS measures and coding. Supports the implementation of quality improvement interventions and audits in relation to plan providers. Assists in resolving deficiencies impacting plan compliance to meeting State and Federal standards for HEDIS. Conducts telephonic outreach, while embedded in the providers' offices, to members who are identified as needing preventive services in support of quality initiatives and regulatory/contractual requirements. Provides education to members regarding the care gaps they have when in the providers office for medical appointments. Schedules doctor appointments on behalf of the practitioner and assists member with wraparound services such as arranging transportation, connecting them with community-based resources and other affinity programs as available. Maintains confidentiality of business and protected health information.
Required a Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Social Work, Health Administration, or related health field or equivalent work experience required (a total of 4 years of experience required for the position); work experience should be in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment. 2+ years of experience work experience should be in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment. License/Certification One of the following is preferred. Licensed Practical Nurse (LPN); Licensed Master Social Work (LMSW); Certified Social Worker (C-SW); Licensed Social Worker (LSW); Licensed Registered Nurse (RN) preferred.
Acts as a liaison and member advocate between the member/family, physician and facilities/agencies. Acts as the face of WellCare in the provider community with the provider and office staff where their services are embedded. Advises and educates Provider practices in appropriate HEDIS measures, and HEDIS ICD-10 /CPT coding in accordance with NCQA requirements. Assesses provider performance data to identify and strategizes opportunities for provider improvement. Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment, Operations (claims and encounters). Schedules doctor appointments for members with care gaps to access needed preventive care services and close gaps in care in the provider’s office. Conducts face-to-face education with the member and their family, in the provider’s office, about care gaps identified, and barriers to care. Conducts telephonic outreach and health coaching to members to support quality improvement, regulatory and contractual requirements. Arranges transportation and follow-up appointments for member as needed. Documents all actions taken regarding contact related to member. Interacts with other departments including customer service to resolve member issues. Refers to case or disease management as appropriate. Completes special assignments and projects instrumental to the function of the department. Performs other duties as assigned Complies with all policies and standards
DaVita Integrated Kidney Care (DaVita IKC) is an the integrated care division of DaVita Inc. working on DaVita’s vision to provide integrated care to all ESRD patients, who are some of the most medically complex and vulnerable patient populations in the US. Our more than 600 dedicated nurses, care coordinators, nurse practitioners (NPs) and business professionals integrate and manage care for more than 20,000 patients with late-stage chronic kidney disease (CKD) and end stage renal disease (ESRD) across the US each month. We’ve proven that integrating care achieves the triple aim of improved patient quality of life, better outcomes and lower total cost of care. What sets DaVita IKC apart is that we not only provide great care management but we start with our heart with our patients and each other. We focus on creating both a great experience for our patients and a special place to work for our teammates. We’re on a mission to revolutionize kidney care, with a vision of making integrated care the standard of care for all renal patients. To help us achieve our vision, we’re investing extensively in developing both our model of care and our team. When you join DaVita IKC, you're joining a compassionate team committed to quality patient care. Through our commitment to training, growth and quality we consistently achieve superior clinical outcomes while giving teammates the opportunity to excel in an award-winning environment that enables them to thrive both professionally and personally.
This DaVita IKC RN Case Manager position is for the IKC National Flex Team who remotely covers IKC markets when needs arise. This position functions autonomously and in collaboration with all members of the healthcare team to coordinate and facilitate quality, cost-effective care while minimizing fragmentation of the healthcare delivery system for ESRD and CKD patients. This position provides coordination of care between the patient, family, physician, provider and care teams, the community, and Regional Operations Manager.
A.D.N degree from accredited school of nursing required; B.S.N preferred; three-year diploma from accredited diploma program may be substituted for nursing degree Monday- Friday schedule with the ability to accommodate patient’s availability. We serve patients nationwide. Minimum of 1 year IKC Experience as a DaVita IKC RN Case Manager, required Compact Nursing License, highly preferred PST or MST preferred Continuing education credits maintained as required by state of practice required Minimum of five (5) years’ experience in clinical nursing required Minimum of three (3) years’ experience in renal nursing preferred Demonstrated knowledge and understanding of data and managing to clinical, financial, and patient satisfaction outcomes Demonstrated experience and effectiveness in change agent role Demonstrated knowledge and understanding of CQI techniques Previous experience in healthcare performance coaching required Certified Nephrology Nurse (CNN) or Certified Case Manager (CCM) preferred Current CPR certification required Ability to modify personal practice patterns to adapt to new / electronic processes and increased productivity expectations as it pertains to Capella implementation Current driver’s license in state employed with positive driving record and able to meet requirements of insurance coverage required Basic computer skills and proficiency in MS Word and Outlook required Functional proficiency with DaVita specific clinical software programs, including Capella, required within 90 days of employment Home office with internet connectivity at minimum of 1MB upload and 1MB download speed required
Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
Humana Healthy Horizons in Virginia is seeking a RN, Field Care Manager Nurse (Maternal-Health) who will assess and evaluate high acuity member's needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and well-being of members who are pregnant and postpartum. The RN, Field Care Manager Nurse (Maternal-Health) work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action and requires travel throughout the community.
Required Qualifications: Must reside in the Central Region (Richmond Area) in the Commonwealth of Virginia and travel to see members in region-based facilities and homes for face-to-face assessments and interactions with members and/or families. In the counties/independent cities of Richmond City, Chesterfield County, Petersburg, Hannover County, Caroline County, Dinwiddie County, New Kent, King William, Richmond County. Active Registered Nurse (RN) license in the Commonwealth of Virginia without disciplinary action. 2 years of prior experience in health care and/or case management. 1 year of acute care experience working in obstetrics, women's care, labor and delivery, mother, baby, NICU and/or clinical triage. Knowledge of community health and social service agencies and additional community resources. Intermediate to advanced computer skills and experience with Microsoft Word, Outlook, and Excel with the ability to use a variety of electronic information applications/software programs including electronic medical records. Excellent keyboard and web navigation skills. Exceptional oral and written communication and interpersonal skills with the ability to quickly build rapport. Ability to work with minimal supervision within the role and scope. Ability to travel to region-based facilities and homes for face-to-face assessments and interactions with members and/or families. Preferred Qualifications: Bachelor's of Science in Nursing (BSN). 3+ years of experience. Lactation experience as a certified lactation consultant. Experience with health promotion, coaching and wellness. Previous managed care experience. Certification in Case Management (CCM). Motivational Interviewing Certification and/or knowledge. Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Must be able to speak, read and write in both languages without limitations or assistance. See "Additional Information" for more information. Work At Home Requirements 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 required. 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. Additional Information Workstyle: Field - This is a field position where employees perform their core duties at non-company locations, such as providing services at business partner facilities or prospects' and members' homes. Workdays and Hours: 40 hours a week - Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST). Travel: 50 - 75% region-based travel to meet with members, their families and providers. May need to attend occasional onsite meetings in Humana Healthy Horizons office in Glen Allen, VA. This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Insurance: Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher. Screening: This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB. Language Assessment Statement: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government. Interview Format As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year
Responsible for health risk assessments along the continuum of care for members. Assesses members, creates individualized care plans, and attends interdisciplinary care team meetings. Employs a variety of strategies, approaches, and techniques to manage a member's physical, environmental, and psycho-social health issues. Identifies and resolves barriers that hinder effective care. Ensures members are progressing towards desired outcomes by continuously monitoring their care through assessments and/or evaluations. 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. Collaborates with internal and external providers or departments to meet the member's needs. Meets requirements for contractual and regulatory compliance. Follows established guidelines/procedures.
Not only will you experience significant cost savings, but our process infrastructure and tools guarantee an efficient and thorough good faith evaluation. We understand every client has different needs and expectations, and Spakinect works hard to meet or exceed them all. With our virtual GFE service currently offered across the country, it's never been easier to receive quality service and patient care at the click of a button. With Spakinect, Never Turn a Patient Away™!
This is a remote position. *This remote PART-TIME position will be primarily scheduled for weekend shifts only! (Thursday/Friday/Saturday). We are looking to fill this position as early as June 1st, 2026* Are you an Aesthetic Nurse Practitioner seeking a new and exciting growth opportunity in a remote environment? Spakinect is a successful and growing business in the Aesthetic Telehealth arena with hundreds of clients located in Arizona, California, Colorado, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Utah, Virginia, Washington, Washington D.C., Wisconsin, and Wyoming. We are looking for a Nurse Practitioner with multiple state licensures and candidates must have availability between the hours of 9am-6pm PST on Thursday, Friday, and Saturday. The part-time role requires a minimum of 12 hours of availability weekly and must be able to commit to Saturday shifts. Any additional weekly availability is a plus! To be considered for this opening, you must have prior aesthetic medicine experience, hold active licenses in California and Texas, AND hold a MINIMUM of eight (8) of the following state licenses: AZ, FL, GA, IL, IN, KY, MA, MN, NC, NM, NV, NY, OR, PA, TN, VA, WA, WI. Applicants may be considered if licenses are in pending status in addition to having previous aesthetic medicine experience. The starting base rate for this position is $63/hour, however candidates with additional desirable licensure and experience may be eligible to receive a higher starting rate.
Education and/or Experience: Master's degree from an accredited college/university or equivalent with related experience in the aesthetic industry. Aesthetic Industry Experience In-depth knowledge of aesthetic medicine and treatments offered by industry. Knowledge of legal regulations and best practices in healthcare. Up to date with ever-changing standards in telehealth and aesthetic administration. Licensing: Minimum licensure requirements for hire are active licenses in California and Texas, AND hold a MINIMUM of eight (8) of the following state licenses: AZ, FL, GA, IL, IN, KY, MA, MN, NC, NM, NV, NY, OR, PA, TN, VA, WA, WI. Applicants may be considered if licenses are in pending status in addition to having previous aesthetic medicine experience. Preferred licensure for hire are active medical licenses in good-standing in additional states of operation. Aesthetic Telehealth Provider candidates must be willing and able to acquire additional licensure in requested states of operation. Availability: Must be able to provide Thursday, Friday & Saturday availability during the hours of 9am-6pm PST. Must provide a minimum of 12 hours of availability per week and commit to working Saturday shifts. Additional weekly availability is a plus!
The Aesthetic Telehealth Provider conducts live, interactive Good Faith Evaluations (GFEs) for medical spas and clinics with patients seeking aesthetic treatments throughout the United States from the comfort of their home office. This fast-paced and dynamic position requires excellent communication skills, efficiency, adaptability, independent clinical decision making, and the ability to provide impeccable customer service. The Aesthetic Telehealth Provider maintains a positive, figure-it-out attitude, and is proficient with technology. Spakinect medical providers embrace teamwork and seek collaboration with their colleagues to deliver safe, evidenced-based, high-quality care. Deliver thorough, efficient, and exceptional healthcare by reviewing health histories, screening for any contraindications to treatment, and providing treatment plan recommendations for desired aesthetic treatments. Displays superior customer service by addressing client and patient care concerns, answering clinical questions, and providing medical guidance as necessary. Demonstrates behavior that is kind, compassionate, polite, friendly, and respectful towards patients, clients, and co-workers. Effectively communicates with office staff regarding any administrative issues that arise in a timely manner; demonstrates accountability. Documents electronically using an Electronic Health Record (EHR) system to submit completed GFEs in real-time. Exhibits the ability to troubleshoot basic technical problems to resolve any potential issues, reaches out appropriately for further assistance when needed. Adheres to company guidelines and policies, completes all required training, attends continuing education opportunities for growth and development. Improves productivity and efficiency by developing and implementing standards and processes. Fosters and embraces best care practices. Demonstrates Spakinect’s company core values and mission. Performs other duties as assigned.
Not only will you experience significant cost savings, but our process infrastructure and tools guarantee an efficient and thorough good faith evaluation. We understand every client has different needs and expectations, and Spakinect works hard to meet or exceed them all. With our virtual GFE service currently offered across the country, it's never been easier to receive quality service and patient care at the click of a button. With Spakinect, Never Turn a Patient Away™!
This is a remote position. *This remote PART-TIME position will be primarily scheduled for afternoon/evening shifts only! We are looking to fill this position as early as June 1st, 2026* Are you an Aesthetic Nurse Practitioner seeking a new and exciting growth opportunity in a remote environment? Spakinect is a successful and growing business in the Aesthetic Telehealth arena with hundreds of clients located in Arizona, California, Colorado, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Utah, Virginia, Washington, Washington D.C., Wisconsin, and Wyoming. We are looking for a Nurse Practitioner with multiple state licensures and availability to work between the hours of 9am-6pm PST on weekdays and Saturday. The part-time role requires a minimum of 12 hours of availability weekly and must be able to commit to Saturday shifts. Any additional weekly availability is a plus! What you will do at Spakinect: The Aesthetic Telehealth Provider conducts live, interactive Good Faith Evaluations (GFEs) for medical spas and clinics with patients seeking aesthetic treatments throughout the United States from the comfort of their home office. This fast-paced and dynamic position requires excellent communication skills, efficiency, adaptability, independent clinical decision making, and the ability to provide impeccable customer service. The Aesthetic Telehealth Provider maintains a positive, figure-it-out attitude, and is proficient with technology. Spakinect medical providers embrace teamwork and seek collaboration with their colleagues to deliver safe, evidenced-based, high-quality care.
To be considered for this opening, you must have prior aesthetic medicine experience, hold active licenses in California and Texas, AND hold a MINIMUM of eight (8) of the following state licenses: AZ, FL, GA, IL, IN, KY, MA, MN, NC, NM, NV, NY, OR, PA, TN, VA, WA, WI. Applicants may be considered if licenses are in pending status in addition to having previous aesthetic medicine experience. The starting base rate for this position is $63/hour, however candidates with additional desirable licensure and experience may be eligible to receive a higher starting rate. Education and/or Experience: Master's degree from an accredited college/university or equivalent with related experience in the aesthetic industry. Aesthetic Industry Experience: In-depth knowledge of aesthetic medicine and treatments offered by industry. Knowledge of legal regulations and best practices in healthcare. Up to date with ever-changing standards in telehealth and aesthetic administration. Licensing: Minimum licensure requirements for hire are active licenses in California and Texas, AND hold a MINIMUM of eight (8) of the following state licenses: AZ, FL, GA, IL, IN, KY, MA, MN, NC, NM, NV, NY, OR, PA, TN, VA, WA, WI. Applicants may be considered if licenses are in pending status in addition to having previous aesthetic medicine experience. Preferred licensure for hire are active medical licenses in good-standing in additional states of operation. Aesthetic Telehealth Provider candidates must be willing and able to acquire additional licensure in requested states of operation. Availability: Must be able to provide afternoon/evening availability on weekdays & Saturday during the hours of 9am-6pm PST. Must provide a minimum of 12 hours of availability per week and commit to working Saturday shifts. Additional weekly availability is a plus!
Deliver thorough, efficient, and exceptional healthcare by reviewing health histories, screening for any contraindications to treatment, and providing treatment plan recommendations for desired aesthetic treatments. Displays superior customer service by addressing client and patient care concerns, answering clinical questions, and providing medical guidance as necessary. Demonstrates behavior that is kind, compassionate, polite, friendly, and respectful towards patients, clients, and co-workers. Effectively communicates with office staff regarding any administrative issues that arise in a timely manner; demonstrates accountability. Documents electronically using an Electronic Health Record (EHR) system to submit completed GFEs in real-time. Exhibits the ability to troubleshoot basic technical problems to resolve any potential issues, reaches out appropriately for further assistance when needed. Adheres to company guidelines and policies, completes all required training, attends continuing education opportunities for growth and development. Improves productivity and efficiency by developing and implementing standards and processes. Fosters and embraces best care practices. Demonstrates Spakinect’s company core values and mission. Performs other duties as assigned.
Company Benefits: Choice of three health insurance plans Dental insurance coverage Vision insurance coverage 401(k) with company match and profit-sharing plan Company-paid short-term and long-term disability coverage Company-paid life insurance for you and your family Access to company-provided training and educational resources Eligibility for annual merit-based performance increases Eight company-paid holidays Special company events, including Christmas parties, Family Day, employee engagement activities, and Spirit Days Complimentary Employee Assistance Program (EAP) for all employees and their dependents.
We are seeking a highly motivated and skilled Advanced Practice Provider (NP/PA) to join our full-time Cardiology Nocturnal Team, supporting a group of nationally recognized, top-tier cardiologists. This is an excellent opportunity for an APP who is passionate about practicing at the top of their license, delivering exceptional patient care, and contributing to a high-performing cardiovascular service line. This position offers the flexibility of remote work. Compensation: Pay starting at $112,000 plus an additional night shift differential
Provide patient care using established standards, practice protocols, and clinical guidelines. Perform comprehensive histories, physical exams, daily progress notes, discharge/transfer summaries. Order, perform, and interpret diagnostic tests; formulate diagnoses and treatment plans. Prescribe pharmacologic and non-pharmacologic therapies within scope. Monitor patient response, modify care plans, and provide patient/family education. Document patient encounters using the S.O.A.P. format; complete all records accurately and timely. Coordinate referrals, interdisciplinary communication, and patient advocacy. Participate in research, quality improvement, continuing education, and professional development activities. Precept students/new staff and support clinic operations as needed. Maintain BLS/ACLS and required clinical competencies.
w3r Consulting is an award-winning, best-in-class IT consulting and management company that delivers enterprise solutions at the intersection of innovation and ingenuity. Organizations throughout the healthcare payor, financial services, and professionals and business services sectors turn to w3r for a strategic, IT-fueled advantage that elevates their stature and capabilities in competitive global markets. As a minority-owned business, w3r brings diverse and multifaceted people from across different backgrounds and life experiences to the table, unlocking the power of unique perspectives and inventive ideas to help clients achieve their evolving goals.
As a Case Manager RN, you will lead the coordination of a multidisciplinary team to deliver holistic, person-centered care for a diverse member population. You will serve as the primary point of contact for members, caregivers, and providers, using phone, email, and digital platforms to manage and support care plans.
Required Qualifications: Nursing Diploma or Associate Degree in Nursing (BSN preferred) Minimum 3 years of clinical nursing experience (acute/post-acute/community setting) Active, unrestricted Multistate Compact RN license Strong communication, organizational, and critical thinking skills Proficiency with Microsoft Office tools Preferred: Case management experience in a managed care setting Experience with telephonic or digital patient management CCM or CCP certification
Coordinate care across a multidisciplinary team including social workers, dietitians, pharmacists, and medical directors Assess members’ clinical, psychosocial, and support needs Develop, implement, and monitor individualized care plans Identify care gaps, address barriers, and improve health outcomes Connect members with community and healthcare resources Provide education on self-management, medications, and overall health Support care transitions and ensure continuity of care Document all interactions accurately and maintain compliance with guidelines
NeueHealth is a value-driven healthcare company grounded in the belief that all health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid. NeueHealth delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all.
The Utilization Management (UM) Prior Authorization (PA) Nurse is a full-time role with NeueHealth, dedicated to promoting quality and cost-effective outcomes for the designated population. Working in collaboration with Medical Directors and the clinical team, the PA Nurse ensures members receive the appropriate benefit coverage for services requiring prior authorization. Responsibilities include reviewing prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria. The PA Nurse also collects and analyzes utilization data and monitors the quality and appropriate use of services. This role demands clinical expertise, keen attention to detail, and strong communication skills to effectively engage with healthcare providers, patients, and health plans. For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $27.10-$40.65 Hourly. Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.
EDUCATION AND PROFESSIONAL EXPERIENCE Education: Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required. Experience: Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field. Experience in a managed care setting with medical necessity reviews is strongly preferred. Certifications: Preferred: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM). Additional clinical nursing or case management certifications are a plus. PROFESSIONAL COMPETENCIES: Strong analytical and critical thinking skills. Proficiency in medical terminology and pharmacology. Effective written and verbal communication skills. Ability to work independently and collaboratively in a fast-paced environment. Adaptable and self-motivated. Experience with EMR systems and prior authorization platforms. Proficient in Microsoft Office Suite (Word, Excel, Outlook).
Authorization and Review Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines. Assess medical necessity and the appropriateness of requested services using clinical expertise. Verify patient eligibility, benefits, and coverage details. Collaboration and Communication Act as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process. Communicate authorization decisions to providers and patients promptly. Provide detailed explanations for denials or alternative solutions and collaborate with Medical Directors on adverse determinations. Ensure compliance with regulatory requirements regarding adverse determination notices, including readability standards and appeal information. Documentation and Compliance Accurately document all authorization activities in electronic medical records (EMR) or authorization systems. Maintain compliance with federal, state, and health plan regulations. Stay updated on policy and clinical criteria changes. Quality Improvement Identify trends or recurring issues in authorization denials and recommend process improvements. Participate in team meetings, training sessions, and audits to ensure high-quality performance.
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visitwww.ustechsolutions.com.
Duration: 8 months contract (with possible extension) *Note: Candidates can be remote but must have an active unrestricted Massachusetts RN License Job Summary: The Clinical Reviewer, Precertification RN, is a licensed Registered Nurse that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for determining medical necessity and benefit coverage for members. The Clinical Reviewer ensures consistent and timely disposition of coverage decisions as required by product specific compliance and regulatory time frames. The Clinical Reviewer functions as a member of the Precertification / Outpatient Utilization Management (UM) team and works under the general direction of the Precertification Team Manager or department Director. The Clinical Reviewer is expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Clinical Reviewer will be expected to demonstrate sound clinical and health plan business knowledge in their decision-making processes, on behalf of the health plan.
