You see new roles the moment I find them. Browse below.
PREMIUM ACCESS
This is the no-delay view of the job board. Accelerator members see new roles the moment I find them — plus I personally rebuild your resume.
Displaying your bookmarked jobs
At Mercy Health, we understand that every family is a universe. A network of people who love, and support, and count on one other to be there. Everybody means the world to someone and we are committed to care for others so they can be there for the ones they love. With nearly 35,000 employees across regions of Ohio and Kentucky, we’re one of the largest health care systems in the country. At each of our more than 600 points of care, we deliver high-quality, compassionate care with one united purpose: to help our patients be well in mind, body and spirit.
The RN Triage Specialist provides telephonic triage to assist callers to determine the most appropriate level of care needed for the current situation expressed or assessed, following workflows and utilizing protocols/resources to provide supportive service to patients and customers. The RN Triage Specialist will maintain a performance standard that prioritizes safety, quality and experience and coincides with the organization's mission and identified key strategic or performance initiates. Please note the following details prior to apply: This position REQUIRES an active Compact RN license. This position REQUIRES a HIPAA compliance at home workspace. (Secure physical areas with a lock on door to office space and ensuring screens are not visible to unauthorized individuals.) This position REQUIRES home office space equipped highspeed internet of 100mbps download speed and 20mbps upload speed. If your current internet does not meet expectations, we will ask that you upgrade prior to your interview. You will need the speeds to be able to participate in the job shadowing, during the last 30 minutes of the one hour and fifteen-minute interview. This position REQUIRES a secondary workspace with access to highspeed internet private access, within :30 minutes of their home office. 4 Week Orientation/Training schedule is Monday thru Thursday 8:00am ET - 4:30pm ET. We offer opportunities across all shifts - days, afternoon/evenings, and nights - with full-time and on occasionally part-time and PRN positions. Schedules are set and follow a six-week rotation, which includes an every-other-weekend requirement. There is also an on-call component and a rotating holiday requirement for all positions. Once you're placed into a schedule, you'll be expected to work that set schedule for at least six months before any schedule change request is considered. Please note that while schedule change requests are reviewed every six weeks, they are not guaranteed and are evaluated based on our established standard operating procedures. *Hours subject to change based on need of operations
Licensing/Certification: RN license required in applicable state(s). Multistate/Compact RN Licensure required. Education: ADN or Diploma Nursing required BSN preferred Work Experience 1 year of acute care nursing experience required. Triage experience preferred. Training EPIC Electronic Health Record (preferred) IT Requirements Minimum internet speed of primary and secondary work locations is: Download speed of 100Mpbs Upload speed of 20Mbps Office Setting Must have a designated workspace with a locked door, per HIPAA regulations. Associates are encourages to also identify a secondary work location, meeting HIPAA regulations in case of power outages as well. Working Conditions Periods of high stress and fluctuating workloads may occur. General office environment. May have periods of constant interruptions. Required to car travel to off-site locations, occasionally in adverse weather conditions. Prolonged periods of working alone. Skills Inform medical professionals regarding patient conditions and care Assessment of condition via telephone or video Attention to detail Critical thinking Communication Teamwork Conflict resolution Active listening Relationship building Agility and adaptability
Provides telephonic triage or requested support and / or virtual monitoring. Offers subsequent recommendations, education or care advice using decision making tools, clinical judgement, and defined workflows. Participates in care coordination, by partnering with customers to reduce readmissions, enhance chronic disease management, manage health risk and injury reporting. Schedules provider appointments and facilitates provider communication. Ensures accurate, timely documentation in the EMR (Electronic Medical Record) according to best practice, guidelines, or workflows. Participates in virtual monitoring and subsequent reporting and escalation to support services identified by customer. Provides additional support to Conduit Health Partners business functions as identified to ensure all patient needs are being met and continuity of Conduit Health Partners business operations is maintained. Participates in process improvement, professional development, peer development and peer review This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation and appropriate within the scope of practice for the registered nurse.