Certification and Licensure: Registered Nurse with a current and unrestricted Massachusetts license required Education: Required (minimum): Associate Degree Preferred: BSN (Bachelor of Science in Nursing) Experience Required (minimum): Five years’ clinical experience in utilization management, case management or quality assurance. Previous experience in a managed care setting. Preferred: Skill Requirements: Requires an individual with highly developed critical thinking skills and the ability to investigate, evaluate and problem solve using sound clinical judgment and business knowledge. Requires the ability to work in an extremely complex and fast-paced production environment. Demonstrates skill in responding to inquiries from providers and/or members Must exhibit initiative and creativity in planning of work and be able to resolve cases correctly, effectively, expeditiously and within tight timeframes. Good organizational skills and a customer centered focus required. Individual must be able to use multiple software applications simultaneously. Excellent oral and written communication skills required. Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel): Fast paced business environment that requires prioritization and balancing of multiple demands. Continuous use of PC and telephone required. Ability to adjust work schedule on short notice to adapt to departmental, case driven needs. Must be able to work under normal office conditions and work from home as required. Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations. May be required to work additional hours beyond standard work schedule.
Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames. Collaborates with Medical Directors when determination to deny a request is indicated, advising the Medical Directors on standard business processes, ensuring those processes are followed or variances to the process are escalated, if needed, and agreed to and well documented. Coaches letter writers to assure that appropriate medical necessity language is clearly defined in the denial letter. Communicates frequently through the day with physicians, practices, facilities, and/or allied health providers. Communicates frequently through the day with external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as well as the status and disposition of cases. Orients new staff to role as needed. Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines. Facilitates communication between Precertification and other internal departments by acting as a liaison or committee member on the development or implementation of new programs. Provides input to the Medical Policy Department regarding the development of Medical Necessity Guidelines and adding input to purchased criteria through participation in the IMPAC medical systems. Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM processes. Assists in the screening of appeal cases to provide clinical input as needed or requested. Models professionalism and leadership in all capacities of the position to all audiences. Other projects and duties as assigned.
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.
Hours/Schedule - M-F 8:30AM-5:00PM NICE TO HAVE skill sets/qualities: Prior hospital experience. Flexibility, comfortable learning new/multiple computer systems easily and quickly as there are multiple programs we utilize—this is a must. Prior UM and/or case management experience is preferred but not required. A typical day would like in this role: Inpatient admission review for hospitals, SNFs, rehab and LTAC facilities and continued stay reviews for all of these. Clinicals received are reviewed using Milliman & company policies. If they do not meet criteria, then a writeup is done and submitted to one of our MDs for review and a decision. Letter writing using company templates. Communicate/coordinate with case management, transplant coordinators, Team Leads, medical directors and supervisors. Expectation is to be at desk working all day except for breaks/meals. If there are children/elderly/special needs residents in the home, per policy there must be someone else available to care for them as if the employee were working in the office on site. Attend quarterly and monthly meetings via Teams. Understanding the need to be in constant communication with leadership and peers via email and Teams as priorities may shift throughout the workday and there are often new policies/issues that need to be acknowledged immediately We work closely together and are good about covering for each other when someone is out/assisting someone with an exceptionally heavy caseload or a difficult case. There is a specific Teams chat for our group to discuss things/ask questions.
Experience: 2 years clinical experience. Skills: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools: Microsoft Office. Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Knowledge of contract language and application. Thorough knowledge/understanding of claims/coding analysis/requirements/processes. Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access or other spreadsheet/database software. Education: Associate Degree - Nursing or Graduate of Accredited School of Nursing Required License and Certificate: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions. Utilizes clinical proficiency and claims knowledge/analysis to assess, plan, implement, health coach, coordinate, monitor, and evaluate medical necessity and/or care plan compliance, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes. Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. May initiate/coordinate discharge planning or alternative treatment plans as necessary and appropriate. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions that consist of: intensive assessment/evaluation of condition, at risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement. Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services. Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
At Curana Health, we’re on a mission to radically improve the health, happiness, and dignity of older adults—and we’re looking for passionate people to help us do it. As a national leader in value-based care, we offer senior living communities and skilled nursing facilities a wide range of solutions (including on-site primary care services, Accountable Care Organizations, and Medicare Advantage Special Needs Plans) proven to enhance health outcomes, streamline operations, and create new financial opportunities. Founded in 2021, we’ve grown quickly—now serving 200,000+ seniors in 1,500+ communities across 32 states. Our team includes more than 1,000 clinicians alongside care coordinators, analysts, operators, and professionals from all backgrounds, all working together to deliver high-quality, proactive solutions for senior living operators and those they care for. If you’re looking to make a meaningful impact on the senior healthcare landscape, you’re in the right place—and we look forward to working with you. For more information about our company, visit CuranaHealth.com.
At Curana Health, we are committed to supporting the health, dignity, and comfort of residents in senior living communities. Our National After-Hours Call Team plays a vital role by providing compassionate telephonic care and clinical direction during evenings, nights, weekends, and holidays—ensuring that residents receive timely, high-quality support without unnecessary transfers. In this work-from-home role, you’ll deliver after-hours care virtually (primarily by phone) to aging residents across multiple states. This position offers both autonomy and purpose—you’ll be the trusted voice and clinical partner helping residents and facility staff during critical times, making an immediate impact in the lives of older adults. In this position the provider must be comfortable managing high call volumes and performing at least 30% telehealth visits, including evaluation of acute changes, falls, and controlled substance visits. Providers must be able to manage multiple calls independently while providing care across several states. Scheduling & Hours: While shift times can vary, we provide coverage to skilled nursing and senior living facilities on weeknights from 5pm- 8am local time, continuous coverage from Friday at 5pm to Monday at 8am. Holiday coverage is also provided beginning at 5pm of the end of the last business day to 8am of the resumption of business hours. Availability and Coverage expectations for this role 24 hours per week, set schedule Weeknight shifts between 5pm and 8am Every other weekend coverage for 12-hour shifts covering day shifts on both Saturday and Sunday Overnight and holidays are required for all After Hours Call Team Members Two 12 hour holiday shifts per year required. Holiday scheduling is completed at the beginning of the year for advanced planning
Education and Experience: Master's Degree as a Nurse Practitioner Current unrestricted NP license in Iowa, Missouri, Kansas, or Ohio (must be licensed in 2 of these states for consideration). Ability to obtain further multi-state licenses including but not limited to Illinois, Indiana, Minnesota, Nebraska, & Wisconsin. Nurse Practitioner national certification as ANP, FNP, or GNP Ability to obtain DEA licensure / Prescriptive Authority Background in acute and chronic disease management Clinical background in adult, family, or geriatrics 3+ years of experience as a NP Ability to gain a collaborative practice agreement, if applicable in your state(s) Ability to work scheduled shifts in accordance with scheduling policies Proficient computer skills including the ability to document medical information with written and electronic medical records Preferred Qualifications: Experience working in a nursing home, or with seniors in an acute care facility Understanding of Geriatrics, Chronic Illness, and acute disease management Understanding of Advanced Illness and end of life discussions Ability to develop and maintain positive customer relationships Adaptability to change
Serve as the first line of support for residents and facility staff after-hours, providing direction and medical care over the phone. Use Curana’s telephonic platform to take and place calls, coordinating care between facilities, hospitals, and clinics. Deliver high-quality, cost-effective care to patients—addressing acute, chronic, and behavioral health needs in collaboration with physicians and specialty providers. Perform comprehensive assessments and document encounters accurately and thoroughly in the EMR, ensuring compliance with CMS requirements. Apply Curana’s clinical protocols and practice guidelines to support safe, effective treatment in place whenever possible. Participate in mandatory education and training to stay current with standards of care.
Performs an age specific plan of care for a designated group of patients using the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation of patient care. Collaborates with physicians and other health team members in coordinating and implementing procedures and treatments. Uses leadership skills/clinical judgment in coordinating patient care and directing/delegating activities of the patient care unit team. This role will provide outpatient virtual lactation consultations.
Graduate from an accredited School of Nursing. Bachelor’s Degree in Nursing, preferred. Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date. Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed. IBCLC certified (International Breastfeeding Certified Lactation Consultant), highly preferred. Additional Salary Detail The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).
Conducts patient interview, explains policies and procedures to patient/ significant others, reviews patient’s chart and answers questions correctly and courteously; assesses gastrointestinal, cardiovascular, respiratory, renal and neurological health status; determines mobility, sensory deficits, prostheses use, and skin condition and adjusts plan of care, as appropriate; assesses level of pain and pain management; communicates/documents patient’s physiologic health status and plan of care; assesses patient’s psychosocial health status; elicits perception of medical/nursing care and the expectation of care. Determines coping mechanism, knowledge level, and ability to comprehend; identifies cultural/ethnic requirements to reduce anxiety and ensure patient satisfaction; communicates and documents psychological status and care plan of support groups, counseling services, and social services; identifies patient outcome; develops criteria for measurement of patient outcomes; identifies actual/potential patient problems; identifies patient’s need for teaching based on psychosocial and developmental assessment. Develops patient outcome statement (s) and establishes individualized patient goals; identifies care activities and establishes the priorities necessary to achieve expected outcome; coordinates the cost-effective use of supplies, equipment and medication to achieve expected outcome; documents the plan of care and collaborates with physicians and other health team members; implements the plan of care; maintains constant vigilance over patients care to ensure that safety precautions/needs are followed (side rails up, call lights and bedside stand within reach, etc.). Exercises professional skills related to the plan of care; reassesses patients as needed and appropriately revises plan of care; correctly administers prescribed treatments; correctly uses equipment necessary for patient care; provides emotional support to patient and significant other; applies scientific principles in performing procedures; carries them out safely, timely and efficiently; makes accurate observations of patient’s conditions during treatments/procedures; reports and records same as appropriate; Keeps accurate documentation of patient’s treatment, activity and condition, as well as patient’s responses to medical and nursing interventions; uses appropriate methods of documentation according to departmental policy; acts rapidly and effectively during any emergency situation, managing self, patients and other employees; provides a calm, quiet, restful atmosphere; communicates effectively with the patient’s family or caretakers; participates in planning for discharge and coordinates referrals, as appropriate; provides discharge instructions to patient and significant other; evaluates care provided for patient outcome. Demonstrates ability to measure effectiveness of care provided and documents same; performs variance analysis related to outcome data for performance improvement; designs, implements, and evaluates systems to improve care in unit; keeps accurate documentation of patient’s treatment, activity and condition; uses appropriate methods of documentation according to departmental policy; collaborates with other care team members in planning and carrying out treatment regimen; provides direction to other members of the care team; collaborates with the appropriate physician on patient’s plan of care. Accurately interprets and implements treatment regimen as prescribed by the Physician; assists the Physician during treatments and/or diagnostic procedures; keeps the Patient Care Manager/designee and/or physician, abreast of changes in patient’s condition and/or treatments, as appropriate; uses clinical judgment in delegating assignments in providing patient care, and ensures that assignments are completed in a timely fashion; performs grade I-IV Decubitus Care; performs preventive skin care measures; applies simple dressings, maintaining principles of aseptic technique. Applies warm and cold compresses, consistent with facility procedure; performs irrigations, consistent with Facility procedure; performs other procedures related to skin care, as necessary; administers medications correctly and safely; correctly identifies medication in terms of action, dosage, side effects, and implications for the patient; meets standard on medication administration examination; demonstrates preparation of local solutions. Administers and documents medication correctly; educates patients and significant others related to drug and food interactions; educates patients and significant others related to drug and food interactions; participates in patient and family education; provides patient with an explanation of his/her condition as indicated; communicates assessment data in an orderly fashion by recording, updating and verbalizing pertinent information to care team members and to appropriate agencies; recognizes and utilizes health teaching opportunities and resources /materials available for this teaching; provides for early discharge planning and appropriate referrals for post-hospital care; evaluates the effectiveness of teaching by feedback from patient/ family and documents same. Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
At Curana Health, we’re on a mission to radically improve the health, happiness, and dignity of older adults—and we’re looking for passionate people to help us do it. As a national leader in value-based care, we offer senior living communities and skilled nursing facilities a wide range of solutions (including on-site primary care services, Accountable Care Organizations, and Medicare Advantage Special Needs Plans) proven to enhance health outcomes, streamline operations, and create new financial opportunities. Founded in 2021, we’ve grown quickly—now serving 200,000+ seniors in 1,500+ communities across 32 states. Our team includes more than 1,000 clinicians alongside care coordinators, analysts, operators, and professionals from all backgrounds, all working together to deliver high-quality, proactive solutions for senior living operators and those they care for. If you’re looking to make a meaningful impact on the senior healthcare landscape, you’re in the right place—and we look forward to working with you.
For more information about our company, visit CuranaHealth.com. At Curana Health, we are committed to supporting the health, dignity, and comfort of residents in senior living communities. Our National After-Hours Call Team plays a vital role by providing compassionate telephonic care and clinical direction during evenings, nights, weekends, and holidays—ensuring that residents receive timely, high-quality support without unnecessary transfers. In this work-from-home role, you’ll deliver after-hours care virtually (primarily by phone) to aging residents across multiple states. This position offers both autonomy and purpose—you’ll be the trusted voice and clinical partner helping residents and facility staff during critical times, making an immediate impact in the lives of older adults. In this position the provider must be comfortable managing high call volumes and performing at least 30% telehealth visits, including evaluation of acute changes, falls, and controlled substance visits. Providers must be able to manage multiple calls independently while providing care across several states.
Education and Experience: Master's Degree as a Nurse Practitioner Current unrestricted NP license in North Carolina and South Carolina required. Additional active licenses in Florida and Georgia are strongly preferred. Nurse Practitioner national certification as ANP, FNP, or GNP Ability to obtain DEA licensure / Prescriptive Authority Background in acute and chronic disease management Clinical background in adult, family, or geriatrics 3+ years of experience as a NP Ability to gain a collaborative practice agreement, if applicable in your state(s) Ability to work scheduled shifts in accordance with scheduling policies Proficient computer skills including the ability to document medical information with written and electronic medical records Preferred Qualifications: Experience working in a nursing home, or with seniors in an acute care facility Understanding of Geriatrics, Chronic Illness, and acute disease management Understanding of Advanced Illness and end of life discussions Ability to develop and maintain positive customer relationships Adaptability to change
Serve as the first line of support for residents and facility staff after-hours, providing direction and medical care over the phone. Use Curana’s telephonic platform to take and place calls, coordinating care between facilities, hospitals, and clinics. Deliver high-quality, cost-effective care to patients—addressing acute, chronic, and behavioral health needs in collaboration with physicians and specialty providers. Perform comprehensive assessments and document encounters accurately and thoroughly in the EMR, ensuring compliance with CMS requirements. Apply Curana’s clinical protocols and practice guidelines to support safe, effective treatment in place whenever possible. Participate in mandatory education and training to stay current with standards of care. Scheduling & Hours While shift times can vary, we provide coverage to skilled nursing and senior living facilities on weeknights from 5pm- 8am local time, continuous coverage from Friday at 5pm to Monday at 8am. Holiday coverage is also provided beginning at 5pm of the end of the last business day to 8am of the resumption of business hours. Availability and Coverage expectations for this role Weeknight shifts between 5pm and 8am Every other weekend coverage for 12 hour shifts covering day shifts both Saturday and Sunday Overnight and holidays are required for all After Hours Call Team Members, 2 holidays per year required for part time Holiday scheduling is completed at the beginning of the year for advanced planning
Ways2Well is redefining the future of healthcare. As a leader in regenerative and preventive medicine, we empower patients to take control of their health through data-driven, personalized care. We’re breaking away from outdated models—leveraging cutting-edge technology, digital care platforms, and bold thinking to deliver high-impact healthcare at scale.
As a Nurse Practitioner, you will provide evidence-informed, patient-centered care via telemedicine. Your role involves conducting comprehensive health assessments, interpreting advanced lab results, designing personalized wellness and hormone optimization plans, and supporting patients through lifestyle and supplement-based interventions. You will collaborate with a multidisciplinary team in a fast-paced, fully virtual environment.
Active and unencumbered Nurse Practitioner license in at least 5 U.S. states (multi-state licensure required) National certification (e.g., AANP, ANCC) Active DEA Minimum of 2 years of NP experience, with exposure to functional, integrative, or hormone therapy preferred Strong knowledge of hormone replacement therapy (HRT) (testosterone, estrogen, thyroid), peptides, and targeted supplementation preferred Prior experience in a telehealth or digital health setting is strongly preferred Comfortable navigating EHRs, telemedicine platforms, and cloud-based tools Exceptional communication, patient engagement, and clinical documentation skills Work Environment & Physical Requirements: Primarily clinic/office-based setting for telehealth visits Remote work environment; home office or dedicated workspace required Must be able to work independently with minimal supervision Virtual meetings via video conferencing (camera on expected) Reliable high-speed internet connection required Must maintain a distraction-free, professional background for video calls Schedule: Monday - Friday, 8am-5pm Central
Conduct virtual consultations using both asynchronous and synchronous telehealth platforms Review and interpret functional and traditional lab results (e.g., hormone panels, micronutrients, inflammatory markers) Develop personalized care plans focusing on hormonal balance, metabolic health, nutrition, and preventive strategies Educate patients on treatment options, supplement protocols, and lifestyle modifications Document thoroughly and accurately in the EHR system (i.e., Charm or similar) Collaborate with clinical support staff, pharmacists, and health coaches to ensure continuity of care Adhere to state and federal telehealth regulations and best practices Participate in ongoing training, case reviews, and team huddles to support professional development and care quality
Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.
Position: Registered Nurses Type: Contract Compensation: $60–$110/hour Location: Remote Duration: 3–4 weeks Commitment: 30–40 hours/week
Must-Have: 4+ years professional experience in nursing. Excellent written communication with strong grammar and spelling skills. Start Date: Immediately
Create deliverables addressing common requests in the nursing domain. Review peer-developed deliverables to enhance AI research. Diagnose and solve real issues in your domain to advance machine learning systems. Work independently and remotely on your own schedule. Contribute expertise to cutting-edge AI research.
Accompany Health is on a mission to give patients with complex needs the dignified, high-quality care they deserve but rarely receive. A primary, behavioral, and social care provider, Accompany Health walks alongside patients for their entire care journey, offering at-home and virtual care, as well as 24/7 support. Partnering with innovative payors, Accompany Health is powered by remarkable care teams, elegant technology, and a commitment to evidence-based practice. We build long-term relationships with our patients so they know, without question, that our team is here for them day or night, year after year. We focus on the health outcomes most important to our patients to make it clear that they lead the way. To achieve our mission, we collaborate with community-based organizations, local providers, and health plans. While our headquarters is in Bethesda, MD, our teams are distributed across the country. If you’re eager to make a tangible difference in people’s lives, to help correct long-standing disparities in health care, join us.
We’re seeking a Med/Psych Advanced Practice Clinician (APC) who thrives in a dynamic, collaborative environment and is eager to deliver high-quality care across both medical and behavioral health domains. The ideal candidate brings clinical expertise in primary care and psychiatric management—comfortable managing complex, comorbid patients in virtual settings. As a Med-Psychiatric Advanced Practice Clinician, you will serve patients in our High Risk Advanced Behavioral Health Model in a BH-first model as their longitudinal provider with the primary goal of keeping our patients healthy at home. Our High Risk Advanced BH patients are those who have Serious Mental Illness (SMI) and/or Substance Use Disorder (SUD) and often also have co-occurring complex chronic medical conditions who have high risk of hospital and ED utilization for either or both medical and psychiatric reasons. You will work as a part of a multidisciplinary team consisting of supervising med-psychiatric physicians, behavioral health clinicians (LCSW/LPC), and health advocates who have BH expertise. With your team, you’ll provide longitudinal care and build trusted relationships with your patients—delivering care virtually and often facilitated by an in-home BH-trained health advocate. You’ll diagnose and manage chronic psychiatric and medical conditions, ensure evidence-based preventive care, address urgent needs, and identify and help overcome any barriers or obstacles to their health. This role is ideal for an APC who embraces innovation, values autonomy, and wants to help shape clinical models that merge technology, compassion, and evidence-based practice.