The ExamWorks Group platform, family company services, applications and portals for the management of independent medical claim review are the assets of choice among claims professionals. Our global service network and private cloud-based computing platform connects medical professionals, case managers, and claimants to property, casualty, and disability insurers, third-party administrators, and legal professionals so they can provide evidence-based independent expert medical opinions and analysis for claims resolution. Secure, streamlined, automated, customized, independently audited and accredited workflows assist clients to manage costs by verifying the validity, nature, cause, and extent of claims, identifying fraud and providing fast, efficient and quality IME services.
Are you a Nurse (LPN, LVN or RN) seeking a role that challenges you, helps you grow, and lets you work from the comfort of your own home? ExamWorks has the perfect opportunity for you! We’re looking for a Clinical Quality Assurance Coordinator to join our team! In this role, you’ll ensure Peer Review case reports meet the highest standards of quality, integrity, and compliance with client agreements, regulatory guidelines, and federal/state mandates. Why This Role Rocks 100% Remote - Enjoy the flexibility of working from home! Impactful Work - You’ll play a key role in ensuring the quality and compliance of critical reports. Schedule - Monday to Friday; 8:30am-5:00pm EST
High school diploma or equivalent required with a minimum of two years clinical or related field experience; or equivalent combination of education and experience. Experience in peer review, clinical documentation review, or medical necessity assessments. Familiarity with CMS guidelines, InterQual, Milliman/MCG, or payer policies. Prior employment with insurance carriers, TPAs, or managed care organizations. Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values. Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; Ability to compute rates and percentages. Must be a qualified typist with a minimum of 40 W.P.M Must be able to operate a general computer, fax, copier, scanner, and telephone. Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet. Must possess excellent skills in English usage, grammar, punctuation and style. Ability to follow instructions and respond to upper managements’ directions accurately. Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met. Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed. Must be able to work independently, prioritize work activities and use time efficiently. Must be able to maintain confidentiality.
Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews. Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations. Ensure that all client instructions and specifications have been followed and that all questions have been addressed. Ensure each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications. Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards. Ensure the appropriate board specialty has reviewed the case in compliance with client specifications or state mandates and is documented accurately on the case report. Verify that the peer reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists. Ensure the provider credentials and signature are adhered to the final report. Identify any inconsistencies within the report and contacts the Peer Reviewer to obtain clarification, modification or correction as needed. Assist in resolution of client complaints and quality assurance issues as needed. Ensure all federal ERISA and state mandates are adhered to at all times. Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications. Promote effective and efficient utilization of company resources. Participate in various educational and or training activities as required. Perform other duties as assigned.
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
4+ years professional experience in nursing. Excellent written communication with strong grammar and spelling skills.
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.
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. Founded in 2017, we've grown fast and now serve members all across the United States. We've gathered 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. We're only just getting started!
We want to 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. As a Triage Clinical Guide (Registered Nurse), you’ll be responsible for providing telephonic advice and clinical triage when Devoted Health members call us for support. You'll serve as a fierce advocate, helping them achieve better health outcomes and connecting them with the necessary resources. Our ideal Triage Clinical Guide is caring, compassionate, solution-oriented, and enthusiastic about providing an outstanding member experience. You possess excellent clinical judgment, are ready to innovate, and are excited about changing the way healthcare is delivered. You will be joining a team of adaptable, scrappy, and resilient professionals who are proud to be part of the Devoted family, creating a revolution in care delivery. Schedule Details: This is a full-time, night shift role. You will work three (3) scheduled clinical shifts per week on a rotating basis, including weekends and holidays. Shifts are scheduled based on business needs and may include: 8:00 PM – 8:30 AM ET (current primary shift) or 6:00 PM – 6:30 AM ET (alternate shift). The remaining 2.5 hours per shift are reserved for administrative work, training, and team meetings. Shift assignments are subject to change based on operational needs, and candidates must be flexible to work either schedule as required.
Required Skills & Experience: Licensure: An active, unencumbered Compact RN license OR a willingness to obtain additional state licenses as needed (for non-compact states). Experience: A minimum of 5 years of direct patient care experience. Triage Expertise: Prior clinical triage experience in an Emergency Department, Intensive Care Unit, Primary Care, or Telephonic Triage setting. Telehealth: Prior telehealth experience is required. Technical Agility: Eager to learn and able to quickly master electronic medical records (EMR), remote telephone software, and virtual video systems. Work Style: Exceptional communication and active listening skills. You enjoy fast-paced work, are eager to task-switch, and are always happy to help colleagues. Desired Skills & Experience: BSN (Bachelor of Science in Nursing) degree preferred. Experience caring for older adult populations. Experience working within population health or value-based care programs. Attributes to Success: Curious & Compassionate: You listen to others, lead with empathy, and aren't afraid to be wrong or change your mind. Detail-Oriented: You hold high standards for patient care, are well-organized, and possess meticulous attention to detail. Happy Warrior: As long as you’re in a great environment with smart, caring people working toward a common aim, you’re comfortable working hard and tackling tough challenges. Innovative: You are wired for learning and change. You want to make a difference by testing new ways of doing things to build a better care system. Agile: Agility and collaboration are critical. We are a growing organization with a start-up mentality—you believe we can do hard things together!
Clinical Triage: Engage with members via telephone and the patient portal to provide clinical advice, educational materials, answer questions, and direct patients to the appropriate level of care. Care Coordination: Connect members with the exact care they need, whether routing them to providers within Devoted Medical, primary care, urgent care, or emergency services. Telehealth Support: Deliver exceptional support to patients with urgent complaints across multiple geographies, leveraging video telehealth visits to keep them safely at home whenever possible. Interdisciplinary Collaboration: Work seamlessly alongside a multidisciplinary team—including other RNs, NPs, PAs, MDs, and medical assistants—safeguarding our collaborative, team-based culture. Continuous Growth: Enthusiastically participate in learning sessions and be eager to grow your own skills while teaching others. Patient Advocacy: Fiercely promote our model of treating and caring for patients like they are our own family members.
CircleLink Health’s AI-enabled SphereCM platform accelerates compassionate, intelligent care management at scale. We pair dedicated tele-RNs with the latest in supervised, agentic AI, augmenting and extending the reach of your care teams across CCM, RPM, RTM, and APCM programs.
This is a remote role. CircleLink Health is looking for passionate, tech savvy registered nurses to work remotely and serve patients enrolled in Medicare’s Chronic Care Management Program. In this part time role (about 20-25 hrs. per week), an RN Care Coach will be assigned a group of patients that they will be following and calling each month. In these monthly calls you will provide education, coordinate care, close preventive care gaps, and coach on strategies for self-management to keep them out of the hospital. This Role Requires Precision, Discipline, and Accountability Role The Care Manager role is not a step back from bedside nursing — it’s a step into a more complex, structured, and performance-driven environment. To succeed, you must bring more than clinical knowledge: Excellent documentation skills — Your charting must be complete, timely, and accurate. Strong time management — Case tasks must be prioritized and closed on schedule. Ownership of outcomes — Each case is closely tracked for quality, compliance, and effectiveness. Expectations are high, and performance is regularly reviewed. This is not a role where details can be missed or timelines pushed — we need professionals who take initiative, stay organized, and consistently deliver. If you’re ready for a challenging, fast-paced environment where your work is held to high standards and makes a real difference, we encourage you to apply.