What makes you a fit for the team: Passionate about patient-centered, holistic healthcare Desire to work primarily with patients with severe mental illness and substance use disorders to improve both their medical and behavioral health care through true integration Thrives in a fast-paced environment and able to adapt and contribute to continuous improvement Exhibits calm, confident clinical decision-making even in ambiguous or rapidly changing situations Demonstrates a strong clinical ‘detective’ mindset, investigating across multiple systems to uncover the right diagnosis and supporting evidence, consistently seeking the ‘how’ and ‘why’ while thoroughly documenting patients’ conditions and needs Comfortably manages high volumes of work, and adapts quickly as priorities shift Fluent in technology and excited to incorporate new technology and systems into daily practice Adaptable and flexible, embracing evolving systems and technology-driven workflow enhancements Demonstrates strong growth mindset, including the willingness to unlearn prior workflows and embrace new approaches Works collaboratively with teammates and actively seeks opportunities to learn, grow, and elevate team performance, which includes trusting the clinical skills of team members such as behavioral health clinicians Displays trust in the organization’s mission, values, and direction, and contributes positively to a culture of shared purpose Flexible and adaptive—comfortable working in a fast-paced, evolving startup culture Excited about leveraging technology to improve outcomes and access A strong communicator and collaborator who values teamwork and innovation Desired skills and experience: Required Active Nurse Practitioner (NP) or Physician Assistant (PA) license in the state of employment and willingness to obtain additional licensure as requested Active DEA registration or eligibility to obtain; X-waiver preferred but not required Active or eligible state-controlled substance license Current Basic Life Support (BLS) certification Demonstrated strong clinical judgment and ability to make independent medical decisions Proficiency in using electronic medical record (EMR) systems 5+ years of experience working in high risk populations with serious mental illness and substance use disorder with co-occuring complex medical conditions 2+ years of experience in assessing, provisional diagnosis, planning, and managing behavioral patient care as acquired through clinical experience Expertise with DSM5 diagnostic criteria Highly skilled in trauma-informed care and culturally sensitive care. Experience and comfort working within an interdisciplinary care team, and specifically closely collaborating with community health workers and primary care providers Preferred: Certification by the American Nurses Credentialing Center (ANCC) in Psychiatric Mental Health (PMH) as a Psychiatric Mental Health Nurse Practitioner (PMHNP) or Physician Assistant with Psychiatry CAQ Experience in working in community mental health and/or integrated care settings Experience working with patients with substance use disorders including prescribing suboxone, naltrexone, acamprosate, and benzodiazepines for detoxification Experience working in value-based care setting and/or managed care, including how to appropriately assess STARS/HEDIS measures, accurately and appropriately diagnose and code clinical comorbidities, and identify clinical care gaps
Patient Care Delivery: Conduct virtual onboarding and follow-up visits, facilitated by a Health Advocate, to complete comprehensive biopsychosocial assessments, diagnose and manage chronic conditions using evidence-based guidelines, perform preventive screenings, and close preventive and quality care gaps This includes addressing BOTH medical and behavioral health diagnoses and treatment plans including chronic disease management, acute medical issues, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance use disorders, and other mental health disorders Guarantees every patient is seen face-to-face annually and proactively completes additional visits when clinical needs or care gaps arise Order and follow up on labs and imaging to inform diagnosis, prevention, and treatment Manage patients with chronic conditions (e.g., hypertension, diabetes, COPD, heart disease) in collaboration with external providers by developing individualized, evidence-based care plans to optimize health outcomes Manage patients with substance use disorders and prescribe medications for opioid use disorders, such as suboxone, and medications for alcohol use disorder, such as naltrexone (IM/PO) or acamprosate (this includes suboxone induction and outpatient alcohol detox for patients who are candidates, in supervision with the our Psychiatrist) Prescribe long-acting injectable medications for appropriate patients Provide health coaching, lifestyle counseling, and patient education to promote self-management and improved outcomes Coordinate necessary referrals or home-based services with specialists and community partners Participate in a rotating call schedule to address urgent clinical needs and support more healthy days at home Clinical coverage and training in the Collaborative Care and Bridge Programs, including Behavioral Health Case Conference, for coverage when colleagues are on leave or vacation Interdisciplinary Collaboration Work in close collaboration with Health Advocates- providing clinical support and guidance to their activities to help them coach and empower patients on successful self-management of their health, particularly with outpatient SUD treatment, LAI management, and mental health accompaniment Work in close collaboration with our Behavioral Health Clinicians in supporting clinical goals and co-managing patients Refer, collaborate and co-manage patients with our nursing and pharmacy teams Collaborate with external providers and community organizations to ensure care aligns with patient goals as well as social, home health, and DME needs (this particularly includes external psychiatrists and care managers in community mental health) Participate in the Advanced BH Case Conference where you will refine treatment plans in a multi-disciplinary fashion, addressing clinical documentation, quality gaps, treatment planning, transitions of care, and complex care planning Clinical Diagnosis and Documentation, Quality, and Compliance Ensure accurate and appropriate diagnosis, coding and documentation of chronic conditions with evidence-based treatment plans, including BOTH physical and mental health conditions Maintain timely, accurate documentation in EMR and custom care platforms Own the quality of preventative care delivered by helping patients close HEDIS quality gaps Respond to clinical documentation queries in a timely manner Technical Fluency and Innovation Quickly learns and adapts to new tools, software, and systems—including AI-driven solutions—that support patient engagement, care coordination, and clinical decision-making Understands the intersection of healthcare and technology, leveraging data-driven platforms, electronic medical records, and AI-enabled insights to independently problem solve and improve patient outcomes and operational efficiency Performs other duties as assigned
Fidelis Care - New York is proud to provide quality, affordable health coverage for more than 2 million members, at all stages of life. At Fidelis Care - New York, we’re dedicated to serving residents of New York State who need quality, affordable health coverage. Grassroots outreach - from inner-city neighborhoods to the most rural towns - is central to our mission. From provider offices, to schools, churches, food pantries, and community agencies, Fidelis Care - New York works closely with hundreds of partners to reach local residents in need and to be a resource in our community. Fidelis Care - New York provides coverage through Child Health Plus, Essential Plan, Medicaid, Health and Recovery Plan, Qualified Health Plans, Managed Long Term Care, and Medicare and Dual Advantage Plans.
You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. This is a fully remote position with required bi‑annual travel to New York. Candidates must have the flexibility to work a schedule of their choosing within the hours of 600 a.m. to 600 p.m. Eastern Time.*** Position Purpose Develop, conduct, administer and analyze clinical training programs, conduct audits of clinical systems entry and/or processes, and assist in development of audit tools
Education/Experience Bachelor’s degree in Nursing, related clinical field or equivalent experience. 4+ years of experience in nursing, training, or auditing in a managed care healthcare setting. Experience in a lead or supervisory role preferred. License/Certification Current state nursing license. Driver’s license may be required for certain positions.
Develop and conduct clinical education courses, including case management education and training for new employees Develop and maintain complex audit processes and audit tools related to authorizations, appeals, quality, case management, inter-rater reliability and data entry Audit established guidelines (e.g. Interqual) for medical necessity Analyze training needs and identify, select or develop appropriate training programs including training aids and materials Audit staff in accordance with established auditing processes, work with staff to identify and resolve errors in data and reporting, and present findings and recommendations for improvement to management Train audit staff in the use of audit tools and identification of patterns or trends that require additional training or corrective action Evaluate effectiveness of training programs including cost/benefit analyses Research, analyze, and recommend internal/external training programs Maintain records of training activities and employee progress Assist with revisions to Policy and Procedure and/or work process development Participate in Quality and Advisory committees) or provider education meetings Travel may be required
Prometric is a leading provider of technology-enabled testing and assessment solutions to many of the world’s most recognized licensing and certification organizations, academic institutions, and government agencies. We support more than 7 million test takers annually at our testing locations in 180 countries around the world. With over three decades of experience working with clients of all sizes across a multitude of industry sectors, our mission is to design and deliver the highest quality and most innovative testing solutions anytime, anywhere.
Job Title: Nurse Aide Subject Matter Expert (SME) Location: Remote Job Type: Contract / Project-Based Position Summary: The Nurse Aide Subject Matter Expert (SME) provides specialized expertise in the development and validation of nurse aide competency exams. SMEs ensure that exam content reflects current practice standards, regulatory requirements, and promotes safe, effective care.
Active nurse aide certification or RN/LPN license with experience in long-term care settings. Minimum 2 years of direct care experience or approved nurse aide instructor status. Strong understanding of resident rights, safety protocols, and care planning processes. Ability to commit to scheduled review sessions and meet project deadlines. Commitment & Compensation Part-time, project-based engagement.
Participate in job task analyses to identify essential skills and knowledge areas for nurse aides. Develop, review, and validate written and clinical exam items for accuracy and relevance. Assign criticality ratings and validate skill checkpoints for performance-based assessments. Engage in standard-setting studies and quality assurance reviews to maintain exam integrity. Collaborate with committees and stakeholders to ensure compliance with OBRA 1987 and state-specific regulations.
Devoted Medical was founded on the belief that if we treat each patient like we would our loved ones, we can meaningfully improve healthcare experiences and outcomes for some of America’s most vulnerable patient populations. We help members navigate the healthcare system in a better and safer way. This means getting the right care at the right place at the right time.
Our virtual Palliative Care program serves Devoted members with complex needs and life-limiting illness who otherwise would not have access to specialized palliative care. We pride ourselves on providing highly compassionate, patient-centered goals of care counseling, advanced care planning and symptom management for members projected to be in the final year of life. We meet patients where they are and support them in defining quality of life, achieving meaningful goals, and transitioning to hospice care. Virtual, multi-state palliative care is a novel concept and we are looking for a highly motivated, innovative, experienced palliative care nurse practitioner to help build the foundation of our clinical team. Our ideal NP is an expert palliative clinician with excellent communication and team-building skills who is adaptable to a continuously evolving startup environment.
Required: An unrestricted advanced practice license in 1 or more of the Devoted Membership states: FL, TX, AZ, OH, CO OR, TN, IL, AL, HI, NC, SC, PA Obtain additional state licenses as requested within 90 days of request 5 years in advanced practice, with at least 3 in Palliative care ACHPN® credential, or ability/ willingness to obtain within first six months of employment Willingness to flex between time zones Comfortable with technology and a fast-paced environment Self-starter with ability to succeed in a work-from-home environment Strong interpersonal and communication skills Comfort working within an interprofessional care team Preferred: ELNEC® or EPEC® training Prior ICU, oncology or geriatrics nursing experience Prior home-based palliative care experience Prior interprofessional team leadership experience Prior program development experience Attributes to success: You have great clinical and non-clinical judgment. You are thorough and take the time to address the needs of your patients. You understand that seamless interprofessional teamwork and communication is fundamental to the success of a palliative care program; you prioritize caring for yourself and your teammates with patience, compassion, curiosity, and resilience. You are deeply empathetic and humanistic, and want to go the last mile for your patients. You are comfortable working with members over video and phone. You enjoy a fast-paced, high-energy, organization. Agility and collaboration are key as we will change and improve quickly. You are comfortable engaging and learning new technologies including electronic health records, operating systems and programs (Google Office, Slack). You thrive on knowing your work can help make these technologies better for you and your patients. You learn from every experience and are not afraid to fail - that's how you're wired. Finally and most importantly, you have a passion for making healthcare better for patients with serious illness, solving complex problems, and supporting the delivery of healthcare that we would want for our own family members.
Panel management Perform initial assessments and develop Palliative Plans of Care for members newly enrolling to the Palliative Care Program. Follow a longitudinal panel of the highest risk patients (~ 40-50 patients) via regular telephonic and/or video encounters. Provide consultative visits to patients empaneled to the RNs, including but not limited to: advanced symptom management; complex goals of care; advanced disease education; prognostication; medical orders for home health, DME, medications, and hospice transitions. Evaluate hospital admissions for root-cause; support transitions of care for engaged patients, identify trends in readmissions and help develop solutions for achieving/ maintaining readmission rate less than or equal to 15% Required Palliative team activities: Regular huddles with clinical & ops team members Weekly interprofessional team meetings Monthly panel reviews with your Medical Director & Operations Manager Host one 30 min office hours per week Help support the team during periods of rapid growth or PTO/absences; you may be asked to help man the phone line, make outreach calls, perform initial visits, monitor incoming consults, etc. Collaborate with interdepartmental clinical teams and leadership to help coordinate seamless care of shared patients Required Devoted Medical activities: Attend Devoted Medical meetings as role appropriate. These may include but not limited to All-Hands, Clinical Excellence and Orinoco Updates meetings Provide on-call weekend/holiday coverage on a rotating basis Support the Devoted Health mission by caring for members like family
At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States.
This position represents an amazing opportunity for a caring nurse practitioner (APRN). Your primary focus will be delivering world class comprehensive care to our members. One of Devoted Medical’s missions is to bring care to where our members live – meaning your visits will be predominantly virtual telehealth care with an opportunity for a small amount of home based care. You will also utilize and help improve our home-grown technology and electronic health information platform to carry out these visits. On a day-to-day basis you will work closely with co-clinicians at Devoted Medical including physicians and other APRNs as well as medical assistants, documentation experts, practice administrators, and our close social work and clinical nurse partners at Devoted Health Plan. You will also have amazing opportunities for professional growth within the organization.
Attributes to success: You have great clinical and non-clinical judgment. You are thorough and take the time to address the needs of your patients. You are deeply empathetic and humanistic, and want to go the last mile for your patients. You enjoy a fast-paced, high-energy, organization. Agility and collaboration are key as we will change and improve quickly. You welcome learning and using new technologies that are being developed in parallel. You thrive on knowing your work can help make these technologies better for you and your patients. You learn from every experience and are not afraid to fail - that's how you're wired. Finally and most importantly, you have a passion for making healthcare better, solving complex problems, and supporting the delivery of healthcare that we would want for our own family members. Desired skills and experience: APRN with 3 or more years working in outpatient clinical practice. Prior home based practice is a plus, but not necessary. Experience in primary care, family medicine, geriatrics and/or palliative care. Experience performing Medicare annual wellness visits or in-home comprehensive visits with elderly patients or Medicare patients. Experience performing visits over telehealth video platforms. An understanding of managed care is a plus, including how to appropriately assess STARS/HEDIS measures, code clinical comorbidities, and identify clinical care gaps. A strong desire to continue practicing clinical nursing and perform house calls as well as virtual visits - you believe in the mission of bringing care to where the patient lives. Extra interest in bilingual Spanish or Haitian Creole speakers or strong cultural competencies across a range of cultures. Multi-state licensure preferred or willingness to obtain additional licensure as requested. Licensure and Certification: An active and clear RN and APRN license in the state of [MARKET] as well as APRN certification is required at time of hire and must be maintained while employed at Devoted Medical. Active BLS is required at time of hire and must be maintained while employed at Devoted Medical.
Conduct primarily telehealth video visits to members with the opportunity for a small volume of home based visits (drive to member’s home). In some instances when appropriate and compliant with licensure, you may also provide telehealth visits to members located in other geographies. Primarily perform comprehensive assessment visits (CAVs) including comprehensive diagnosis/disease review, medication review, and assessment for quality of care (STARS/HEDIS) interventions as well as social and home health/DME needs. Perform appropriate diagnostic tests including mobile screenings and fingerstick tests. Work closely with other members of the member’s care team including their PCP, specialists, and other Devoted team members including pharmacy, clinical nursing, and social work as well as interfacing with family members and caregivers in order to coordinate care for the member and deliver a collaborative care plan. Utilize our home grown electronic health information system for visits while also providing feedback on how to improve the interface. In certain geographies, there may be an infrequent weekend on-call component to support our clinical nurses who triage calls from our members during the weekend.
At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States.
We want to help patients navigate the healthcare system in a better and safer way, and case management is critical to achieving this for our most vulnerable and complex patients. You'll be responsible for providing telephonic, short-term, interdisciplinary care management in the 30 days post-discharge for patients at high risk for readmission. You'll serve as an advocate for these patients, coordinating care and ensuring they have the necessary resources and support to achieve better health outcomes. Our ideal RN is caring, compassionate, solution-oriented and enthusiastic about providing an outstanding experience for Devoted Health’s patients. They are committed to integrity, excellence, and empowering our patients to confidently navigate the healthcare system and live healthier lives. They are ready to innovate, adaptable to a continuously evolving startup environment, working with the whole Devoted family to create a revolution in how care is delivered.
Required skills and experience: An unrestricted Compact RN license obtained in the United States with the ability to secure other licensure states 3-4 Years of Experience of RN Care Management/telephonic case management experience Fully bilingual in English/Spanish Working hours are Monday-Friday 10am-6:30pm ET or 10:30am-7:00pm ET. We are looking for candidates who are located in CT/MT/PT time zones. Desired skills and experience: Enthusiasm for working in a setting where meaningful time is spent on the phone with patients and/or their caregivers to build trust, educate, and coordinate care Comfort and confidence working in an environment guided by performance and productivity metrics, with a focus on quality outcomes and patient experience Health insurance experience, particularly Medicare Advantage Prior Special Needs Plan, Population Health, or Transitions of Care case/care management experience Clinical analytical thinking that allows you to apply your skills to the individual needs of each patient Telephonic care/case management experience
Working with patients: Engaging with our newly discharged patients telephonically to understand their needs, supported by technology and data tools. Conducting assessments to identify comorbid conditions, ED/hospitalization history, medications, psychosocial factors, and patient values and preferences. Developing care plans in partnership with patients and their caregivers - problems, goals, interventions - while continuously evaluating the patient’s progress. Explaining complicated medical terms in plain language. Educating patients on their chronic conditions including teaching “red flags,” developing plans during an exacerbation, and identifying barriers to important care elements such as medication adherence. Hearing the red flags and providing active care management to close the gaps. Working with other providers and resources: Partnering with the TOC Nurse Practitioners and Physicians to ensure smooth handoffs, comprehensive follow-up, and coordinated care during the post-discharge period. Referring patients to Devoted Medical when applicable and working closely on partnering for patient care. Working closely with Devoted Community Guides (locally-based social workers) to identify community-based organizations to support our patients in meeting their goals. Coordinating post-treatment care and DME needs. Collaborating closely with our PCP partners, to coordinate care and deliver evidence based, effective, and accessible health care.
At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States.
We want to help patients navigate the healthcare system in a better and safer way, and case management is critical to achieving this for our most vulnerable and complex patients. You'll be responsible for providing telephonic, short-term, interdisciplinary care management in the 30 days post-discharge for patients at high risk for readmission. You'll serve as an advocate for these patients, coordinating care and ensuring they have the necessary resources and support to achieve better health outcomes. Our ideal RN is caring, compassionate, solution-oriented and enthusiastic about providing an outstanding experience for Devoted Health’s patients. They are committed to integrity, excellence, and empowering our patients to confidently navigate the healthcare system and live healthier lives. They are ready to innovate, adaptable to a continuously evolving startup environment, working with the whole Devoted family to create a revolution in how care is delivered.
Required skills and experience: An unrestricted Compact RN license obtained in the United States with the ability to secure other licensure states 3-4 Years of Experience of RN Care Management/telephonic case management experience Working hours are Monday-Friday 10am-6:30pm ET or 10:30am-7:00pm ET. We are looking for candidates who are located in CT/MT/PT time zones. Desired skills and experience: Enthusiasm for working in a setting where meaningful time is spent on the phone with patients and/or their caregivers to build trust, educate, and coordinate care Comfort and confidence working in an environment guided by performance and productivity metrics, with a focus on quality outcomes and patient experience Health insurance experience, particularly Medicare Advantage Prior Special Needs Plan, Population Health, or Transitions of Care case/care management experience Clinical analytical thinking that allows you to apply your skills to the individual needs of each patient Telephonic care/case management experience
Working with patients: Engaging with our newly discharged patients telephonically to understand their needs, supported by technology and data tools. Conducting assessments to identify comorbid conditions, ED/hospitalization history, medications, psychosocial factors, and patient values and preferences. Developing care plans in partnership with patients and their caregivers - problems, goals, interventions - while continuously evaluating the patient’s progress. Explaining complicated medical terms in plain language. Educating patients on their chronic conditions including teaching “red flags,” developing plans during an exacerbation, and identifying barriers to important care elements such as medication adherence. Hearing the red flags and providing active care management to close the gaps. Working with other providers and resources: Partnering with the TOC Nurse Practitioners and Physicians to ensure smooth handoffs, comprehensive follow-up, and coordinated care during the post-discharge period. Referring patients to Devoted Medical when applicable and working closely on partnering for patient care. Working closely with Devoted Community Guides (locally-based social workers) to identify community-based organizations to support our patients in meeting their goals. Coordinating post-treatment care and DME needs. Collaborating closely with our PCP partners, to coordinate care and deliver evidence based, effective, and accessible health care.
In October 2025, Machinify acquired Performant and we are now part of the Machinify organization. Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, Machinify’s AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We’re reshaping healthcare payment through seamless intelligence.
Hiring Range: $78,500 - 90,000 The Medical Review Nurse - Home Health primarily performs medical claims audit reviews on Home Health claims. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government and Commercial Payers. You will work remotely in a fast paced and dynamic environment and be part of a multi-location team.
Knowledge, Skills And Abilities Needed: Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual. Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding. Knowledge of insurance programs program, particularly the coverage and payment rules. Ability to maintain high quality work while meeting strict deadlines. Excellent written and verbal communication skills. Ability to manage multiple tasks including desk audits and claims review. Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings. Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload Effectively work independently and as a team, in a remote setting. Required And Preferred Qualifications: Active unrestricted RN license in good standing, is required. Must not be currently sanctioned or excluded from the Medicare program by the OIG. Minimum of five (5) years diversified nursing experience providing direct care in a Home Health setting. One (1) or more years' experience performing medical records review. One (1) or more years' experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required. Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions. Physical Requirements & Additional Notices: If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required. Proof of such may be required prior to an offer being made. It is the Employee’s responsibility to maintain this Internet access at their home office location. The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary. Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse. Regularly reads and comprehends information in electronic (computer) or paper form (written/printed). Regularly sit/stand 8 or more hours per day. Occasionally lift/carry/push/pull up to 10lbs. Requirements: Machinify is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position: Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions. Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists. Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures. Other requirements may apply.
Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules. Document all findings referencing the appropriate policies and rules. Generate letters articulating audit findings. Supporting your findings during the appeals process if requested. Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse. Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits. Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients. Work with the team to minimize the number of appeals; Suggest ideas that may improve audit workflows; Assist with QA functions and training team members. Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines. Interface with and support the Medical Director and cross train in all clinical departments/areas. Other duties as required to meet business needs.
At Cardiac Study Center, we believe in compassionate, innovative care that improves heart health and transforms lives. With over 50 years of experience serving the Pacific Northwest, we continue to expand our dedicated team of professionals committed to exceptional patient care. Join us in building the future of cardiology—one heartbeat at a time.
Why You'll Love Working With Us Remote-first role (approx. 90%) with occasional site visits Monday–Friday schedule – no nights, weekends, or holidays Competitive compensation based on experience Tuition Assistance to support your continued education Excellent benefits, including medical, dental, vision, and 401(k) with match Paid holidays, floating holidays, and vacation Access to mental health resources and wellness initiatives Mission-driven organization with a tight-knit, collaborative team Opportunity to lead meaningful clinical and operational improvements About The Role: The Nurse Navigator plays a critical role in bridging the gap between patients and the complex healthcare system. Acting as a registered nurse, case manager, and patient advocate, this role supports patients across the continuum of cardiology care—from referrals and specialty access to outcomes monitoring and education. This role is ideal for someone passionate about guiding patients through their care journey, enhancing program performance, and delivering top-tier care through leadership, clinical insight, and coordination. Join Our Team: If you're a registered nurse who thrives in a supportive, innovative care model and wants to empower patients and teams alike, we'd love to connect with you.