Requirements: Fluent in English Self-directed, able to work independently with little supervision while meeting performance metrics Passion for nursing and improving patient outcomes Good with technology and eager to learn and use new software Excellent organizational and time management skills Timely communication is essential, and nurses are expected to respond to all messages and emails within 24–48 hours. Strong critical thinking and problem-solving skills Education And Experience: Current, unrestricted Compact License / multistate RN license Proficiency with electronic health records and web-based applications 3+ years' experience as a Registered Nurse Preferred Education And Experience, But Not Required: Spanish fluency Case Management or Chronic Disease Management experience highly preferred Certified Diabetes Educator Experience with Motivational Interviewing or other behavior change communication techniques Scheduling And Other Requirements: RN needs a STRONG internet-connected computer Minimum of 20 hours of availability per week required You will commit to your own schedule using our software. This is a 1099 contract position with no end date. Care coaches are responsible for their own taxes and insurance.
Utilize our specialized care management software to call Medicare patients with 2 or more chronic conditions (Diabetes, CHF, Chronic Pain, COPD, etc.) on a monthly basis Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc. Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions. Close care gaps by encouraging and assisting with preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up/specialist appointments, etc.
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.
We're seeking a passionate and highly motivated Nurse Care Manager to join our dynamic Care and Case Management team. In this telephonic role, you'll play a crucial part in holistically guiding our members through their healthcare journey, ensuring their needs are met with industry-leading interventions. This position places a special emphasis on proactive engagement with high-risk and rising-risk members, particularly around discharge planning and care transitions. You will partner with a multidisciplinary clinical team that includes a variety of healthcare professionals, care coordinators, and records specialists, to deliver integrated remote care in an innovative way. The ideal candidate will enjoy spending time on the phone, actively listening to members’ needs, answering questions, and serving as a dedicated advocate. You should excel at creating cohesive care plans and possess the clinical acumen to guide members through complex situations, leveraging available benefits and resources. Schedule: Monday-Friday, 9:00 AM-6:00 PM local time zone
Bachelor of Science in Nursing (BSN) Compact Nursing License and must reside in the state in which you hold the license. 5+ years of experience in clinical nursing 2+ years of experience working in care management, case management, and/or disease management, preferably within a health plan, health navigator, or third-party administrator (TPA) environment. Remote care or case management experience Comfortable discussing a wide variety of medical conditions and experienced working with populations across all age ranges. Strong comfort with technology and high competence in using multiple computer/medical record systems.
Engage in high-value Care Management outreach calls for Included Health members with the primary goal of clinically engaging high-risk and rising-risk members, fostering strong relationships and promoting proactive health management. Make proactive calls to members once their hospital discharge is confirmed, conducting thorough intake assessments if the member is reached. Collaborate with hospital-based case managers to understand & support members' specific discharge needs and actively encourage members to engage with our Care Management program. Perform initial assessments encompassing activities of daily living, cognitive functions, social determinants of health (SDOH), health beliefs and behaviors, and life planning activities to develop truly holistic care strategies. Deliver coordinated, patient-centered virtual Care Management by telephone and/or video that consistently improves members’ health outcomes. Generate impactful care plans collaboratively with members and our multidisciplinary care team, empowering members to achieve their desired health goals. Coordinate necessary resources that holistically address members’ problems, whether clinical or social.
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives. Why Work for Us? Trillium believes that empowering others begins with supporting our team. We offer our employees: A collaborative, mission-driven work environment Competitive benefits and work-from-home options for most positions Opportunities for professional growth in a diverse inclusive culture Every day, our work changes lives – from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.
Trillium Health Resources has a career opening for a Complex Transitional Care Nurse to join our team! The Complex Transitional Care Nurse is responsible for providing Complex Care Coordination targeting those with chronic, unresolved or complex physical, behavioral health and social determinant needs. This includes providing care planning with foundations in national evidence based and informed standards to do whole person care. The Complex Transitional Care Nurse completes required documentation/paperwork/tasks in a software platform according to timelines. Typical working hours: 8:30 am – 5:00 pm; flexible work schedules with some roles with management approval. Work-from-home options available for most positions Health Insurance with no premium for employee coverage Flexible Spending Accounts 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook 401k with 5% employer match and immediate vesting Public Service Loan Forgiveness (PSLF) qualifying employer Quarterly stipend for remote work supplies
Required: Fully licensed by the North Carolina State Board of Nursing as a Registered Nurse (RN) with a minimum of one (1) year experience as a Registered Nurse. Must have a valid driver’s license. Must reside within Trillium’s Mid State Region, which includes the following counties: Anson, Guilford, Montgomery, Randolph, and Richmond. Must be able to travel within catchment as required. Preferred: Experience working with BH/MH/SU/IDD population. Knowledge of QM, UM procedures as well as experience in using data analytics for population health management. Experience assessing and coordinating care for members in adult care homes, family care homes, home residence or other settings.
Complex care coordination to assigned individuals who may have identified needs with mental health, physical health, co-occurring, co-morbid or multi-morbid conditions. Collaborate with Internal Staff across discipline/teams (Care Coordinators, Clinicians, OT, COTA, Housing Specialists, Peers, etc.) to facilitate integrated care. Monitor the Care Plan (physical, behavioral health and social determinant concerns), service delivery and health and safety of the members. Perform clinical functions of discharge/transition planning and diversion including clinical interviewing; obtaining and reviewing clinical records; identifying potential treatment needs; assessing barriers to treatment and recommending solutions; and assessing general health needs and recommending referrals. Provide education about all available services and natural and community supports, treatment options, diagnosis, etc.
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.
This is a remote role. CircleLink Health is looking for passionate, tech savvy registered nurses to work remotely and serve patients enrolled in Medicare’s Chronic Care Management Program. In this part time role (about 20-25 hrs. per week), an RN Care Coach will be assigned a group of patients that they will be following and calling each month. In these monthly calls you will provide education, coordinate care, close preventive care gaps, and coach on strategies for self-management to keep them out of the hospital. This Role Requires Precision, Discipline, and Accountability Role: The Care Manager role is not a step back from bedside nursing — it’s a step into a more complex, structured, and performance-driven environment. To succeed, you must bring more than clinical knowledge: Excellent documentation skills — Your charting must be complete, timely, and accurate. Strong time management — Case tasks must be prioritized and closed on schedule. Ownership of outcomes — Each case is closely tracked for quality, compliance, and effectiveness. Expectations are high, and performance is regularly reviewed. This is not a role where details can be missed or timelines pushed — we need professionals who take initiative, stay organized, and consistently deliver. If you’re ready for a challenging, fast-paced environment where your work is held to high standards and makes a real difference, we encourage you to apply.
Fluent in English Self-directed, able to work independently with little supervision while meeting performance metrics Passion for nursing and improving patient outcomes Good with technology and eager to learn and use new software Excellent organizational and time management skills Timely communication is essential, and nurses are expected to respond to all messages and emails within 24–48 hours. Strong critical thinking and problem-solving skills Education And Experience: Current, unrestricted Compact License / multistate RN license Proficiency with electronic health records and web-based applications 3+ years' experience as a Registered Nurse Preferred Education And Experience, But Not Required Spanish fluency Case Management or Chronic Disease Management experience highly preferred Certified Diabetes Educator Experience with Motivational Interviewing or other behavior change communication techniques Scheduling And Other Requirements RN needs a STRONG internet-connected computer Minimum of 20 hours of availability per week required You will commit to your own schedule using our software. This is a 1099 contract position with no end date. Care coaches are responsible for their own taxes and insurance.
Utilize our specialized care management software to call Medicare patients with 2 or more chronic conditions (Diabetes, CHF, Chronic Pain, COPD, etc.) on a monthly basis Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc. Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions. Close care gaps by encouraging and assisting with preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up/specialist appointments, etc.
Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.