Current WA State RN license (Multistate license required within 6 months of hire) Bachelor's degree in Nursing (Associate degree with additional experience may be considered) 3+ years of recent clinical experience in cardiology or related specialty Strong knowledge of clinical workflows, payer guidelines, and case management High level of independence, critical thinking, and communication skills Must reside in Washington State Preferred: Master's degree in Nursing Certification in the assigned area of specialty Work Environment Remote role Occasional travel required to clinics Home office must be located within Washington State Standard business hours (Mon–Fri, 8AM–5PM)
Care Navigation & Patient Advocacy: Coordinate referrals, specialty access, and follow-ups Serve as liaison between patients, providers, and the care team Ensure patients receive appropriate psychosocial and emotional support Guide patients through the health system and address barriers to care Program Monitoring & Quality Improvement: Collect, trend, and analyze outcomes data for performance enhancement Identify best practices and support training plan development Recommend and implement program or workflow improvements Education & Community Engagement: Educate patients and families on treatment and navigation Support staff training, in-services, and skill development Create educational materials and participate in outreach activities Team Collaboration & Leadership: Serve as a clinical expert and resource across hospital and clinic settings Establish collaborative communication across providers and stakeholders Participate in multidisciplinary meetings and drive coordination of care
CircleLink Health is a company of passionate clinicians, technologists and businesspeople tackling the $600B problem of preventable chronic and post-acute complications. We're building a world-class Care Management platform to enable providers while accelerating the shift to preventative care instead of status quo reactive care. Learn more about us here.
Contract | Remote | We're hiring 10 elite nurses CircleLink Health is building a team of top-tier Compact Registered Nurses who want more than a typical remote role. This is a performance environment for nurses who thrive on ownership, efficiency, and measurable impact — and who want their income to reflect their output. If you want predictable shifts and low expectations, this isn't the role for you.* If you want autonomy, scale, and the ability to grow your earnings, keep reading. You'll manage a large 100+ panel of Medicare patients with chronic conditions, delivering monthly clinical calls that drive real outcomes and reduce hospitalizations. This role is built for nurses who can operate independently, manage complexity, and execute consistently at a high level. We expect our Care Coaches to treat this role as their primary professional focus, not a side gig. Your earnings scale with your output. $15 per completed clinical encounter per patient Large caseloads = higher income Very High performers can exceed $3,000/month $300 performance bonus after 3 months of consistent results No cap on productivity If you want control over your income, this is where you get it. Schedule & Structure Flexible scheduling between 8am-5pm EST, Monday-Sunday Fully remote 1099 contractor role You own your schedule, your workflow, and your results. This Role Is for You If: You want autonomy instead of micromanagement You're comfortable being measured on performance You want your effort to directly impact your income You thrive in structured, fast-paced environments You take pride in efficiency and ownership You want to build a serious remote nursing career 🚫 This Role Is NOT For You If: You prefer slow-paced environments You need constant supervision You're looking for occasional side income You struggle with time management or organization
Compact RN licensed Extremely self-directed Comfortable owning large caseloads (>100 patients/month) Highly organized and metrics-driven Tech fluent and fast learners Motivated by performance and results Comfortable working with minimal supervision with multiple practices, workflows and EHRs Accountable, disciplined, and reliable Requirements: Current unrestricted Compact RN license 3+ years clinical experience Strong internet and dedicated workspace Confident with multiple software platforms Strong communication and critical thinking skills Strongly preferred: Case management or chronic disease management EHR experience Motivational interviewing Diabetes education
Run monthly clinical calls with chronic care patients Drive behavior change through coaching and education Maintain precise, compliant documentation using our platform Close preventive care gaps and coordinate services Update care plans and track interventions Support transitions of care to reduce readmissions Manage your panel efficiently and consistently
Imagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.
We are looking for a Telephonic Nurse Case Manager (RN), who independently manages medical aspects of Workers’ Compensation claims, ensuring the delivery of high-quality, timely, and cost-effective care to injured employees. This role monitors, analyzes, evaluates, and coordinates medical treatment throughout the continuum of care to promote medically appropriate, prompt return-to-work outcomes. The Telephonic Case Manager proactively identifies barriers to recovery, develops action plans, and serves as both patient advocate and clinical resource while maintaining compliance with regulatory and client-specific guidelines.
Skills, knowledge & expertise: Active, unrestricted RN license. Minimum 3 years of clinical experience (medical-surgical, orthopedic, neurological, ICCU, industrial, ER, or occupational health). Workers’ Compensation case management experience preferred. Strong knowledge of treatment guidelines and utilization management principles. Excellent verbal and written communication skills. Ability to work independently in a remote environment. Proficiency in computer systems and claims/case management software. Telephonic case management experience. Experience applying evidence-based disability duration guidelines. Prior experience training or mentoring staff.
Provide telephonic case management for Workers’ Compensation cases. Assess medical appropriateness of treatment plans and coordinate services to optimize recovery and cost efficiency. Develop, implement, and modify individualized case management care plans. Perform ongoing clinical assessments and review medical records to ensure quality and timely care. Identify and address barriers to recovery with proactive action planning. Coordinate communication between injured workers, employers, providers, insurers, and other stakeholders. Promote and document return-to-work capability at each medical milestone. Ensure compliance with state-mandated treatment guidelines, nationally published protocols, and client requirements. Track outcomes including patient satisfaction, return-to-work progress, and disability duration. Utilize utilization review tools when indicated (pre-certification, concurrent review, retrospective review, medical director review). Monitor provider and vendor performance to ensure quality and appropriate care delivery. Maintain detailed and accurate documentation within the case management system. Serve as a patient advocate while adhering to all legal, ethical, accreditation, and regulatory standards. Participate in Quality Assurance, Grievance, or other committees as assigned. Provide training or mentorship to claims staff or junior team members as appropriate. Perform additional duties as assigned.
Medasource is a leading consulting and professional services firm supporting organizations across the healthcare ecosystem – including Life Sciences, RCM/Payers, Technology, Government and Nursing & Allied Health. Recognized for our commitment to our employees, consultants, and the communities we serve, we deliver solutions that drive meaningful progress across healthcare. With a nationwide footprint of 33 offices and 1,900+ active consultant placements across 120+ clients who are actively engaging Medasource talent, we continue to expand our impact as we advance the future of healthcare, one client at a time.
Position: Clinical Appeals Nurse (Medicare) Client: Health Insurance Client Location: 100% Remote (EST Hours) Start Date: ASAP
Top Denial Types / Case Mix Pre-service / expedited appeals (high priority) Radiology denials Durable Medical Equipment (DME) Dual-eligible / waiver services (e.g., PCS) Required Qualifications: Active Registered Nurse (RN) license (compact preferred) Strong experience in clinical appeals, preferably Medicare Background in payer-side utilization management or appeals Experience with: GuidingCare (preferred) Facets (preferred) Strong clinical documentation and writing skills High attention to detail (audit-sensitive environment)
Review and evaluate Medicare appeals cases (pre-service and post-service) Conduct clinical documentation review and apply medical necessity criteria Draft appeal determinations using standardized templates Ensure complete and accurate documentation, including attachments Manage case workload aligned to productivity expectations (~5/day) Collaborate with internal teams and perform required outreach as needed Utilize AI-assisted tools while maintaining clinical judgment
Houston Methodist is one of the nation’s leading health systems and academic medical centers. The health system consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the Texas Medical Center, seven community hospitals and one long-term acute care hospital throughout the Greater Houston metropolitan area. Houston Methodist also includes a research institute; a comprehensive residency program; international patient services; freestanding comprehensive care clinics, emergency care and imaging centers; and outpatient facilities. Come lead with us!
At Houston Methodist, the Registered Nurse (RN) II position is a licensed staff nurse, an experienced clinician, functions at the Competent to Proficient stage of Benner's model of clinical practice. The RN II position provides professional nursing care to a diverse patient population, conducts nursing assessments, assists with exams and treatment, patient education, and maintenance of medical records. The RN II position provides direct patient care effectively and efficiently which may include patients with varied and complex needs. This position communicates and collaborates with the physicians and interprofessional health care team to facilitate, coordinate and maintain compassionate, efficient, quality care and achievement of desired treatment outcomes. The RN II position demonstrates clinical competence when providing care, using technology, administering medications, performing procedures and managing emergencies, acting as a patient and family advocate in order to monitor and maintain patient rights. This position assumes leadership roles with progressive responsibility including but not limited to participating in or leading unit and shared governance initiatives, serving as charge nurse or preceptor to students or new employees, and possibly contributing to service line or hospital-wide initiatives in partnership with management.
EDUCATION: Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section EXPERIENCE: Twelve months registered nurse experience in a healthcare environment LICENSES AND CERTIFICATIONS: Required RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure - must obtain permanent Texas license within 60 days (if establishing Texas residency) and BLS - Basic Life Support or Instructor (AHA) - American Heart Association Preferred Magnet - ANCC Recognized Certification SKILLS AND ABILITIES: Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations as defined in orientation checklist and annual departmental competency checklist Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles Strong assessment, organizational and problem solving skills as evidenced by capacity to prioritize multiple tasks and role components Ability to function independently and exercise judgment in interactions with physicians, interprofessional care team and patients and their families Uses critical thinking skills and clinical judgment to work autonomously as defined by the Nurse Practice Act Demonstrates proficient time management skills Maintains level of professional contributions as defined in Clinical Career Path program guide Working knowledge of Microsoft products including Outlook SUPPLEMENTAL REQUIREMENTS WORK ATTIRE Uniform: No Scrubs: Yes Business professional: No Other (department approved): No ON-CALL* *Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below. On Call* Yes TRAVEL** **Travel specifications may vary by department** May require travel within the Houston Metropolitan area Yes May require travel outside Houston Metropolitan area No QUALIFICATIONS EDUCATION Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section EXPERIENCE Twelve months registered nurse experience in a healthcare environment LICENSES AND CERTIFICATIONS Required RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure - must obtain permanent Texas license within 60 days (if establishing Texas residency) and BLS - Basic Life Support or Instructor (AHA) - American Heart Association Preferred Magnet - ANCC Recognized Certification
PEOPLE ESSENTIAL FUNCTIONS: Uses therapeutic communication, which includes active listening and teaching, to establish a relationship with patients, families and interprofessional health care team to collaborate on the plan of care. Contributes to teamwork by awareness of overall unit acuity, consistently offering assistance, and responding positively to requests for assistance. Collaborates to foster healthy relationships in the work environment. Seeks guidance from and offers guidance to interprofessional health care team, when appropriate, and applies feedback to improve patient outcomes. Implements staff education specific to patient populations and unit processes; coaches and mentors other staff and students. May include preceptorship. Uses peer-to-peer accountability towards improvement of department score for turnover/retention/employee engagement on unit-based scorecard. SERVICE ESSENTIAL FUNCTIONS: Follows the patient and family-centered care standards, as outlined in the Houston Methodist Professional Nursing Practice document. Conducts nursing assessments, assists with exams and treatment, and maintenance of medical records. Develops, updates and communicates plan of care, including discharge, in partnership with the patient, family and interprofessional health care team, using the nursing process. Prioritizes care based on the patient’s needs, abilities and preferences. Advocates on patient/family’s behalf to identify and resolve clinical and ethical concerns, utilizing appropriate resources. Provides patient teaching based on learning needs, uses appropriate resources, incorporating planning for care after discharge. Consistently evaluates the patient’s comprehension and adapts teaching methods accordingly. Helps drive improvement of department score for patient satisfaction on unit-based scorecard, through peer-to-peer accountability to service standards. QUALITY/SAFETY ESSENTIAL FUNCTIONS: Follows the standards of care related to the nursing process, as outlined in the Houston Methodist Professional Nursing Practice document. Follows the standards related to regulatory requirements and professional practice as outlined in the Houston Methodist Professional Nursing Practice document. Identifies areas of practice improvements with research-based evidence to achieve core measure and patient safety outcomes, supported by accurate documentation. Provides and modifies care to complex patients and coordinates care with the interprofessional team based on evaluation of the patient’s condition, supported by accurate documentation. Utilizes clinical judgement, using an evidence-based analytical approach. Improves quality and safety scores on the unit-based scorecard, through peer-to-peer accountability, reporting near misses, and collaborating with the interprofessional health care team. FINANCE ESSENTIAL FUNCTIONS: Displays self-motivation to independently manage time effectively, timely document care, minimize incidental overtime, and prioritize daily tasks. Provides input into the unit resource utilization including unit capital and operational budget needs. Contributes towards meeting department financial targets on unit-based scorecard through decreasing length of stay, optimizing efficiency and other areas according to department specifications. GROWTH/INNOVATION ESSENTIAL FUNCTIONS: Identifies and presents areas for innovation, efficiency and improvement in patient care or unit operations using evidence-based practice literature. Offers innovative solutions through evidence-based practice/performance improvement projects and shared governance activities. Champions new care pathways or service line implementation to improve service to the community. Identifies trends for improvement opportunities or practice changes and supports initiatives. Researches the change and presents options to shared governance and leadership.
Every day at Conviva, we inspire each senior to live their best life by practicing wellness, prevention, and holistic care. In short, we believe in helping our patients age well, no matter their stage of life. Conviva’s physician-led Care Teams are driven by the passionate belief that patient care always comes first.
The Utilization Management Nurse uses clinical nursing skills to support the coordination, documentation and communication of medical services and benefit administration determinations.
Required Qualifications: Active and unrestricted Registered Nurse license (RN) in the (appropriate state) with no disciplinary action 3+ years of Medical Surgery, Heart, Lung or Critical Care Nursing experience Previous experience in utilization management Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting Comprehensive knowledge of Microsoft Word, Outlook and Excel Preferred Qualifications: BSN or Bachelor's degree in a related field Health Plan experience Previous Medicare/Medicaid Experience Call center or triage experience Bilingual in English and Spanish with the ability to read/write/speak in both languages Work environment: This is a remote position. Additional Information 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. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
The Utilization Management Nurse uses clinical knowledge, towards interpreting criteria and procedures to provide the best treatment, care or services for members. You will coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment. You will understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas. You will report to a Utilization RN Manager.
PARKVIEW HEALTH SYSTEM INC is a company based out of 10501 CORPORATE DR, Ft Wayne, Indiana, United States. Parkview Hospital Randallia has served area residents at its current location since 1953. Located in central Fort Wayne, we continue to be a full-service center of healthcare activity and excellence, and we are dedicated to providing exceptional service with kindness and concern for your personal situation. Below, we hope you find some resources that will help you during your time here, whether as a patient or visitor.
Independently plans and provides excellent professional nursing care for patients in accordance with physician orders, established hospital and departmental policies and procedures, American Nurses Association Standards of Clinical Practice, Indiana Nurse Practice Act, and the ANA Code of Ethics.
Education: Requires a Diploma in Nursing or an Associate of Science in Nursing (ASN); Bachelor of Science in Nursing (BSN) strongly preferred. Licensure/Certification: Valid Indiana Registered Nurse license or current active multi-state Registered Nurse license required at time of hire. Must have current CPR certification. Current Advanced Cardiac Life Support (ACLS) preferred, but not required. Additional certifications may be required for specified areas. Experience: Minimum of at least three-five years of RN experience in medical/surgical, progressive care, or critical care setting required. Experience with Electronic Medical Records required. Other Qualifications: Must have excellent verbal and written communication skills. Comfortable with technology.
UPMC is a world-renowned, nonprofit health care provider and insurer committed to delivering exceptional, people-centered care and community services. Headquartered in Pittsburgh and affiliated with the University of Pittsburgh Schools of the Health Sciences, UPMC is shaping the future of health through clinical and technological innovation, research, and education. Dedicated to advancing the well-being of our diverse communities, we provide nearly $2 billion annually in community benefits, more than any other health system in Pennsylvania. Our 100,000 employees — including more than 5,000 physicians — care for patients across more than 40 hospitals and 800 outpatient sites in Pennsylvania, New York, and Maryland, as well as overseas. UPMC Insurance Services covers more than 4 million members, providing the highest-quality care at the most affordable price. To learn more, visit UPMC.com.
Are you an experienced nurse looking for the next challenge in your career? Do you have knowledge of care management or care coordination? The UPMC Health Plan is hiring a full-time Telephonic Care Manager to support our Medicare Case Management team. The Telephonic Care Manager is responsible for care coordination and health education for identified Health Plan members through telephonic collaboration with members and their caregivers and providers. Identifies members’ medical, behavioral, and social needs and barriers to care. Develops a comprehensive care plan that assists members to close gaps in preventive care, addresses barriers to care, and supports the member’s self-management of chronic illness based on clinical standards of care. Collaborates and facilitates care with other medical management staff, other departments, providers, community resources and caregivers to provide additional support. Members are followed by telephone or other electronic communication methods. This position is primarily remote; however, occasional travel to Downtown Pittsburgh will be required. This position will work standard daylight hours, Monday through Friday with occasional evenings required.
Minimum of 2 years of experience in a clinical setting and case management nursing required. BSN preferred. Ability to interact with physicians and other health care professionals in a professional manner required. Excellent verbal and written communication and interpersonal skills required. Computer proficiency required. Meet minimum internet system/service and speed/ latency requirements as set forth by UPMC. Equipment must be connected directly or hard-wired to the internet modem/router with an ethernet cable. Most cable and fiber optic providers can meet the requirement. Private, secure designated workspace required in the home office setting or the ability to work from a designated UPMC office location daily. Licensure, Certifications, and Clearances: Case management certification or approved clinical certification preferred Registered Nurse (RN) *Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.
Present complex members for review by the interdisciplinary team summarizing clinical and social history, healthcare resource utilization, case management interventions. Update the plan of care following review and communicate recommendations to the member and providers. Contact members with gaps in preventive health care services and assist them to schedule required screening or diagnostic tests with their providers. Review member’s current medication profile; identify issues related to medication adherence, and address with the member and providers as necessary. Refers member for Comprehensive Medication Review as appropriate. Conduct comprehensive assessments that include the medical, behavioral, pharmacy, and social needs of the member. Review UPMC Health Plan data for services the member has received and identify gaps in care based on clinical standards of care. Refer members to appropriate health plan programs based on assessment data. Engage members in education or self management programs. Provide members with appropriate education materials or resources to enhance their knowledge and skills related to physical health, emotional health, or lifestyle management. Successfully engage member to develop an individualized plan of care in collaboration with their primary care provider that promotes healthy lifestyles, closes gaps in care, and reduces unnecessary ER utilization and hospital readmissions. Coordinates and modifies the care plan with member, caregivers, PCP, specialists, community resources, behavioral health contractor, and other health plan and system departments as appropriate. Document all activities in the Health Plan’s care management tracking system following Health Plan standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers. Conduct member outreach in response to assist with member issues or concerns or facilitate specific population health goals. Seek input from clinical leadership to resolve issues or concerns.
Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.
Remote Care Management Nurse (Future Opportunities) Work from home within Oregon, Washington, Idaho or Utah *Please be advised that this role is part of our candidate pool, which allows us to identify and attract exceptional talent for future opportunities. Although we may not have immediate openings, we invite you to submit your resume for consideration. By doing so, you will be included in our database and considered for all suitable positions as they become available, ensuring that you are among the first to be notified of new opportunities that match your skills and experience.* Every day, Cambia’s dedicated team of Care Management RN's are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our Care Management RN's provide clinical care management (such as case management, disease management, and/or care coordination) to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes. Oversees a collaborative process with the member and those involved in the member’s care to assess, plan, implement, coordinate, monitor and evaluate care as needed - all in service of creating a person-focused health care experience. Are you a Registered Nurse looking to transition out of bedside care and into a role that still utilizes your clinical expertise, but offers a fresh challenge? Is your goal to promote quality, cost-effective outcomes and improve overall health and wellbeing? Then this role may be the perfect fit.
Nursing or health/human services degree (Associate's or Bachelor's minimum), or equivalent experience in lieu of a degree At least 3 years of direct clinical care or experience in case management, utilization management, disease management, auditing, or retrospective review Active, unrestricted licensure or certification in a U.S. state or territory that allows you to independently conduct assessments within your scope of practice — RN license required for medical care management Must be eligible for licensure in Idaho, Oregon, Utah, and Washington Skills and Attributes: Knowledge of health insurance industry trends, technology and contractual arrangements. General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems. Strong oral, written and interpersonal communication and customer service skills. Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively. Strong organization and time management skills with the ability to manage workload independently. Ability to think critically and make decision within individual role and responsibility. Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired
Conducts case management activities, including assessment, planning, implementation, coordination, monitoring, and evaluation to identify and meet member needs. Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care, utilizing evidence-based criteria and practicing within the scope of their license. Collaborates with physician advisors, internal and external customers, and other departments to resolve claims, quality of care, member or provider issues, and identifies problems or needed changes, recommending resolutions and participating in quality improvement efforts. Serves as a resource to internal and external customers, responding to inquiries in a professional manner while protecting confidentiality of sensitive documents and issues. Provides consistent and accurate documentation, ensuring compliance with performance standards, corporate goals, and established timelines. Coordinates resources, organizes, and prioritizes assignments to meet goals and timelines. Monitors and evaluates the effectiveness of case management plans, gathering sufficient information to determine the plan's effectiveness and making adjustments as needed.
Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. About Mass General Hospital Mass General Hospital is a world-renowned hospital that provides the highest quality care to patients. We are a leader in medical research and education, and we are committed to delivering our employees with a rewarding and fulfilling career.
*** Minimum of Five Years of Recent Oncology Experience required for this 100% Remote Job *** The MGH Cancer Center is expanding the Early Detection and Diagnosis (EDDx) Nurse Navigator team. Working collaboratively with the physician, APP and administrative team, the EEDx Nurse Navigator is the first point of contact for patients referred to the EEDx clinic for cancer screening, early detection and genetic testing and surveillance. The Nurse Navigator must have the ability to guide patients through the process of this screening and across the continuum of care. The qualified candidate with have foundation knowledge in cancer and strong and compassionate communication skills. The Nurse Navigator has a strong collaboration with both the clinical and administrative team. We offer an outstanding benefits packages to eligible employees including… Medical, Dental and Vision insurance Tuition Reimbursement Generous paid time off Subsidized MBTA pass (50% discount) Resources for childcare and emergency backup care Hospital paid retirement plan and tax-sheltered annuity plan Employee “Perks” - enjoy discounts on tickets and passes for everything from ski resorts to museums to sporting events. You contribute to our success. Every role has an impact on our patients' lives, and you can make a difference. We are looking for someone as dedicated as you to be a part of our team. Job Summary: Responsible for coordinating the complex care needs of patients and is the primary patient contact for service access, diagnostics, treatment activities, schedules, patient and family education, and multidisciplinary collaboration. Does this position require Patient Care? Yes
Education: Bachelor's Degree Nursing required or Master's Degree Nursing preferred Can this role accept experience in lieu of a degree? No Licenses and Credentials Registered Nurse [RN - State License] - Generic - HR Only required Experience Experience in an acute care setting and/or provider practice and/or experience in a community-based role or with discharge/transitional planning background 2-3 years preferred Knowledge, Skills and Abilities Strong attention to detail and organization. Strong cultural awareness competencies. Proficiency in Microsoft Office. Maintains good communication skills. Readily adapts to change and welcomes new approaches when circumstances demand it.
In collaboration with the interdisciplinary team, help create a tailored health care plan for assigned patients. Develop an individualized plan with the MD for appropriate services for the patient. Reports pertinent observations and reactions regarding clients to the appropriate person (i.e., primary care provider, social worker, or Director). Assesses and coordinates patient's discharge planning needs with members of the healthcare team. Resolves patient problems and needs by utilizing multidisciplinary team strategies. Educates patients regarding how to navigate throughout the health system.
Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey. Position: Personal Health Expert Type: Contract Compensation: $60–$85/hour Location: Remote
Must-Have: 3+ years as an RN, patient advocate, MA, or in a similar health-literate role. Expertise in insurance appeals, payer navigation, lab result interpretation, medication management, or patient portal workflows. Comfortable with creating and interpreting personal health artifacts like timelines and symptom logs. Strong written communication skills to articulate reasoning and encode it into deterministic rubrics. Compensation & Legal Hourly contractor, paid based on task quality and throughput.
Develop long-horizon health-admin tasks with deterministic rubrics to evaluate agent performance against verifiable ground truth. Build scenarios in Records and Visits, Medications and Labs, and Payer and Documentation to ensure accurate and structured outputs. Evaluate medical timelines, medication schedules, and insurance appeals for consistency with ground-truth data and known outcomes. Collaborate with AI labs to enhance agent evaluations in personal health navigation. Work independently and asynchronously to meet deadlines and improve task quality and throughput.
Rasmussen University, a university accredited by the Higher Learning Commission, an institutional accreditation agency recognized by the U.S. Department of Education (www.hlcommission.org), is dedicated to changing lives and the communities it serves through innovative educational programs. As a pioneer in career-focused education since 1900, the University is defining a new generation of higher education that focuses on competency-based education, technology and transferable skills. Rasmussen offers undergraduate and graduate programs online and in person at 20 campuses around the country. The University is designed to lift and support its students every step of the way, from each student’s first credential to their last. Rasmussen is dedicated to global enrichment, serving the underserved, and meeting the evolving needs of diverse students, communities, and economies. Rasmussen encourages its students, faculty, and staff to strive for academic excellence, community enrichment and service to the public good. Rasmussen is a wholly owned subsidiary of American Public Education, Inc. (Nasdaq: APEI). For more information about Rasmussen University, please visit www.rasmussen.edu.
Clinical Coordinator, School of Nursing Rasmussen University Online/Remote The Clinical Coordinator is responsible for securing, maintaining, and evaluating clinical sites for diverse and robust programs within the School of Nursing. The Clinical Coordinator promotes and supports the vision and mission of the Nursing program at the University. The incumbent is expected to establish and maintain professional relationships inside and outside of the organization, regularly representing the University and the core values of the organization, regularly representing the University and the core values of the organization.
Associate's degree required, Bachelor's degree preferred. Minimum of two (2) years of customer service or sales experience, with preference given to those with experience in a healthcare setting. Sales Force experience preferred. Highly organized and focused professional who addresses problems and innovates with accountability and continuous improvement as guiding lights. Able to work independently and meet deadlines consistently.
Build relationships with health care facilities and potential adjunct faculty. Collaborate with Dean of Nursing, Area Dean of Nursing, or Regional Dean of Nursing to identify clinical experiences that are evidence-based; reflect contemporary practices and nationally established patient health and safety goals; and support the achievement of the end-of-program student learning outcomes. Review written agreements for clinical practice agencies to ensure they are current, specify expectations for all parties, and ensure the protection of students. Review evaluation findings related to clinical experiences and report them to the Dean of Nursing, Area Dean of Nursing, or Regional Dean of Nursing. Collect, document and store all required student programmatic paperwork according to University and programmatic policies. Assist with the clinical course scheduling as directed by Nursing Deans. Collaborate with the campus staff to assign student clinical placement and collect required documentation. Track and maintain all community-based activities in Sales Force as appropriate, utilizing the Clinical Tracking Tool as the primary database for clinical activities and documents of record. Work collaboratively across program, school, and campus in order to maximize community clinical relationships for Rasmussen stakeholders. Participate in campus, community and professional events to represent Rasmussen University to students, professional organizations, community partners, and other relevant constituencies within the communities. Student Support (25%) Assist students with clarification of clinical attendance requirements of the program. Maintain and monitor active, clinical partnership agreements in order to ensure sustained and non-interrupted student access to sites. Work collaboratively with the Rasmussen legal and compliance team to ensure a going concern of contracts and agreements. Curriculum (25%) Assist Dean with data collection related to the achievement of the end-of-program student learning outcomes directly related to clinical learning experiences.
At LaserAway, we redefine excellence in aesthetic dermatology. Every treatment is performed by licensed medical professionals supported by 25 board-certified dermatologists who craft and monitor our protocols for unmatched safety and effectiveness. With state-of-the-art technology and premium products, we treat all skin types with precision and care, combining clinical expertise with cutting-edge innovation. Our 160+ locations and growing footprint make life-changing treatments accessible to everyone. Open seven days a week, we prioritize convenience and self-care. Guided by a patient-first approach, we deliver exceptional experiences that build trust and loyalty.
About the Role: Telehealth Good Faith Exam Nurse Practitioner The Good Faith Exam (GFE) Telehealth Clinician provides Good Faith Exams in licensed states, per state rules and regulations, in collaboration with medical directors, if applicable, in that state. Compensation: This role is a remote role, with a starting hourly rate of $60 plus weekend differential. You must reside in a compact state to be considered!
Education: Graduate of an accredited NP program with current board certification Must have CA NP license upon application Multi-Licensed Preferred: CA + (HI WA OR AZ NV CO UT ID NM TX IL OK KS TN MN MO WI NY VA MA GA DC NC MD NJ PA CT OH IN NE MI LA) Open availability including evenings and weekends (PST) Must reside in a compact license state: WA, ID, MT, WY, CO, NM, AZ, UT, TX, OK, KS, NE, SD, ND, IA, MO, AR, LA, MS, AL, TN, WI, IN, KY, TN, GA, FL, SC, NC, VADE, MD, NJ, NH, VT, ME, OH Physical Requirements/Working Conditions: Work-from-home in a quiet private office Must have strong internet connection Must be able to FaceTime/Doximity patients and have a phone from which to speak with patients and a computer on which to chart.
Full Time: 4-5 Days a week with weekend requirement of 4-6 weekend shifts per month, dependent on business need. Provide excellent customer service in a timely manner to patients and colleagues alike: Provide Good Faith Exams for patients in states where licensed and in accordance with our protocols. Sending in Prescriptions per protocol under our Medical Directors. Apply for licensure in states assigned by Senior Director Fielding 8x8 calls from sales and patients Answer Slack posts on #remotemedical #remotesales #medical2 #gfe-and-va-team channels Complete 5 Medallia responses each shift. Must be willing to work afternoon/evening shifts (PST)
Insight Global is an international talent and consulting company that delivers business outcomes in an ever-changing world. We obsess over solving problems and building solutions that move our customers further, faster. With access to top talent in more than 50 countries, our tech-enabled recruiters can build teams quickly. Our technical experts across Cloud, AI, Data, Enterprise Operations, and Applied Engineering deliver solutions tailored to each customer’s needs. As those needs evolve, so do we. As we evolve, though, we stay true to our purpose: to develop people personally, professionally, and financially so they can be the light to the world around them. It shows up in everything we do, from investing in our people to delivering results for our customers to making a meaningful impact in our communities.
The Clinical Appeals Nurse is responsible for processing clinical appeals and attending state hearings within compliance and regulatory standards, clinical guidelines, and contractual obligations.
Process Clinical Appeals & Hearings: Complete member and provider clinical appeals and prepare for state hearings within required timeframes and compliance standards. Conduct Clinical Reviews: Evaluate medical, dental, behavioral health, pharmacy, and waiver service appeals using medical records, documentation, and guidelines. What specific clinical reviews will they be reviewing? Inpatient, outpatient, behavioral health, etc. Apply Policies & Guidelines: Utilize CareSource Medical Policy and Milliman criteria; issue administrative denials and refer medical necessity cases to medical directors. Collaborate & Communicate: Work with medical directors, pharmacists, and internal teams; communicate outcomes clearly to members, providers, and state agencies. Documentation & Compliance: Maintain accurate clinical rationale and ensure adherence to regulatory and organizational standards. Support Quality & External Reviews: Assist in preparing cases for Independent External Review and contribute to quality improvement initiatives. Maintain Expertise: Participate in ongoing training to stay current with clinical and regulatory requirements.
Location: Remote Company: BoardCerts Job Type: Contract, Temporary Title: Remote RN for Board Certification Review Question Bank JOB DESCRIPTION: We are seeking Registered Nurses to join us as Board Certification Review Question Bank Editors. In this role, you will be responsible for reviewing and editing practice questions to ensure they meet the highest standards of quality, accuracy, and relevance for nurse leaders preparing to pass the certification exams.
QUALIFICATIONS: A valid and current US Nursing License is required.
Question Bank Review: Evaluate and refine practice questions on nursing topics for the question banks. Content will be provided, and your primary task will be to ensure alignment with certification standards and the exam content outline. Content Accuracy: Verify that all questions are accurate, relevant, and reflect the latest practices and guidelines in nursing leadership and management. Quality Assurance: Ensure all questions are clear, well-formatted, and meet board standards for quality and rigor. Feedback Integration: Incorporate input from certification candidates and other stakeholders to continuously enhance the question bank's effectiveness.
Ruby Health is redefining how healthcare supports aging and complex populations; not only in what we do, but how we do it. Our vision is bold: to build a first-of-its-kind, human-first, tech-enabled care model that helps patients thrive at home and avoid unnecessary hospitalizations. We focus exclusively on patients who are complex enough to require in-home nursing care, partnering with Home Health Agencies to ensure patients have more days at home. As a startup, we move fast, think creatively, and value people who want to help shape something new. We’re not inheriting legacy systems; we’re building the future. Every team member helps design, iterate, and grow. If you’re a nurse who thrives at the top of your license, believes in proactive care, and is ready to help design care delivery from the ground up, this is your moment.
The Quality Review Nurse is a critical member of Ruby Health’s clinical team, responsible for driving quality improvement across the organization. This role sits at the intersection of clinical oversight, staff development, and operational excellence, ensuring that our care delivery meets the highest standards and that our team has the support and tools they need to perform at their best. This role is ideal for a clinically strong nurse with a quality mindset who understands that consistent, well-documented care is what enables safe outcomes at scale. You’re not just reviewing charts; you’re helping shape how care is delivered and continuously improved across the program. Other Information: This role will primarily be work from home with regular but very modest in-person collaboration expectations. Ruby requires reliable internet and the ability to participate in video-based meetings and team calls. Ruby Health is proud to be an equal opportunity employer. We welcome diversity and are committed to creating an inclusive environment for all employees.
An RN with strong clinical judgment and a quality-focused mindset Experienced in clinical quality, care management, home health, or a similar complex care environment Skilled in documentation review, audit processes, and performance improvement methodology A confident educator and communicator who can develop training and hold clinical standards with clarity and care Proactive and comfortable with change; you think like a builder, not a follower Comfortable with technology, AI-enabled tools, and EMR navigation Collaborative and solutions-oriented with a flexible mindset Passionate about helping patients age safely at home Preferred Qualifications: 3+ years of experience in clinical quality, care management, home health, or ambulatory complex care BSN preferred Experience with Medicare, Medicare Advantage, or Medicaid populations Familiarity with value-based care and transitional care principles Background in staff education, onboarding, or clinical training program development
Quality Improvement: Conduct record reviews and clinical audits to identify opportunities for improvement in quality indicators Identify performance improvement opportunities related to structure, process, and outcomes of patient care coordination Audit clinical documentation and call recordings to evaluate accuracy, completeness, and adherence to standards Perform clinical review and auditing of AI agents and their outcomes, ensuring alignment with clinical protocols and patient safety expectations Staff Development & Education: Develop and implement staff orientation and onboarding processes that set clear expectations and build clinical confidence Design and deliver staff education programs in response to identified quality gaps and organizational learning needs Serve as a clinical resource and point of consultation for nursing staff across the team Policy & Standards: Develop and implement clinical policies and procedures that reflect current evidence, regulatory requirements, and Ruby’s care model Participate in team huddles, case reviews, and program development conversations to help refine and improve our approach as we scale Collaborate with the Clinical and Engineering teams to share insights and help shape new workflows and standards Documentation & Operations: Ensure accurate and timely documentation within Ruby’s EMR Support care transitions, quality monitoring, and escalation processes as a senior clinical voice
TAP Health MSO is revolutionizing Adult Primary Care with a focus on proactive, preventive health. Our vision is to rebuild the critical relationship between members (patients) and clinicians, offering personalized, lifelong healthcare solutions. We aim to move beyond the outdated "sick-care" model and instead promote wellness, vibrancy, and well-being. TAP Health MSO offers affordable Direct Primary Care at a fraction of current insurance costs, creating a sustainable, member-focused, and innovative healthcare system. Join us in transforming how Adult Concierge Primary Care is delivered for everyone—everywhere.
We are seeking part-time Virtual Nurse Practitioners based in the USA to provide exceptional remote care and support to our members. In this role, you will conduct comprehensive medical evaluations, diagnose illnesses, develop treatment plans, and educate members to promote preventive care. You'll utilize virtual tools and technologies to deliver care, collaborate closely with a multidisciplinary team, and ensure continuity in patient-provider relationships. The positions require a commitment to prioritizing patients' well-being and delivering top-tier healthcare services.
Clinical skills including member assessment, diagnosis, and formulating treatment plans. Expertise in Preventive Care, Chronic Disease Management, and Transitional Care Management. Strong communication skills to educate and encourage our members effectively. Experience in using virtual care tools and electronic health recording systems is preferred. Active Nurse Practitioner (NP) or Physician Assistant (PA), in any state Commitment to patient-centered care and innovation in healthcare delivery. Experience in Primary Care, Internal Medicine, Family Practice, or Functional Medicine is preferred. Remote Nurse Course Certificate from Marie Peppers of Remote Learning Services is preferred. Currently, we are taking applicants for our future openings. We will eventually be needing NPs/PAs in all 50 states. We are unable to take applications from NPs or PAs with only a Pediatrics or Maternal Health/OB background.
Medix provides workforce solutions to clients and creates opportunity for talent in the Healthcare, Life Sciences, Engineering and Technology fields. Through our core purpose of positively impacting lives, we have earned our reputation as an industry leader by providing unsurpassed customer service and top quality professionals to our clients.
Utilization Management RN – Inpatient Appeals (Remote | Contract) Equipment - need to have their own equipment - Laptop (windows OS) & extra monitor Contract: until Nov 2026 We’re partnering with a growing Medicare Advantage health plan seeking experienced Utilization Management RNs to support inpatient appeals during a period of rapid expansion and increased case volume. This is a high-impact, fast-paced role ideal for nurses who can step in quickly, think critically, and produce strong, defensible clinical determinations with minimal ramp time.
Active, unrestricted RN license 3+ years of Utilization Management experience Direct inpatient appeals experience (payer/health plan required) Strong knowledge of InterQual and/or MCG criteria Proven ability to write clinical justifications for appeals Ability to work independently in a high-volume environment Nice to Have: Medicare Advantage experience Exposure to appeals & grievances processes Experience with complex/escalated cases Background in both hospital and payer settings Key Strengths for Success Strong clinical judgment & analytical thinking Clear, concise documentation skills High attention to detail Confident, independent decision-making Ability to balance quality with productivity Comfortable navigating pushback and escalations Process-driven and compliance-focused mindset What Success Looks Like: Independently managing inpatient appeals with minimal oversight Producing clear, defensible determinations Maintaining strong productivity and accuracy Helping reduce appeals backlog quickly
Review inpatient cases at the appeals level (post-denial) Evaluate medical necessity, level of care, and length of stay Apply InterQual and/or MCG (Milliman) criteria Develop clear, defensible clinical rationales (uphold or overturn) Ensure compliance with Medicare Advantage and regulatory guidelines Collaborate on complex or escalated cases Maintain accurate and timely documentation Manage a consistent caseload while meeting productivity expectations
A growing network of remote healthcare organizations is seeking Nurse Practitioners to provide virtual care across multiple specialties, including primary care, psychiatry care womens health, wellness, and acute telehealth consults. Whether you’re looking for flexible part-time telemedicine work or a full-time remote opportunity, there’s a position that fits your lifestyle and clinical strengths.
Active Nurse Practitioner license in at least one U.S. state (multi-state preferred) FNP, AGNP, PMHNP, ENP, ANP, or WHNP certification accepted Strong communication and patient-centered care skills Comfortable using telehealth platforms and EMRs New graduates welcome to apply
Conduct virtual consultations for wellness, chronic care, or acute conditions Manage patient assessments, prescriptions, and follow-ups via telehealth Collaborate with experienced clinical and administrative support teams Choose from contract, part-time, or full-time opportunities Enjoy flexible scheduling — work when it fits your life
Skilled private LVN needed for a prominent individual in Bel Air, CA! MUST have at least five years of experience as an LVN for a private client with a valid LVN license. MUST have excellent communication skills and be able to work 3 days during the week (Monday, Wednesday, and Thursday) AND every other weekend. Shift is 12 PM to 8 PM.
Duties include but are not limited to–full patient care, administering medication as directed by the doctor, assisting with bathing/changing, and physical therapy/activities. LVN also needs to drive patient to necessary appointments and destinations, do light meal prep, and assist with feeding.
Job Title: Personal Financial Strategist Location: Remote Employment Type: Part-Time or Full-Time (1099 Commission Based) Experience Level: No Prior Financial Experience Required Full Training Provided About the Opportunity: Are you looking to take your people skills, work ethic, and leadership experience into a career with flexibility, purpose, and unlimited growth potential? We are expanding our national team and seeking motivated individuals with backgrounds in Health Care who are ready to build a new professional path. Your Health Care experience has already equipped you with the discipline, communication skills, and reliability needed to succeed in this role. This is not an internship or a short-term side job it’s a career building opportunity with structured training, mentorship, and a clear path for growth.
Excellent interpersonal and communication skills. Reliable, self motivated, and comfortable in performance based roles. Coachable, with a strong desire for personal and professional growth. U.S. Citizen Willing to obtain financial licenses within 30 days (training provided). Ability to pass a background check. This Opportunity Is Not a Fit If You: Are a full-time student or require visa sponsorship. Are seeking short-term or hourly employment. Prefer a salaried, clock-in/clock-out position.
Educate individuals and families on strategies to build wealth, protect income, and secure their legacy. Guide clients through tailored financial solutions, including life insurance, retirement strategies, investments, and tax advantaged planning. Build and manage your own client base, with ongoing support from experienced mentors and leaders. Utilize a proven, duplicatable system to grow your business, income, and impact. Develop leadership skills and the opportunity to build and lead your own team.
OpenLoop was co-founded by CEO, Dr. Jon Lensing, and COO, Christian Williams, with the vision to bring care anywhere. Our telehealth support solutions are thoughtfully designed to streamline and simplify go-to-market care delivery for companies offering meaningful virtual support to patients across an expansive array of specialties, in all 50 states.
OpenLoop is looking for a Medical Director to join our team. In this role, you will be responsible for serving as a member of the Clinical Operations Team, reporting to the Chief Medical Officer (CMO), and working with and managing our talented and growing group of providers (largely 1099) to ensure the delivery of safe, effective telehealth care across a wide variety of clients and clinical conditions.
Licensed and board certified nurse practitioner (NP) degree required. 5+ years of management of nurse practitioners (NPs) or other healthcare professionals at a similar level in a US health system within the past 3 years or recent relevant experience required. Prior experience in virtual care required. Prior experience in clinical operations (or working closely with operations teams) required. Availability to work extended hours and certain weekends. Active unrestricted medical license in at least 10 states within the United States is recommended. Prior experience leading clinical teams, preferably with educational experience and/or strategic planning experience. Prior experience in clinical quality management is a plus. Prior experience with clinical and operational data analysis is a plus. Computer proficient with Google Suite, Zoom, Zoho, Notion, Slack and other similar platforms. Able to quickly adapt to new technologies, such as software and operating systems. Excellent verbal and written communication skills. Ability to work cross-functionally across multiple teams and stakeholders. Team player. Able to quickly pivot as needed in a rapidly growing startup environment. Passionate about motivating and growing a successful team.