Other Information: Expected Hours of Work: Monday - Friday 8 am – 5 pm PST; with ability to adjust to Client schedules as needed Travel: May be required, as needed by Client Direct Reports: None Salary Range: $70,000 – $100,000
Competencies: Ability to translate member needs and care gaps into a comprehensive member centered plan of care Ability to collaborate with others, exercising sensitivity and discretion as needed Strong understanding of managed care environment with population management as a key strategy Strong understanding of the community resource network for supporting at risk member needs Ability to collect, stage and analyze data to identify gaps and prioritize interventions Ability to work under pressure while managing competing demands and deadlines Well organized with meticulous attention to detail Strong sense of ownership, urgency, and drive The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families. Excellent analytical-thinking/problem-solving skills. The ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads. The ability to offer positive customer service to every internal and external customer Experience: Current unencumbered Oregon RN license required; Compact license preferred in addition to Oregon Minimum of 5+ years of acute clinical experience Minimum 2 years’ experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.) 2+ years of utilization management experience Strong knowledge of utilization management processes and industry best practice In-depth knowledge and experience with the application of standard medical criteria sets (MCG, InterQual) Detailed knowledge and demonstrated competency in all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care and home health care. HMO and risk contracting experience preferred In-depth knowledge of current standard of medical practices and insurance benefit structures. Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills. Proficiency in Microsoft Office Physical Requirements: Must be able to sit in a chair for extended periods of time Must be able to speak so that you are able to accurately express ideas by means of the spoken word Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types Must be able to fluently communicate both verbally and in writing using the English language Time Zone: Mountain or Pacific
Specific: Determine appropriateness of services through the application and evaluation of medical guidelines, benefit determinations and compliance with state mandated regulated based on approved criteria (MCG, InterQual, etc.) Perform 15-30 reviews per day Performs initial and concurrent review of inpatient admissions Performs reviews for outpatient surgeries, and ancillary services Concludes medical necessity and appropriateness of services using clinical review criteria Collaborate with Medical Director(s) for appropriate referrals, complex cases and adverse determinations to ensure timely access to medically necessary/ appropriate services Accurately documents all review determinations, contacting providers and members according to established requirements and timeframes General: Perform daily work with a focus on the core principles of managed care: Patient Education, Wellness and Prevention Programs, Early Screening and Intervention and Continuity of Care Work proactively to expedite the care process Identify priorities and necessary processes to triage and deliver work Empower members to manage and improve their health, wellness, safety, adaptation, and self-care Assess and interpret member needs and identify appropriate, cost-effective solutions Identify and remediate gaps or delays in care/ services Advocate for treatment plans that are appropriate and cost-effective Work with low-income/ vulnerable populations to ensure access to care and address unmet needs Gather and evaluate clinical information to assess and expedite referrals within the healthcare system including consideration of alternate levels of care and services Facilitate timely and appropriate care and effective discharge planning Work collaboratively across the health care spectrum to improve quality of care Leverage experience/ expertise to observe performance and suggest improvement initiatives Ensure understanding of industry standard competencies and performance metrics to optimize decisions and clinical outcomes Ensure individual and team performance meets or exceeds the performance competencies and metrics Contribute actively and effectively to team discussions Share knowledge and expertise, willingly and collaboratively. Provide outstanding customer service, internally and externally Follow and maintain compliance with regulatory agency requirements
Akkodis is a global digital engineering company and Smart Industry leader. We enable clients to advance in their digital transformation with Talent, Academy, Consulting, and Solutions services. Our 50,000 experts combine best-in-class technologies, R&D, and deep sector know-how for purposeful innovation. We are passionate about Engineering a Smarter Future Together. With a shared passion for technology and talent, 50,000 engineers and digital experts deliver deep cross-sector expertise in 30 countries across North America, EMEA and APAC. Akkodis offers broad industry experience, and strong know-how in key technology sectors such as mobility, software & technology services, robotics, testing, simulations, data security, AI & data analytics. The combined IT and engineering expertise brings a unique end-to-end solution offering, with four service lines – Consulting, Solutions, Talents and Academy – to support clients in rethinking their product development and business processes, improve productivity, minimize time to market and shape a smarter and more sustainable tomorrow.