Work alongside other members of the clinical and operations leadership teams to ensure the delivery of safe, effective, and compassionate care via telemedicine to patients across the country for a wide variety of conditions. Manage and lead a team of nurse practitioners (NPs), registered nurses (RNs), and registered dieticians (RDs) in an environment of rapid growth. Participate in recruitment initiatives for the above teams. Establish recurring 1:1s with leaders of the above groups. Work alongside clinical and operations leadership to maintain quality, productivity, and performance improvement to promote practice growth and development. Work alongside clinical and operations leadership to create and support a positive work culture for OpenLoop’s providers. Engage with clinical leadership regularly to provide clinical and operational insight - including reviewing and providing input into guideline and operational SOP development, education and training, quality, and product enhancements. Maintain the clinical standards via which the above groups are recruited. Identify areas of process improvements and inefficiencies. Be willing and able to engage in direct virtual patient care (both asynchronous and synchronous) across a variety of service lines. Client engagement as necessary. Ability to effectively communicate expectations, motivate individuals, foster collaboration between departments, and demonstrate a proven ability to provide positive leadership that supports teamwork. Other duties as assigned.
OpenLoop was co-founded by CEO, Dr. Jon Lensing, and COO, Christian Williams, with the vision to bring care anywhere. Our telehealth support solutions are thoughtfully designed to streamline and simplify go-to-market care delivery for companies offering meaningful virtual support to patients across an expansive array of specialties, in all 50 states.
OpenLoop’s mission is to bring care anywhere by powering telehealth solutions at scale. This is an incredible opportunity to support the Clinical Quality team in a fast-paced, innovative company that puts the patient at the center of everything we do. This role is for a clinical care professional with a demonstrated passion for clinical quality and exceptional attention to detail. This pivotal Registered Nurse role offers a unique opportunity to contribute to OpenLoop's commitment to clinical excellence. Supporting the Director of Quality, you will help drive key initiatives that optimize clinical outcomes, ensure adherence to best practices, and maintain high standards of patient care. This role leverages your clinical expertise and analytical skills to support continuous quality improvement across programs and enhance the safety and effectiveness of care delivery.
5+ years of clinical experience (telemedicine, acute care, or case management preferred). Strong understanding of clinical quality principles and best practices. Excellent attention to detail and analytical skills. Experience with data tracking and reporting. Strong communication and collaboration skills. Proactive, solution-oriented mindset with a focus on continuous improvement. Experience in quality assurance, training, or operations is a plus. Strong organizational skills with the ability to manage multiple priorities. Proficient with telehealth technology and EHR systems. Ability to troubleshoot technical issues and support others. Commitment to high-quality, patient-centered care. Ability to work independently and in a fast-paced team environment. Professional, reliable, and timely. Telemedicine or virtual care experience preferred.
Collaborate closely with the entire team to provide essential support in key areas. Conduct in-depth Root Cause Analyses (RCAs) of submitted incident reports, employing a meticulous and systematic approach to identify underlying factors. Develop actionable improvement strategies based on RCA findings. Provide targeted outreach to providers, focusing on education and feedback. Track individual provider quality metrics to support performance improvement initiatives. Assist the Director in overseeing all quality initiatives to ensure consistent high-quality care across the organization's diverse programs. Develop a comprehensive understanding of all program operations and their unique requirements. Conduct regular audits to verify clinical compliance with established treatment protocols. Monitor adherence to service level agreements to ensure quality standards are met. Monitor and analyze both provider and patient satisfaction data to identify areas for improvement in care delivery. Contribute to ensuring consistent adherence to established standards of care among all clinicians. Assist in overseeing and developing a robust system for tracking laboratory results and other critical clinical elements, tailored to the specific needs of each program. Collaborate with program leadership to define essential data points and establish efficient tracking mechanisms. Serve as a vital liaison between the company and clients, effectively addressing provider-related concerns and patient complaints regarding providers in a professional and timely manner. Utilize strong communication and problem-solving skills to ensure positive resolutions and maintain strong client relationships. Serve as an integral member of an interdisciplinary care team, collaborating effectively with colleagues to deliver exceptional patient care. Maintain confidentiality and adhere to HIPAA regulations when handling patient information. Participate in ongoing training and professional development activities to stay updated on survey protocols, healthcare regulations, and best practices. Meet productivity targets and quality standards established by the organization. Participate in training and onboarding. Complete additional project work as assigned to support continuous improvement of team operations and patient experience. Other duties as assigned.
TimelyCare is a clinically accountable virtual care provider built specifically for education. Trusted by nearly 500 campuses across the U.S., TimelyCare combines URAC-accredited clinical standards with a measurement-based approach and a partnership-first model to help institutions champion well-being with clarity, accountability, and real-world impact. Through a seamless, easy-to-access platform, TimelyCare offers a comprehensive range of services, including a crisis line, mental health counseling, on-demand emotional support, medical care, psychiatric care, health coaching, success coaching, basic needs assistance, faculty and staff guidance, peer support, and self-guided wellness tools. TimelyCare drives clinically validated improvements in depression and anxiety, supporting healthier learning environments.
Under the general supervision of the Executive Director of Medical Services, we are currently looking for a Telehealth Medical Nurse Practitioner, who will provide clinical evaluation, assessment, and treatment of our members (students, faculty & staff) who use the TimelyCare platform. While all qualified candidates are encouraged to apply, significant preference will be given to those with 40+ licenses to serve broader outreach. Location: We offer a remote work environment. Work from home criteria includes but is not limited to maintaining your own internet with approved speed requirements, a secure and HIPAA compliant workspace free from distractions, and successful completion of the credentialing, onboarding, and training programs. Adherence to HIPAA, compliance standards, and all policies/procedures are required for this role. Schedule: This full-time role averages 40 clinical hours per week. Coverage options are as follows: Option 1: Weekend coverage: Friday, Saturday and Sunday with shifts occurring between the hours of 6:00 a.m. – 11:00 p.m. CST Option 2: Evening coverage: Monday through Friday primarily with shifts occurring between 12:00 p.m. – 12:00 a.m. CST
Current licensure as a Board Certified Nurse Practitioner (NP) (30 + state licenses required, 40 + state licenses preferred) Nursing Compact License Individual NPI number Active Prescriptive Authority to Prescribe Medications Strong Communication and Diagnostic Skills Independent practice authority in CA preferred
Provide synchronous/asynchronous clinical evaluation, assessment, and treatment of patients, in states of licensure Prescribe appropriate medication(s), if indicated Appropriate documentation of encounter in EHR (platform)
Job Title: Utilization Management Nurse (RN/LPN) – Clinical Appeals & Authorization (MUST HAVE NY RN LICENSE) Position Type: Full-Time Schedule: Monday–Friday, 40 hours per week Position Overview: We are seeking an experienced Utilization Management Nurse (RN/LPN) to support clinical review operations, appeals processing, and authorization management across inpatient, outpatient, and ancillary services. This role is responsible for evaluating medical necessity, determining appropriate level of care (LOC) and length of stay (LOS), and ensuring compliance with CMS, Medicare/Medicaid, and state regulatory requirements. The ideal candidate will bring strong clinical judgment, UM experience, and the ability to work collaboratively with providers, physician advisors, and external review agencies to ensure high-quality, compliant care management outcomes.
Required Qualifications: Active, unrestricted RN or LPN license Minimum 3+ years of experience in Utilization Management, Discharge Planning, or Clinical Appeals Strong knowledge of CMS (Medicare/Medicaid) guidelines and state-mandated appeal timelines Proven clinical judgment with the ability to recognize cases requiring escalation Required Technical Skills Decision Support Tools Strong working knowledge of InterQual or MCG for level-of-care determinations UM/Appeals Systems Experience with enterprise clinical platforms such as HealthEdge, Jiva, Salesforce Health Cloud, or similar systems Reporting & Data Interpretation Ability to analyze pharmacy claims, encounter data, and HRA databases Regulatory Portals Experience using secure portals for transmitting files to state and federal external review agencies Preferred Qualifications: Certified Case Manager (CCM) certification ABQAURP certification Experience with Medicare Advantage, Managed Long-Term Care (MLTC), or Special Needs Plans (SNP) Prior experience handling External Appeals and working with regulatory bodies such as DOH or CMS Specialized clinical background in Behavioral Health, Oncology, or Complex Surgical Services Experience conducting internal UM quality audits for NCQA or URAC compliance Bilingual proficiency in a second language preferred
Utilization Management Operations: Perform inpatient admission certification, concurrent review, and outpatient/ancillary service authorizations Ensure all UM activities follow established clinical protocols, regulatory standards, and organizational policies Clinical Determination: Review cases for medical necessity, appropriate level of care (LOC), and length of stay (LOS) Utilize InterQual, CMS/Medicare Guidelines, and internal medical policies for evidence-based decision making Identify cases requiring escalation to Physician Advisors or Medical Directors Appeals Processing: Conduct clinical review of appeals against established criteria and regulatory requirements Prepare clinical summaries and recommendations for Physician Advisor review Ensure all appeal determinations meet strict turnaround times (TAT) External Liaison Coordination: Coordinate with External Review Agencies (ERA) and Clinical Peer Reviewers Ensure timely transmission of all external cases and proper documentation of final determinations within the system Documentation & Compliance: Maintain accurate and detailed records of clinical findings, review actions, and decision rationales Ensure documentation supports audit readiness and compliance with NCQA, URAC, CMS, and state requirements Member & Provider Engagement: Serve as a clinical liaison with Primary Care Physicians (PCPs) to obtain necessary medical documentation Communicate appeal outcomes and recommend appropriate treatment alternatives to members and providers Trend Analysis: Analyze pharmacy claims, encounter reports, and health risk assessments (HRA) to identify utilization trends and member care needs Support proactive interventions to improve care outcomes and cost containment
NPHire connects top NP talent with leading healthcare employers and staffing agencies. We're the only job-matching platform built exclusively for Nurse Practitioners, simplifying both the job search and the hiring process so the best match rises to the top every time.
A respected national telehealth network is expanding and hiring Nurse Practitioners for multiple fully remote roles across the U.S. These positions support a wide range of virtual care services: from acute care visits to primary care, women’s health, wellness, chronic care, and evidence-based lifestyle medicine. 🌎 Whether you're a new graduate seeking your first telehealth role or an experienced NP looking for flexible, high-paying remote opportunities, NPHire has nationwide openings that match every schedule, specialty, and career goal.
Qualifications: Active NP license in at least one U.S. state (multi-state a plus) FNP, AGNP, WHNP, ANP, or similar certification Strong communication and independent clinical decision-making skills Telehealth experience preferred — but training offered for new grads Ability to work autonomously in a fully remote setting
Conduct scheduled or on-demand virtual visits for acute, primary, or wellness-focused care Perform patient assessments, develop treatment plans, and prescribe when appropriate Manage follow-ups, messaging, and EMR documentation through modern telehealth platforms Provide compassionate, patient-centered care across diverse populations Collaborate with supportive clinical and operations teams as needed
Empower AI is AI for government. Empower AI gives federal agency leaders the tools to elevate the potential of their workforce with a direct path for meaningful transformation. Headquartered in Reston, Va., Empower AI leverages three decades of experience solving complex challenges in Health, Defense, and Civilian missions. Our proven Empower AI Platform® provides a practical, sustainable path for clients to achieve transformation that is true to who they are, what they do, how they work, with the resources they have. The result is a government workforce that is exponentially more creative and productive. For more information, visit www.Empower.ai. Empower AI is proud to be recognized as a 2024 Military Friendly Employer by Viqtory, the publisher of G.I. Jobs. This designation reflects the company’s commitment to hiring and supporting active-duty and veteran employees.
Empower AI: As a casual Medical Review Specialist III (Medicare DRG) for Empower AI, Inc., you will perform Medicare comprehensive medical record and claims review to make payment determinations for Diagnosis Related Group (DRG) claims. Perform projects or duties as assigned as a Medical Review Specialist. You will serve as a critical component in meeting our mission of providing excellent services to our clients. Your experience ensures an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. In assuming this position, you will be a critical contributor to meeting Empower AI’s mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments.
Requirements: Must be a Registered Nurse obtained by either a Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing. At least four (4) years claims knowledge either from billing, reviewing, or processing of Durable Medical Equipment. At least three (3) years clinical experience as a Registered Nurse. Minimum two (2) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Physician Office practices, Laboratory, and Ambulance Services. Current licensure as a Registered Nurse in one or more of the 50 states or D.C. Ability to keep sensitive and confidential material private. Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program and must have no conflict of interest (COI). Preferred Education and Experience: Physician Office, Hospital, Suppler, or Clinic providing DME equipment care/services Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus! Physical Requirements: This position requires the ability to perform the below essential functions: Sitting for long periods Standing for long periods
Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare DRG. Performs first level of Medical Review in determination of claims payment review Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles Utilize electronic health information imaging and input medical review decisions by electronic database module. Utilize internet and intranet sources for policy verification. Utilize Microsoft Office suite and other software templates as associated source input for claims review. Make clinical judgment decisions based on clinical experience when applicable. Responsible for review of Medicare DRG claims. Meeting quality and production standards. Ensuring departmental compliance with quality managements system and ISO requirements. Completes other projects or duties assigned by the Medical Review Lead Specialist
Are you a Registered Nurse or Nurse Practitioner who's passionate about helping families - but seeking a career that offers freedom of time, less burnout and long term financial stability? You're not alone. You'll be trained and supported by a team made up primarily of fellow medical professionals. This is a fully remote, work-from-home opportunity as a Financial Professional—ideal for Nurses (RNs/NPs) looking to transition or diversify. Flexible Schedule | Part-Time or Full-Time | Not a Nursing Position High Income Potential | Full Training Provided & Mentorship
Why Nurses Thrive as Financial ProfessionalsNurses are naturally positioned to succeed in the financial industry because of the qualities and skills they already possess: Empathy & Care – Just like in healthcare, financial services require deep care for people’s well-being. Nurses already lead with heart, making them trusted advisors in both health and wealth. Strong Communication – Nurses are trained to explain complex medical information clearly to patients. That same skill translates powerfully into breaking down financial concepts for clients. Problem Solvers – Nurses are trained to assess, analyze, and respond quickly. In financial services, they use those same instincts to guide clients toward solutions that protect and grow their assets. Service-Driven Mindset – The profession is rooted in service—and that doesn’t change. Nurses find deep fulfillment helping families not just heal, but thrive financially. Respected & Trusted – Nurses hold one of the most trusted roles in society. That reputation carries into financial services, where trust is everything.
What You’ll Do:Educate individuals and families on key financial concepts such as income protection, retirement planning, debt management, and wealth building Guide clients through life’s transitions—whether it’s protecting a new baby, preparing for college, or planning for retirement Build genuine, trust-based relationships with clients through empathy, education, and integrity Collaborate with a team of professionals (many with medical backgrounds like yours) for ongoing training, mentorship, and support Maintain and grow your own client base with flexible scheduling—full-time or part-time
Medix provides workforce solutions to clients and creates opportunity for talent in the Healthcare, Life Sciences, Engineering and Technology fields. Through our core purpose of positively impacting lives, we have earned our reputation as an industry leader by providing unsurpassed customer service and top quality professionals to our clients.
Job Title: Clinical Review RN (IDR/Appeals) Experience: Open to various clinical backgrounds/experience. Appeals experience not required. Must have 2+ years of clinical experience post graduation, must has critical thinking and problem solving skills. ***Must have BSN and New York State RN license*** Location: Remote (can sit anywhere in the US as long as you can work EST hours) Hours of Operation: M-F 7a-5:30p *flexible start between 7am-9am (40hrs/wk) Start date: ASAP Pay: $50-53/hr DOE GENERAL RESPONSIBILITIES: This individual will complete the full spectrum of activities related to State and Federal Independent Dispute Resolution (IDR) case determinations. They will conduct clinical level review, Prior Authorization, and disputed benefits review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.
Knowledge and experience with electronic medical records. Ability to oversee, problem solve, and work collaboratively with peers, medical, analytical, and administrative support staff. Excellent written and verbal skills. Ability to work independently with little supervision. Ability and desire to be flexible, innovative, and creative. Ability to meet deadlines in a time sensitive environment. EDUCATION AND EXPERIENCE: Licensed, Registered Nurse in NYS, required. BSN required OR bachelor's degree + ASN is acceptable Minimum of two years’ experience in a clinical setting, required
Conduct reviews up to and including the appeal level. This includes chart screen, compiling regulatory guidance, researching insurer requirements, complete electronic worksheets and preparing final determinations. Act as a resource for the administrative and clinical staff in training, problem solving, and clarifying determinations. Will provide technical assistance and conduct/participate in staff huddles. Training and mentoring new RNs as the project expands. Claims assessment and adjudication. Participate in collaborative training. Other activities as may be deemed necessary.
Nsight Health is transforming how care is delivered through Remote Patient Monitoring (RPM), Chronic Care Management (CCM), and Behavioral Health Integration (BHI). We empower healthcare providers to manage chronic conditions using real-time data, AI-enabled technology, and 24/7 clinical support. Our HIPAA-compliant platform connects patients and care teams nationwide—improving outcomes, adherence, and peace of mind. Join a fast-growing, mission-driven team that blends healthcare and technology to make a measurable difference in people’s lives. Nsight Health — Where Technology Meets Compassion.
Schedule: This position operates on a 4-day work week structure, consisting of 10-hour shifts. Must be available to work rotating holidays throughout the year. Requires mandatory coverage of a minimum of two (2) weekends per month. Training Requirements: All New Hires Must Complete a Comprehensive Training Program Duration: Five weeks Schedule: Monday through Friday, 9:00 AM – 6:00 PM Eastern Time Attendance is mandatory to ensure readiness prior to independently supporting patients. Compensation & Benefits Competitive base pay of $24-$26 per hour. Shift Differentials Evening Differential: +$1.50/hour for hours worked after 7:00 PM ET Late-Night Differential: +$2.00/hour for hours worked after 10:00 PM ET Weekend Differential: +$1.50/hour for all hours worked Saturday and Sunday Shift differentials are paid in addition to base hourly wages and reflected in the applicable payroll cycle.
Required: Active LVN/LPN license required Proficient with computers, EMRs, and telehealth tools Strong communication and organizational skills Bilingual Proficiency: Fluent in English and Spanish Preferred: At least 1 year of nursing experience preferred (RPM, telehealth, or chronic care experience is a plus) Work From Home Requirements Minimum internet speed of 50 Mbps download / 10 Mbps upload Hardwired internet connection required Speed test submission required during the offer process Private, HIPAA-compliant workspace
Conduct outbound phone calls to check in on patients and address health concerns (expected call volume ranges from 70 to 90 calls per day) Handle inbound phone calls and route appropriately based on clinical urgency Route non-clinical inbound calls to the appropriate departments across the company Monitor and respond to Remote Patient Monitoring (RPM) alerts, escalating concerns when clinically indicated Collaborate with providers to coordinate timely and effective patient care Perform monthly wellness assessments and complete comprehensive chart reviews Accurately document all patient interactions in our clinical platform in real time Consistently meet or exceed individual and team performance metrics related to care quality, patient engagement, response times, and adherence to protocol standards Maintain compliance with company policies and applicable regulations Perform other duties as assigned AI Fluency Requirement – Non Negotiable Nsight is an AI-first organization. Every member of our team is expected to actively use AI tools in their day-to-day work — not as a novelty, but as a core productivity multiplier. This role requires genuine curiosity about AI, comfort experimenting with tools like Claude, ChatGPT, and workflow automation platforms to support clinical documentation and care coordination tasks, and the judgment to know when AI helps and when it doesn't. If AI makes you uncomfortable, this is not the right role.
Health Advocate is the nation’s leading provider of health advocacy, navigation, well-being and integrated benefits programs. For 20 years, Health Advocate has provided expert support to help our members navigate the complexities of healthcare and achieve the best possible health and well-being. Our solutions leverage a unique combination of best-in-class, personalized support with powerful predictive data analytics and a proprietary technology platform to address nearly every clinical, administrative, wellness or behavioral health need. Whether facing common issues or an unprecedented challenge like COVID-19, our team of highly trained, compassionate experts work together to go above and beyond expectations, making healthcare easier for our members and ensuring they get the care they need.
Registered Nurse - Personal Health Advocate Your Mission: What Success Looks Like Your primary accountability is to deliver high-quality, member-centered clinical advocacy while meeting service, quality, and case management standards. Work Schedule: Monday-Friday 11am-7:30pm EST. OR 12:30pm-9:00pm EST. Pay: $37 per hour
Who You Are: The Leader We’re Looking For You are an experienced nurse who brings clinical judgment, behavioral health expertise, composure, and accountability to every interaction. You naturally demonstrate: Ownership and follow-through You take responsibility for member outcomes and see cases through with care and precision. Empathy grounded in professionalism You listen deeply and respond with compassion while maintaining clarity, confidence, and appropriate boundaries. Strong critical thinking You quickly synthesize clinical information, prioritize what matters, and determine effective next steps. Clear and confident communication You explain complex medical and insurance concepts in a way members can understand and trust. A commitment to quality and results You are motivated by accuracy, meaningful resolution, and delivering an exceptional member experience. Curiosity and continuous learning You stay current on healthcare trends, systems, and procedures to provide thoughtful, informed guidance. You thrive in active environments where your expertise is trusted, your work has visible impact, and excellence is supported. Minimum Qualifications Education: BSN or RN degree from an accredited college or university (required) Licensure: Active and unrestricted State or Multi-State Registered Nurse license (required) Experience: Minimum 5+ years of clinical and/or medical management experience Core Skills: Strong understanding of medical terminology and healthcare systems Excellent verbal communication skills and professional phone presence Ability to explain complex healthcare topics to diverse populations Highly effective listening, problem-solving, and issue-resolution skills Strong organizational and administrative abilities Proficiency with Microsoft Word and Excel Ability to work effectively in a collaborative, remote team environment Team Interface & Customer Service: Establish and maintain professional relationships with internal and external customers Collaborate with team members to meet departmental goals Deliver customer service that consistently exceeds expectations Treat all individuals with dignity, respect, and professionalism Escalate workflow or communication issues to leadership as appropriate Mental and Physical Requirements: This position is fully remote and requires a dedicated, HIPAA-compliant workspace with reliable internet access. The nature of the work is sedentary, involving prolonged sitting and continuous computer and phone use. Essential functions include repetitive motion, typing, concentration, reading, and ongoing verbal and written communication throughout the workday.
Member Advocacy & Clinical Guidance: Receive inbound member calls related to a wide range of healthcare issues (e.g., infertility, chronic disease, medications, diagnoses) Assess needs and determine the best course of action while adhering to established policies, procedures, and performance indicators (KPIs) Take ownership of member cases by going beyond the initial request and encouraging continued engagement Education, Trust & Relationship-Building: Educate members on their medical conditions, diagnostic testing, test results, and available treatment options Explain complex medical and benefit-related information clearly and compassionately Build trusted relationships that empower members to actively participate in their healthcare decisions Care Coordination & System Navigation: Provide members with options for healthcare providers and services based on clinical needs, geographic location, and benefit coverage Research providers through credentialing, education verification, and affiliations with recognized medical centers Facilitate communication between members, treating physicians, and insurance carriers Assist with scheduling and re-scheduling appointments, transferring medical records, resolving access issues, and clarifying benefit provisions Intercede on behalf of members to obtain earlier appointments or remove barriers to care Support members with prescriptions, pre-service fee negotiations, and authorization-related challenges Case Management, Documentation & Follow-Up: Maintain accurate, timely documentation using approved case management systems and procedures Place outbound follow-up calls when issues cannot be resolved during the initial interaction Respond to delegate box, answer service, and after-hours calls as required Escalate cases appropriately and on a timely basis to supervisors or internal clinical resources Strong technical proficiency. You are comfortable navigating multiple systems, documenting in case management platforms, and using technology to work efficiently in a fully remote healthcare environment. You adapt quickly to new tools and maintain accuracy while managing digital workflows. Professional Growth & Team Contribution: Stay current on patient care procedures, diagnoses, authorizations, denials, and evolving healthcare practices Mentor and support new team members as needed Collaborate with colleagues to maintain service excellence and balanced workflows Related Duties as Assigned: This job description describes the general nature and level of work performed and is not intended to be a comprehensive list of all activities, duties, or responsibilities. Job incumbents may be asked to perform other duties as required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions outlined above. Please contact your local Employee Relations representative to request a review of accommodations.
At Enlyte, we combine innovative technology, clinical expertise, and human compassion to help people recover after workplace injuries or auto accidents. We support their journey back to health and wellness through our industry-leading solutions and services. Whether you're supporting a Fortune 500 client or a local business, developing cutting-edge technology, or providing clinical services you'll work alongside dedicated professionals who share your commitment to excellence and make a meaningful impact. Join us in fueling our mission to protect dreams and restore lives, while building your career in an environment that values collaboration, innovation, and personal growth. Be part of a team that makes a real difference.
This is a full-time (40 hours per week), fully remote position with a Sunday through Thursday schedule, 5:00 AM - 1:30 PM CST. Qualified candidates must be located in a Compact state and hold a Compact RN License in the state in which you reside. Bilingual Spanish/English Language Skills Are Preferred. The Worker’s Compensation Telephone Triage Clinician position provides inbound telephone triage services remotely to injured workers while following the individual state Worker Compensation rules and regulations. Uses clinical expertise and communication skills to triage, consult, and provide recommendations for emergent and non-emergent situations. Focuses on conveying compassion and ensuring service excellence is centered on the injured worker.
Unencumbered RN License in state of residence required, compact state strongly preferred Minimum of three years’ recent RN experience in one of the following adult clinical areas: Telephone Triage, ER, Urgent Care, Medical Surgical Unit, Occupational Medicine Bilingual in Spanish Preferred Ability to obtain other state licenses as required with fees reimbursed Ability to function independently and learn in a virtual work environment Experience using Microsoft Office Suite 24 hour work week, schedules and shifts available dependent on the needs of the business, and schedules may include working every Saturday OR every Sunday This is a remote position and the successful candidate must have a safe and HIPAA compliant home office with high speed internet connection, verified by speed test.
Make safe decisions for appropriate care using critical thinking skills Use departmental evidence-based protocols to triage patients Build and maintain solid interdependent relationships within the team Maintain up-to-date knowledge and skill in professional, clinical, and system areas Demonstrate effective written and verbal communication skills
Nuvance Health is a system of award-winning nonprofit hospitals and outpatient healthcare services throughout the Hudson Valley and western Connecticut, including: Danbury Hospital and its New Milford campus, Norwalk Hospital and Sharon Hospital in Connecticut; Northern Dutchess Hospital, Putnam Hospital and Vassar Brothers Medical Center in New York. Nuvance Health offers the latest prevention, diagnostic, medical, surgical and rehabilitation services, including through the Cancer, Heart & Vascular and Neuroscience Institutes; and primary and specialty care services through Nuvance Health Medical Practices. Nuvance Health also provides convenient healthcare through home care, urgent care and telehealth visits.
PART TIME- 20 hours per week- Mon-Fri 8pm- 12am shift- Rotating weekends Hybrid/Remote Summary: The purpose of the Denial Prevention Nurse is to ensure that all patient admissions are appropriately status within the first 12-24 hours and that ongoing communication (electronic and telephonic) with payers ensures timely approval of all hospital days, preventing delays in reimbursement. This role plays a critical part in preventing payment denials by providing timely and accurate clinical information to all payers, while ensuring compliance with CMS requirements, guidelines, and standardized published criteria to support the medical necessity of patient admission and continued hospital stays. This role will require specialized system skills, best practice application of investigating payer practices, successfully challenging payers as they prevent obstacles and deny claims and escalating any egregious payer behaviors to internal leadership for assistance in resolution.
Education Skills Experience Bachelor’s Degree (BSN) is highly preferred. Minimum of Associate’s Degree in Nursing required when accompanied by strong demonstrated competencies and significant experience. Minimum of 5 years experience in acute care Nursing Proficiency in Milliman and InterQual Guidelines required Minimum of 2-3 years experience as Utilization Management Nurse in an acute care setting required, minimum of 4 years experience required for Associate’s Degreed individuals. PREFER: Master’s Degree in related field Required:Current RN License in Connecticut and New York InterQual/MCG proficiency testing completed (preferred); required within 1 year of hire. As certification becomes available, requirement will be revisited. Knowledge of regulatory requirements for CMS Have the positive attitude and aptitude to adapt to the continuing change in payer behaviors Recognizes that education is the responsibility of the individual as well as the organization Seeks external knowledge on payers (such as free email services as Becker’s) Must have analytical abilities to assist in obtaining solutions to problems Self-starter and highly motivated Must be able to work independently in a fast-paced environment, manage workload and prioritize work Must be able to manage multiple competing priorities and maintain calm professional demeanor during peak demand Must possess a high degree of prioritization skills Exceptional interpersonal skills to effectively communicate with the physicians, payers, and other members of the interdisciplinary care team Current working knowledge of utilization management, performance improvement and managed care reimbursement. Working Conditions Manual: Some manual skills/motor coord & finger dexterity Occupational: Little or no potential for occupational risk Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force Physical Environment: Generally pleasant working conditions
Review all inpatient admission and observation cases using InterQual, or Milliman Care Guidelines or CMS 2 Midnight Rule (depending on payer) within 12-24 hours of admission, seven days a week for assigned shifts. Complete an initial screening review within the first few hours of decision to admit from ED and communicate with appropriate Provider if initial status is to be re-considered. Identify incomplete clinical reviews in work queues and complete them within two hours whenever possible. If clinical information is not available by the time the lack of a review may result in a denial, escalate to the appropriate Provider/VPMA. Identify and complete clinical reviews required for submission to specific payers. Validate admission orders for all new admits/observations/outpatients daily. Ensure that the patient status order documented in the chart aligns with the MCG and/or InterQual criteria, or the CMS Two- Midnight Rule, to support the appropriate status and level of care. Prioritize review of all outpatient observation and outpatient bedded cases at least every 8 hours for conversion to inpatient status or discharge opportunities. Participate in daily Observation Huddles. Conduct concurrent reviews for all payers daily for the first three days of admission, then every 2-3 days, or more frequently if criteria are waning. Submit concurrent reviews to payers to ensure authorization of all days for per diem and percentage of charge reimbursement payers. If concurrent inpatient case does not meet medical necessity review criteria during the first level review, discuss with the attending MD to obtain additional clinical information and documentation to support inpatient level of care. If the case still does not meet, send to the Physician Advisor (PA) for a second level review. Forward cases that require secondary physician review to appropriate resource (e.g., Physician Advisor). Resolve any discrepancy at the time of review. If unable to resolve, escalate to the PA and Utilization Review (UR) Leadership. Coordinate with the care team in changing patient status, as needed. � Notify the care team when patient does not meet medical necessity per InterQual or MCG guidelines or 2 MN Rule and escalate appropriately. Document and proactively communicate relevant clinical information to payers for authorizations for treatments, procedures, and Length of Stay � submit clinical information as required by payers. Ensure completion and delivery of required patient notices (by onsite team member). These include but are not limited to: HINNs, Condition Code 44, MOON, Connecticut notice of conversion, etc. Tracking and trending all appeals and communicating on a daily/regular basis with the Denials Management team. Assists with informing Managed Care contracting team with necessary contractual language to protect organization financial position specific to inpatient medical necessity requirements. Employs creative solutions with team members and leadership to prevent denials. Performs other duties as assigned.
At Gallagher Bassett, we're there when it matters most because helping people through challenging moments is more than just our job, it’s our purpose. Every day, we help clients navigate complexity, support recovery, and deliver outcomes that make a real difference in people’s lives. It takes empathy, precision, and a strong sense of partnership—and that’s exactly what you’ll find here. We’re a team of fast-paced fixers, empathetic experts, and outcomes drivers — people who care deeply about doing the right thing and doing it well. Whether you're managing claims, supporting clients, or improving processes, you’ll play a vital role in helping businesses and individuals move forward with confidence. Here, you’ll be supported by a culture that values teamwork, encourages curiosity, and celebrates the impact of your work. Because when you’re here, you’re part of something bigger. You’re part of a team that shows up, stands together, and leads with purpose.
Provides medical management to workers compensation injured employees, performing case management through telephonic and in-person contact with injured workers and medical providers. Coordinates with employers and claims professionals to manage medical care in order to return injured employee to work. This position will cover the Bakersfield territory with a travel radius of up to 2 hours.
Required: Nursing or medical degree from an accredited institution with an active Registered Nursing license or medical license within the state of practice or states in which case management is performed. 2-4 years of work experience. Responsible for completing required and applicable training, in order to maintain proficiency and licensing requirements. Able to travel to appointments within approximately a 2 hour radius. Intermediate to advanced computer skills; Microsoft Office, Outlook, etc. Desired: Bachelor's degree preferred. Worker's Compensation experience is preferred. Certification in related field preferred. 1-3 years of clinical experience preferred. Work Traits: Demonstrates adequate knowledge of managed care with emphasis on use of criteria, guidelines and national standards of practice. Advanced written and oral communication skills, along with organizational and leadership skills. Self-directed and proactively manage assigned case files. Demonstrates strong time management skills.
Coordinating medical evaluation and treatment Meeting with physician and injured worker to collaborate on treatment plan and to discuss goals for return to work Keeping employer and referral source updated regarding medical treatment and work status Coordinating ancillary services, e.g. home health, durable medical equipment, and physical therapy. Communicates with employers to determine job requirements and to explore modified or alternate employment. Discusses and evaluates results of treatment plan with physician and injured worker using Evidence Based Guidelines to ensure effective outcome. Documents case management observations, assessment, and plan. Generates reports for referral source to communicate case status and recommendations. Generates ongoing correspondence to referral source, employer, medical providers, injured worker, and other participants involved in the injured worker's treatment plan. May participate in telephonic case conferences. Maintains a minimum caseload of 35 files, and 150 monthly billable hours, with minimum 95% quality compliance.
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.
Required Qualifications: At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Ability to prioritize and manage multiple deadlines. Excellent organizational, problem-solving and critical-thinking skills. Strong written and verbal communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications: Certified Professional in Healthcare Management (CPHM). Recent hospital experience in an intensive care unit (ICU) or emergency room.
Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. Processes requests within required timelines. Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. Requests additional information from members or providers as needed. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote the Molina care model. Adheres to utilization management (UM) policies and procedures.
Abridge was founded in 2018 with the mission of powering deeper understanding in healthcare. Our AI-powered platform was purpose-built for medical conversations, improving clinical documentation efficiencies while enabling clinicians to focus on what matters most—their patients. Our enterprise-grade technology transforms patient-clinician conversations into structured clinical notes in real-time, with deep EMR integrations. Powered by Linked Evidence and our purpose-built, auditable AI, we are the only company that maps AI-generated summaries to ground truth, helping providers quickly trust and verify the output. As pioneers in generative AI for healthcare, we are setting the industry standards for the responsible deployment of AI across health systems. We are a growing team of practicing MDs, AI scientists, PhDs, creatives, technologists, and engineers working together to empower people and make care make more sense. We have offices located in the Mission District in San Francisco, the SoHo neighborhood of New York, and East Liberty in Pittsburgh.
As the Clinical Success Director/Manager - Nursing, you will be at the forefront of defining, launching, and growing our generative AI platform for nurses. Your work will directly contribute to improving the cognitive burden associated with clinical documentation. You will collaborate with clients, partners, product managers, designers, machine learners, and healthcare professionals to bring to life products that bridge the gap between clinical conversations and actionable data.
3+ years of experience as an RN, preferably in the inpatient setting Experience with electronic record systems (Epic is a definite plus) Passion for deeply understanding nursing workflows and improving inefficiencies Proven track record of leading successful initiatives from conception through launch Ability to build relationships with different layers of an organization, from front-line staff to executives Strong understanding of the healthcare industry, specifically clinical workflows and regulatory requirements Experience working with cross-functional teams in a fast-paced, startup environment This role requires 30% travel*** To be hired you must be based in the Eastern time zone***
Evaluate new product offerings and provide subject matter expertise to our product teams. Build and maintain relationships across customers, including onboarding users, listening to customer feedback, optimizing nursing workflows, and identifying opportunities for improved engagement and success. Design and recruit a council of trusted nurse advisors to guide product strategy and roadmap. Develop a use case-specific end-user survey and a set of success metrics to help communicate impact and value. Evangelize product capabilities and direction to prospective customers by creating sales collateral, conducting product demos, training, and more.
We are the leading voice of business in the region providing advocacy, resources and solutions for our members. Chamber of Commerce-membership organization, offering programs, events, networking-business support.
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. All applicants must have New York RN licensure*** Position Purpose Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team.
Education/Experience Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience. Knowledge of utilization management principles preferred. License/Certification RN - Registered Nurse - State Licensure and/or Compact State Licensure required All applicants must have New York RN licensure*** Pay Range $75,300.00 - $135,400.00 per year Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards Collaborates with utilization management team to resolve complex care member issues Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards Assists with onboarding, hiring, and training utilization management team members Leads and champions change within scope of responsibility Performs other duties as assigned Complies with all policies and standards
We are the leading voice of business in the region providing advocacy, resources and solutions for our members. Chamber of Commerce-membership organization, offering programs, events, networking-business support.
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ***This position supports our Fidelis state plan and requires NY RN Licensure*** Position Purpose Routinely reviews more challenging prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
Education/Experience Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 4 – 6 years of related experience. Advanced clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Strong knowledge of Medicare and Medicaid regulations preferred. Strong knowledge of utilization management processes preferred. License/Certification LPN - Licensed Practical Nurse - State Licensure required ***This position supports our Fidelis state plan and requires NY RN Licensure***
Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Collaborates with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Manages service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Provides feedback on opportunities to improve the authorization review process for members Manages as appropriate with healthcare providers, utilization management team, and care management team to assess medical necessity of care Partners with interdepartmental teams on projects within utilization management as part of the clinical review team Manages and reviews all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Provides education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Develops in-depth knowledge of the prior authorization process and acts as a trainer to other team members Performs other duties as assigned Complies with all policies and standards
We are the leading voice of business in the region providing advocacy, resources and solutions for our members. Chamber of Commerce-membership organization, offering programs, events, networking-business support.
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Work Location This is a fully remote role. Candidates must hold active New York State Registered Nurse (RN) licensure and be willing to work Eastern Time (ET/EST) hours. Schedule This position follows a Monday–Friday schedule from 830 AM to 500 PM Eastern Time (ET/EST), with a one‑hour assigned lunch break. Candidates must be able to work during these hours. Position Purpose Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.
Licensure Requirement Active and unrestricted New York State Registered Nurse (RN) licensure is required for consideration. Education/Experience Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification LPN - Licensed Practical Nurse - State Licensure required This position is aligned to support Fidelis Care. NYS RN Licensure required.
Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Complies with all policies and standards
Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.
Position: Registered Nurses Type: Contract Compensation: $60–$110/hour Location: Remote Duration: 3–4 weeks Commitment: 30–40 hours/week
Must-Have: 4+ years professional experience in nursing. Excellent written communication with strong grammar and spelling skills. Start Date: Immediately
Create deliverables addressing common requests in the nursing domain. Review peer-developed deliverables to enhance AI research. Diagnose and solve real issues in your domain to advance machine learning systems. Work independently and remotely on your own schedule. Contribute expertise to cutting-edge AI research.
Medasource is a leading consulting and professional services firm supporting organizations across the healthcare ecosystem – including Life Sciences, RCM/Payers, Technology, Government and Nursing & Allied Health. Recognized for our commitment to our employees, consultants, and the communities we serve, we deliver solutions that drive meaningful progress across healthcare. With a nationwide footprint of 33 offices and 1,900+ active consultant placements across 120+ clients who are actively engaging Medasource talent, we continue to expand our impact as we advance the future of healthcare, one client at a time.
Title: Post-Service Clinical Review Nurse (RN) Location: Remote – Must Reside in California Type: Full-Time Contract We are seeking an experienced Clinical Review Nurse (RN) to support a high-impact retrospective claims review program. This role is responsible for evaluating medical claims and records to ensure services align with clinical guidelines, medical necessity, and reimbursement policies. This position is ideal for nurses with experience in post-service review, utilization management, or prior authorization, who are comfortable working in a fast-paced, production-driven environment.
Requirements: Active California RN license (required) Experience in post-service review, prior authorization, or outpatient claims review Strong knowledge of CPT, ICD-10, HCPCS coding and billing practices Ability to work independently and apply clinical judgment Experience in a fast-paced, production-based environment Nice to Have: Experience with retrospective claims review programs Background in utilization management or case management Experience reviewing a wide range of outpatient services
Perform retrospective clinical claim reviews and make initial determinations using evidence-based guidelines Evaluate claims for medical necessity, coding accuracy, and policy compliance Review outpatient services including DME, radiology, labs, and genetic testing Prepare cases for Medical Director review when needed and communicate determinations Ensure documentation meets regulatory and accreditation standards Prioritize workload to meet strict turnaround times Identify quality of care concerns and escalate appropriately Collaborate with claims, appeals, and care management teams
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.
We are seeking a talented individual for the Nurse Reviewer, Associate position. In this role, you will perform clinical reviews to determine whether medical record documentation supports the need for a service, based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by the review methodologies specific to the contract. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy and regulatory support for determinations. What You Should Expect In This Role Home-based position; you must have a work location within the continental U.S. Must provide a high-speed internet connection and a work environment free from distractions. Full-time schedule during normal business hours is required, as the role involves frequent interactions with the team and other departments. May be required to work extended hours for special business needs. May be required to travel up to 10% of the time based on business needs. This position is for pipeline purposes, and we welcome applications on an ongoing basis.
Active, unrestricted RN licensure from the United States and in your state of primary residence; an active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) is also required. 3+ years of clinical experience in an inpatient hospital setting. 1+ years of experience in utilization review or claims auditing. Experience using Milliman or InterQual criteria is preferred. Demonstrated proficiency in computer skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, internet browsers, and typing.
Review and interpret medical records, comparing them against criteria to determine the appropriateness and reasonableness of care. Apply critical thinking and decision-making skills to assess whether the documentation supports the need for the service while maintaining production goals and quality standards. Document decisions and rationale to justify review findings or no findings. Determine approvals or initiate referrals to the physician consultant, processing their decisions while ensuring denials are explained in sufficient detail and completed within contractual deadlines. Perform prior authorization, precertification, and retrospective reviews, and prepare decision letters as needed in support of the utilization review contract. Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure. Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-train to perform reviews of multiple claim types, providing a flexible workforce to meet client needs.
Why Choose Epitec? Founded in 1978 and headquartered in Southfield, Mich., with regional hubs in Chicago, Central Illinois, and Dallas, Epitec is dedicated to making staffing personal. Our customers include Fortune 500 companies across the United States, providing you access to high demand career opportunities. What Makes Epitec Different? Our flexible workforce model is designed with you in mind. Whether you're looking for contract-to-hire, direct hire, or other employment options, we tailor our services to fit your career goals. We are consistently ranked as a top supplier to our customers, ensuring you have access to premier job placements. How We Support You Our recruiting team focuses on understanding your unique skills and aspirations and we expertly match those to our customer job opportunities. We bring together diverse teams to solve complex problems, ensuring you are placed in roles where you can thrive. By leveraging innovative strategies and technology, we adapt to your evolving needs, providing exceptional support every step of the way. Our Commitment to Your Success Epitec’s dedication to excellence has earned us national recognition as a “Best and Brightest Company to Work For” over 20 consecutive years and MMSDC's Minority Supplier of the Year on four occasions. We are committed to your professional growth and success, making sure you have the resources and opportunities to excel in your career.