Akkodis is seeking an Appeals Professional III (Weekend Only) for a 100% remote, contract‑to‑hire opportunity supporting Medicare appeals across the United States. This is for EST Shift, Schedule: Saturday & Sunday only Hours: 8–10 hours per day Start Time: Flexible (preference for 10:00 AM ET or earlier) Pay Range: $36–$44/hour, negotiable based on experience, education, geographic location, and other factors. Job Summary: This senior‑level role supports Medicare appeals and medical necessity reviews through independent clinical review of medical records and issuance of well‑supported reconsideration decisions in compliance with CMS and Medicare regulations. The workload and case complexity are equivalent to full‑time AP III roles.
Required Qualifications: Associate’s degree or higher in Healthcare (or equivalent experience) 3+ years of experience in Medicare appeals, utilization review, medical review, or clinical review Clinical background as RN, PT, RT, or OT Experience with medical necessity decision‑making Strong written and analytical skills Preferred: Medicare Advantage or managed care experience Knowledge of CMS regulations and medical review processes Additional Details: Candidates may maintain another role, subject to no conflict of interest
Review medical records and Medicare appeal case files Prepare clear, concise, and impartial reconsideration decision letters Make independent medical necessity determinations using clinical evidence and Medicare guidelines Research CMS regulations, coverage manuals, and medical literature Participate in case discussions, quality reviews, and special projects Serve as a subject matter expert; mentor or support team members as needed
EmblemHealth is one of America’s largest not-for-profit health insurers. With an 85-year legacy of serving New York communities, EmblemHealth offers a full range of commercial and government-sponsored health plans to employers, individuals, and families. We started back in the 1930s, at the height of the Great Depression. Out of hard times, the idea of health insurance was born — a system that would protect everyday people from financial misfortune if they had an accident or illness. Two companies from those early days of health insurance, Group Health Incorporated (GHI) and Health Insurance Plan of Greater New York (HIP), would later merge and become EmblemHealth. And after 85 years, our purpose as a not-for-profit is still the same — to provide quality, affordable health insurance for New Yorkers and their families. We believe in what we’re doing. And we’re looking for passionate people to join us.
Provide care management, as part of a multi-disciplinary care team, that includes care coordination, performing telephonic or face-to-face assessments of members’ health care needs, identifying gaps in care and needed support, administering/coordinating implementation of interventions. Support and enable members to manage their physical, environmental and psycho-social concerns, understand and appropriately utilize their health plan benefits and remain safe and independent in their home or current living environment in collaboration with health care providers. Provide Care Management services to identified high risk members within the community, including but not limited to Physician Practices, Retail Centers/Neighborhood Care Centers, and members’ homes. Coordinate and provide care that is safe, timely, effective, efficient and member-centered to support population health, transitions of care, and complex care management initiatives. Engage with the most complex members of the health plan with the goal of improving health care outcomes and appropriate and timely utilization of services across the continuum of care. Assist the entire Care Management interdisciplinary team in managing members with Care Management needs.