Job Title: Appeals & Utilization Management Nurse Location: United States Job Type: W2 Contract Expected Hours Per Week: 40 hours per week Schedule: Monday–Friday, 9:00 AM to 5:00 PM, Remote Pay Range: $38 per hour Position Description: We are seeking an experienced Appeals / Utilization Management Nurse to support the resolution of member and provider appeals in a managed care environment. This role partners closely with Utilization Management, Case Management, and Customer Service teams to ensure appeals are processed in compliance with regulatory, accreditation, and organizational standards while delivering a high level of customer service.
Active RN or LPN/LVN license in good standing. Bachelor’s degree or 4+ years of healthcare experience. 5+ years of utilization management, appeals, claims, and mainframe system experience. Experience in healthcare operations and managed care environments. Strong knowledge of NCQA and URAC accreditation standards. Knowledge of state and federal healthcare and health operations regulations. Strong organizational skills with the ability to manage multiple priorities and deadlines. Excellent verbal and written communication skills with internal teams, members, and providers. Proficiency in Microsoft Word, Excel, and Access.
Collaborate with Utilization Management (UM), Case Management (CM), and Customer Service teams to ensure appeals processes meet established guidelines. Facilitate end-to-end resolution of member and provider appeals in compliance with state and federal regulations. Manage individual appeal inventory using established workflows while meeting required turnaround times. Ensure compliance with NCQA, URAC, DOI, and other regulatory and accreditation standards. Participate in NCQA and URAC audits, DOI audits, correspondence revisions, and departmental process improvement initiatives. Provide data and reporting required for audits, regulatory reviews, and internal stakeholders. Facilitate member or member-designee access to appeal files in accordance with federal guidelines. Work directly with members and providers to resolve appeals while maintaining superior customer service standards. Serve on departmental workgroups and support cross-functional teams. Maintain strong working relationships across organizational lines to achieve operational goals. Communicate professionally with leadership, peers, members, and providers. Maintain strict compliance with HIPAA, Corporate Integrity, Diversity Principles, and all applicable corporate policies. Preserve confidentiality of protected health information and company business. Communicate workflow updates, trends, and development needs to management; complete special projects as assigned.
Trinity Health is one of the largest not-for-profit, Catholic health care systems in the nation. It is a family of 123,000 colleagues and nearly 27,000 physicians and clinicians caring for diverse communities across 26 states. Nationally recognized for care and experience, the Trinity Health system includes 88 hospitals, 135 continuing care locations, the second largest PACE program in the country, 136 urgent care locations and many other health and well-being services. Based in Livonia, Michigan, its annual operating revenue is $21.5 billion with $1.4 billion returned to its communities in the form of charity care and other community benefit programs.
Employment Type: Full time Shift: Day Shift Description Purpose Work Remote Position (Pay Range: $31.8795-$47.8193) The Nursing Support (NS) colleague (uncertified, certified, unlicensed, or licensed) provides safe, quality health care services & / or assistance to patients under the supervision & direction of a registered nurse or other designated health care professional in accordance with level of experience, education, policies & procedures. Note: “patients” refers to patients, clients, residents, participants, customers, members
High school diploma or GED; Completion of an accredited program associated with license. License in the applicable state(s) of engagement. Valid driver’s license where required by assignment. Additional Qualifications (nice to have) Registered Nurse, preferred Training or experience according to assignment area
Our Trinity Health Culture: Knows, understands, incorporates & demonstrates our Trinity Health Mission, Values, Vision, Actions & Promise in behaviors, practices & decisions. Work Focus: Performs clinical care activities (direct or indirect) for patients within the “scope of practice” laws & training received; Cares for patients safely by assisting in clinical care services or engaging in administrative activities (e.g., maintaining records or supplies) that enhance or improve coordination, preparation & flow of the care experience. Process Focus: Knows, understands & incorporates basic or essential area of practice (document, coordinate, communicate) & training standards. Communication: Uses clear, effective, respectful language & communication methods / means. Environment: Performs work in a safe, engaging, & supportive manner; Influences the responsible use of resources; Accountable for continuous self-development & supporting the growth of others. Maintains a working knowledge of applicable federal, state & local laws/regulations, Trinity Health Integrity & Compliance Program & Code of Conduct, as well as other policies, procedures & guidelines in order to ensure adherence in a manner that reflects honest, ethical & professional behavior & safe work practices. Functional Role (not inclusive of titles or advancement career progression) NS IV – licensed: Licensed role (direct or indirect healthcare); Provides nursing interventions or clinical knowledge application in decision-making; Participates in the planning, implementation & / or evaluation of & solutions for care; Performs delegated focused / holistic care autonomously according to care plan; May administer medication & carry out the therapeutic treatment within scope of license (state & TH policy); Performs direct & essential care or supportive activities as part of an interdisciplinary team with a deeper understanding, including theoretical knowledge; Demonstrates a level of independence to perform activities with general oversight, through personal contributions, teamwork & initiatives to safely improve outcomes; Advocates for patients & informs / counsels patients & families about illness & care details; May serve as a knowledge resource, role model & mentor or lead / coordinate / supervise direct & essential care activities or role-based service responsibilities of unlicensed / licensed / certified healthcare professionals within licensed scope of practice.
Welcome to DataAnnotation! We pay smart folks to train AI. We offer a remote, flexible work model- you choose your own hours and get to work when you want, whenever you want. Apply now through our open Job Listings.
We are looking for a Clinical Appeals Nurse to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model. In this role, you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include Clinical Documentation & HIM, Medication Management (PharmD), Laboratory Medicine and Pathology Services (MLS, MD), Quality Improvement & Patient Safety, Regulatory Compliance, Accreditation & Medical Staff, Care Coordination & Case Management, Population Health & Value-Based Care, and Managed Care & Utilization Management. Benefits Full-time or part-time remote position Choose which projects you want to work on Flexible schedule Projects are paid hourly starting at $50+ per hour Bonuses available for high-quality and high-volume work
Fluency in English (native or bilingual level) A current or in-progress medical or healthcare-related degree
Provide AI chatbots with diverse and complex healthcare-related problems Evaluate AI outputs for logic, accuracy, and performance Ensure the medical accuracy and overall quality of model responses
With a workforce of more than 3500 employees spread across Ireland, United Kingdom, Mainland Europe, MENA, and the USA, Uniphar is a trusted global partner to pharma and MedTech manufacturers, working to improve patient access to medicines around the world. Uniphar provides outsourced and specialized services to its clients, leveraging strong relationships with 200+ of the world’s best-known pharmaco-medical manufacturers across multiple geographies, enabled by our cutting-edge digital technology and our highly expert teams. Uniphar is organized into three key divisions: Supply Chain & Retail, Global Sourcing, and Pharma. This position will support human resources across the US division. Visit our website to learn more: Uniphar.US
Medical Information Specialists are highly trained on the regulatory aspects of communicating with patients, caregivers, and health care professionals, including the handling of AEs, Medical Device Reports, and PQCs. We are looking for an experienced Medical Information Specialist RN in any state with an unrestricted license. The right candidate will have clinical experience, call center experience and have a current or past job title of Medical Information Specialist and enjoy working remotely. As a Medical Information Specialist, you are responsible for providing specific medical information and product support to healthcare professionals and patients. You will offer support services which require substantial knowledge, judgment and nursing skills based upon principles of psychological, biological, physical and social sciences. You will serve as a clinical and educational resource to other departments and health care practitioners. You will document adverse events and product complaints in accordance with FDA regulations and other regulatory agency requirements. You will be working with products with specific indications, complex mechanisms of action and specific administration techniques which will need a strong comprehension of pharmacology. Candidates must have experience as a Medical Information Specialist and answer all questions to be considered for this position.
Education/Experience: Previous experience as a Medical Information Specialist is required. One year clinical experience preferred to ensure proficiency with clinical assessment practices. Previous experience in a call center preferred. Must be able to use dual monitors and technology autonomously. Experience with MIQ, SharePoint, SalesForce and Genesys phone system. Certificates and Licenses: Valid and unrestricted RN license (any state) in good standing required. Additional certifications as may be required by scope of program and client contractual requirements. Knowledge, Skills and Other Abilities: Accomplish goals without creating distractions or disruptions to other employees Must be at work, on time and ready to work at scheduled start times with limited schedule deviations Remain professional even in times of stress or frustration - this is a customer service call center role. Must have strong customer service skills! Strive for thoroughness and accuracy when completing tasks Motivated to perform at your best and assist the team with meeting both internal and external goals Computer proficient, with demonstrated knowledge of Internet navigation and research Positive work attitude Well-established time management skills Professional level oral and written communication skills Ability to provide courteous customer service in a consistently efficient manner Ability to work well with various personalities and within a team Participate in continuous quality improvement activities Experience as a Medical Information Specialist Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation 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 is frequently required to walk, sit and use hands. The employee is occasionally required to stand.
Maintains a working knowledge of program guidelines, FAQ’s, products and therapeutic areas related to assigned programs. Keeps current with existing treatment trends, treatment standards and updated indications related to assigned programs and products. Follows standard operating procedures for all support-related activities. It is essential to maintain compliance with HIPAA at all times when handling protected health information. Maintains company, employee, and customer confidentiality, as well as compliance with all HIPAA regulations. Resolves product issues and provides appropriate scripted responses. Identifies information requests that are within the scope of the program and provides callers with the necessary information. Provides appropriate additional information and/or resources to callers upon request. Recognizes and handles adverse event reports as outlined in the program standard operating procedures. Recognizes and handle product complaint reports as outlined in the program standard operating procedures. Documents each call properly, using the call record form in the program software database. Maintains the knowledge of drug side effects and interactions.
Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
Medical Mutual employees must submit their applications through MySource. This is a remote-based role, and we are currently seeking candidates located in Ohio. Job Summary: Under limited supervision, promotes effective use of, and provides appropriate resources and assistance to members managing their health care across the continuum of care. Applies evidence-based criteria and benefit interpretations to make coverage decisions. Collaborates with providers, members, and various internal departments to effectively direct care to quality cost-effective network providers at the appropriate level of care.
Education and Experience: Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor’s degree preferred. 3 years of experience as a Registered Nurse with a combination of clinical and utilization/case management experience, preferably in the health insurance industry. Acute care Medical/Surgical/Critical Care and ambulatory care experience preferred. Professional Certification(s) Registered Nurse with current State of Ohio or multistate unrestricted license. Technical Skills And Knowledge Strong knowledge of health insurance benefits and network plan designs. Knowledge of, and the ability to apply fundamental concepts related to HIPAA compliance and related regulations. Ability to apply knowledge of health plans and industry trends to achieve positive outcomes. Knowledge of clinical practices, members’ specific health plan benefits, and efficient care delivery processes. Intermediate Microsoft Office skills and proficiency navigating windows and web based systems.
Conducts pre-certification of basic to complex outpatient services, surgical and diagnostic procedures, and out of network services to ensure compliance with medical policy, member eligibility, benefits, and contracts. Evaluates clinical information using established national decision support criteria, company policies, and individual patient considerations to ensure the provisions of safe, timely, and appropriately covered healthcare services. Promotes effective resource management by directing member care to accessible cost- effective network providers and coordinates services at appropriate level of care. Coordinates with other Pharmacy and Care Management departments to facilitate the timely provision of covered health care services. Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Assists Claims and/or Customer Care Departments as applicable. Keeps up to date on utilization management regulations, policies, and practices, including applicable coding. If assigned to Preceptor/Trainer task: Orients, trains, and provides guidance to more junior or less experienced staff. Supports implementation of new procedures, processes, or clinical systems. Performs other duties as assigned.
At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company Vision Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
Clinical Appeal Nurse Brighton Health Plan Solutions REMOTE – 100% FULL TIME About the Role: BHPS provides Utilization Management (UM) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in a quality-focused, production-driven environment. The position reports directly to the Clinical Appeal Manager. Note: This job description is not intended to be an exhaustive list of duties. Responsibilities may evolve or change at any time, with or without notice. This is a remote role.
Active and unrestricted RN or LPN license; must maintain licensure throughout employment Minimum of 5 years’ experience in Clinical Appeals and Grievances within a managed care or payor setting Minimum of 5 years’ clinical experience across various care settings (Inpatient Acute, SNF/LTAC/ARU, Outpatient, DME, Complex Care) Strong understanding of UM/Appeals regulatory guidelines including URAC, NCQA, and ERISA Proficiency in Clinical Appeals, Utilization Review, and Grievance processes including benefit interpretation, contract language, and medical policy application Excellent written and verbal communication skills Proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint). Ability to work independently with exceptional accountability Adaptability to a fast-paced and evolving environment. Preferred experience in a Third-Party Administrator (TPA) setting Preferred coding certification
Independently review and analyze pre and post service medical necessity and benefit appeals, post-service clinical claim disputes, and quality of care grievances. Utilize member-specific benefit information, nationally recognized clinical criteria, and internal policies and procedures across multiple care disciplines, including, but not limited to, Inpatient Acute, Post Acute, Outpatient, Specialty Pharmaceutical, and Durable Medical Equipment Prepare and present cases to internal Medical Directors and external Independent Review Organizations (IROs) for timely and accurate decisions Ensure strict adherence to Appeals and Utilization Management (UM) processes and regulatory and accreditation requirements from intake through case closure. Prioritize caseload and other assigned duties to meet clinical accuracy expectations and turnaround time requirements Accurately enter case details in medical management platform Collaborate with team members and other departments to achieve exceptional results and drive continuous improvement
About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being.
Clinical Competency, Remediation, Onboarding and Talent Management The Care Integration Clinical Competency & Quality Nurse is a Center of Excellence (CoE) position responsible for ensuring the clinical quality and provider & patient engagement effectiveness for the Clinical Care RN role through nursing chart and recorded visit audits, competency assessments, remediation oversight and talent management. This role bridges clinical excellence with operational leadership, conducting structured audits, and driving remediation for clinical competency gaps (in partnership with Education team support). You will report to the Director of Physician Strategy. Must reside in designated geographic area, in reasonable commutable distance to CenterWell/Conviva market locations; (market-dependent) quarterly or as-needed travel within market. Role Scope Clinical Competency & Oversight: Conduct and oversee clinical competency audits for nursing staff (Clinical Care RN); support remediation in partnership with Center of Excellence leaders and Education team Clinical Competency & Oversight tooling: Develop audit tools, processes, and remediation approaches in partnership with the Medical Director, Care Integration Team & High Risk Patient Management Program Onboarding & Talent Management: Initial interview and assessment of Clinical Care RN candidates; maintenance of onboarding design and process adherence (in partnership with Center Administrators)
Required Qualifications: Bachelor's Degree in Nursing (BSN) Active, unrestricted RN license 5+ years of clinical nursing experience with experience in transitions of care or population health management Strong clinical judgment and ability to apply evidence-based practices Proficiency with EMR and care management platforms (any system) Preferred Qualifications: Master's degree in Nursing, Business Administration, or Healthcare Management Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements Experience in clinical competency assessment, audit development, or compliance oversight Proficiency with electronic health records (Athena EMR), data analytics platforms (DataHub), and Microsoft Office Suite Familiarity with SalesForce, Genesys, and operational platform tools Experience recruiting, interviewing, and onboarding for clinical roles Strong communication, presentation, and stakeholder engagement skills Commitment to health equity, inclusivity, and patient-centered care Basic Life Support (BLS) certification Working Conditions Workstyle: Hybrid Location: Must reside in designated geographic area, in reasonable commutable distance to market clinics; (market-dependent) quarterly or as-needed travel within market Hours: Monday–Friday, 8:00 AM–5:00 PM; additional time may be required for program improvement projects or strategic initiatives 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. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Clinical Competency & Auditing: Develop and maintain clinical competency audit tools and processes aligned with organizational standards and evidence-based best practices Conduct clinical competency audits of RN documentation, clinical decision-making, and patient care practices; perform targeted reviews of charts and recorded successful patient contacts Conducts regular audits on each nurse at prescribed cadence Develop remediation approaches for nurses identified with clinical competency gaps; oversee and monitor remediation execution in collaboration with market operators and Education team. Audit rounds/huddle quality; provide coaching to nurses on case presentation skills. Nursing Staff Development & Recruitment: Support onboarding processes and tools for RNs, in partnership with Stars CoE Program Leads; coordinate with Education team for onboarding activities Develop standard job descriptions and competency frameworks for nursing roles Create and maintain interview guides and recruitment processes; establish guardrails for opening requests (capacity, geography, leader approval) Conduct first-round interviews for Clinical Care RN and project manage talent acquisition process
At CareHarmony, we are singular in focus—we seek to improve the patient experience and clinical outcomes by providing compassionate, whole-person care coordination services. Our high-tech, high-touch offering includes a turnkey Chronic Care Management solution designed to offer healthcare providers an easy, limited-risk first step into value-based care. CareHarmony serves a variety of organizations across the country, including physician practices, ACO and IPAs.
CareHarmony’s Care Coordinators (LPN) (NLC) (LVN) work comprehensively with providers to deliver value-based care management initiatives for their patients. CareHarmony is seeking an experienced Licensed Practical Nurse – LPN Nurse (LPN) (NLC) (LVN) with at least 3 years of direct patient-facing work experience; that thrives in a fast-paced environment, is self-motivated, has impeccable attention to detail, and values the impact they can have on a patient’s healthcare journey. You will have experience identifying resources and coordinating needs for chronic care management patients. What's in it for you? Fully remote position - Work from the comfort of your own home in cozy clothes without a commute. Score! Consistent schedule - Full-Time Monday – Friday, no weekends, rotational on-call-once per year on average. Career growth - Many of our team members move up in the company at a faster-than-average rate. We love to see our people succeed!
Additional Requirements: Active Compact/Multi-State license (LPN) (LVN) Technical aptitude – Microsoft Office Suite Excellent written and verbal communication skills Plusses: Epic Experience Bilingual Additional Single State licensures Remote Requirements: Must have active high-speed Wi-Fi Must have a home office or HIPAA-compliant workspace Physical Requirements: This position is sedentary and will require sitting for long periods of time This position will require the ability to speak clearly and listen attentively, often by telephone, for an extended period of time The position will require the ability to understand, process, and take thorough notes in real-time on telephone conversations
Manage patient census with a resolution-driven approach to close gaps in clinical and non-clinical patient care. Identify and coordinate community resources with patients that would benefit their care. Provide patient education and health literacy on the management of chronic conditions. Perform medication management, including identifying potential medication concerns, reconciliation, adherence, and coordinating refills. Assist in ensuring timely delivery of services to your patients; Home Health, DME, Home Infusion, and other critical needs. Resolve patients' questions and create an open dialogue to understand needs. Assist/Manage referrals and appointment scheduling.
SSM Health is a Catholic, not-for-profit, fully integrated health system dedicated to advancing innovative, sustainable, and compassionate care for patients and communities throughout the Midwest and beyond. The organization’s 40,000 team members and 13,900 providers are committed to fulfilling SSM Health’s Mission: “Through our exceptional health care services, we reveal the healing presence of God.” With care delivery sites in Illinois, Missouri, Oklahoma and Wisconsin, SSM Health includes hospitals, physician offices, outpatient and virtual care services, comprehensive home care and hospice services, a fully transparent pharmacy benefit company, a health insurance company and an accountable care organization. It is one of the largest employers in every community it serves. For more information, visit ssmhealth.com
Oversees and manages the daily operations and activities of the regional Clinical Documentation Improvement (CDI) program. Promotes consistent and standardized operations and documentation across the network. Builds and maintains productive inter/intra departmental and vendor work relationships to optimize operations.
EDUCATION: Graduate of accredited school of nursing or education equivalency for licensing EXPERIENCE: Two years' acute hospital experience or surgical area as a clinical nurse Three years' clinical documentation specialist Two years' demonstrated progressive leadership experience PHYSICAL REQUIREMENTS: Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. Frequent keyboard use/data entry. Occasional bending, stooping, kneeling, squatting, twisting and gripping. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Rare climbing. REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS State of Work Location: Illinois Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) State of Work Location: Missouri Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration State of Work Location: Oklahoma Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) State of Work Location: Wisconsin Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services
Manages the daily operations and resources of assigned Clinical Documentation Improvement (CDI) team, including the development and monitoring of strategic operating goals, objectives, and data analysis; and report operational performance, justification, and/or corrective action. Provides on-going support of CDI with extensive collaboration with physicians, nursing, coding, quality, and leadership. Facilitates improvements to clinical documentation through chart review and educational training sessions (with CDI Educator), which could be performed onsite, with physicians and/or other clinical professionals. Initiates corrective actions to resolve any problem areas identified between CDI and any other areas of the organization. Collaborates with CDI educator for regional education. Provides ongoing clinical documentation management program education for new staff, including new clinical documentation registered nurses, physicians, nurses, and allied health professionals. Participates in the direction and education of all phases of the clinical documentation process. Supports and implements technologies designed to improve and/or ensure the accurate depiction of clinical services, patient’s severity of illness, and risk of mortality. Conducts audits on CDI reviews against quality, coding, and mortality. Provides feedback to staff and CDI educator and director. Reports monthly CDI metrics regarding KPIs and staff productivity. Strengthens technical coding practices and clinician documentation by reviewing patient records with flagged complications to ensure coding accurately reflects the patient’s clinical course and complexity to validate accurate risk-adjustment for administrative metrics used in government incentive/penalty programs. Collaborates with interdisciplinary teams including physicians, nurse practitioners, physicians assistants, and the department managers for revenue integrity, coding and data quality, case management and health information management. Demonstrate leadership and management skills to promote effective and efficient review of physician documentation and the medical record. Communicates with assigned regional/ministry physician leaders. Participates in monthly medical management meetings to report CDI metrics and act as subject matter expert for inquiries. Recruits, engages, develops, leads, and manages assigned staff. Performs other duties as assigned.
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