Bachelor’s degree RN required, with current active RN license - New York State CCM certification preferred Certification in utilization or care management preferred 4 – 6 years of clinical experience Organization/prioritization ability; and the ability to effectively manage a caseload of highly complex members Support an integrated care model tapping into appropriate resources both internally and external to the organization Experience in case management/care coordination, managed care, and/or utilization management Strong communication skills (verbal, written, presentation, interpersonal) Trained in the use of Motivational Interviewing techniques Experience working in medical facility or practice and/or with electronic medical records Computer proficiency: MS Office (Word, Excel, PowerPoint, Outlook); mobile technology (wireless phone/laptop, etc.) System user experience in a highly automated environment Bilingual ability (verbal, written) Strong cross-group collaboration, teamwork, problem solving, and decision-making skills Ability to work a flexible schedule (evenings, weekends and holidays) to meet member and/or caregiver and departmental scheduling needs
Assess and evaluate the needs of our most complex members, acting as the clinical coordinator collaborating with members, caregivers, providers, multi-disciplinary team, and health care and community resources through a variety of assessments to identify areas of (medical, financial, environmental, health insurance benefit, psycho-social, caregiving) concerns and potential gaps in care utilizing the most appropriate resources to support members’ needs. Identify appropriate goals, strategies and interventions that may include referrals, health education, activation of community-based resources, life planning, or program/agency referrals based on areas of concern. Develop, communicate and evaluate medical management strategies and interventions including potential for alternative solutions to ensure high quality, cost effective continuum of care with the member, caregiver, provider(s) and multidisciplinary team. Include member and family as appropriate. Engage actively with the member PCP / designee. Engage with the member in support of their treatment team to identify and establish attainable goals that positively impact clinical, financial, and quality of life outcomes for member. Work collaboratively with all stake holders to ensure knowledge of the action plan, including participation in telephonic and face-to-face case conferences when appropriate. Assess the needs of members and align them with the appropriate member of the care team (wellness team, registered dietitian, social worker, community health workers). Act as the member’s advocate and liaison by completing or facilitating interventions with providers and/or private,non-profit, and governmental agencies. Ensure that all Care Management processes and reporting are compliant with all applicable federal and state regulations, and NCQA and company standards. Participate in delegation collaboration activities, as required. Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making care management recommendations. Enter and maintain documentation in the Electronic Medical Records System (EMR), meeting defined timeframes and performance standards. Maintain an understanding of Care Management principles, program objectives and design, implementation, management, monitoring, and reporting. Actively participate on assigned committees. Attend and complete all department-mandated training as well as satisfy educational in-service requirements. Perform other related projects and duties as assigned. Provide ongoing monitoring, evaluation, support and guidance to the coordination of the member's health care. Develop, implement and coordinate plan of care and facilitate members’ goals. Coordinate interdisciplinary team tasks and activities, with the goal of maintaining team performance and high morale.
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.
Duration: 6 month contract to hire Schedule: Monday - Friday, 9 AM - 6 PM (MST or PST work hours) Start Date: June 1st 2026 (Cannot have any major absences during the first 8 weeks due to training period) Insight Global is looking for a Remote Nurse Care Manager to support a virtual care and healthcare navigation company. This individual will act as a clinical partner helping high-risk and rising-risk members through proactive outreach, post-discharge planning, and care coordination. They will collaborate with a multidisciplinary team to develop and execute holistic care plans while ensuring that each member receives the guidance, education, and support they need throughout their healthcare journey.
Must hold compact RN license and reside in the state in which they hold the license 5 years’ experience as a nurse 2 years’ experience as a case manager Bachelors Degree in Nursing (BSN)
Day-to-day responsibilities include but are not limited to, coordinating communication with hospital care management teams, supporting medication reconciliation efforts, and navigating members to their employee resources. This is an awesome opportunity to join a tech-enabled care integrator and contribute to a growing Care & Case Management team!
At Guardian, you’ll have the support and flexibility to achieve your professional and personal goals. Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.
As the Appeals Case Manager II, Group Disability Claims you are responsible for adjudicating assigned appeals for Group Life and Disability claims. The ACM 2 provides a full and fair reconsideration review, as required under the Employee Retirement Income Security Act (ERISA), by thoroughly assessing the claim file and applying plan provisions in accordance with applicable state and federal regulations. This role supports Group Short-Term Disability, Long-Term Disability and Life Waiver of Premium appeals. You are: A highly motivated and reliable individual who is able to work with varying levels of supervision – independently or collaboratively. You are detail-oriented and a decisive decision maker who is able to manage multiple priorities at the same time with a positive attitude. Location: Remote/Flexible – work primarily from home. May be expected to come into a Guardian work location occasionally, as determined by their people leader. 0-10% possible travel.
A minimum of 5 years of Group Disability and/or Life claims experience. A minimum of 3 years of experience handling appeals or complex claims (preferred). Bachelor’s Degree (preferred) or equivalent professional experience. A client focus with excellent verbal and written communication skills. Strong problem-solving, analytical, math aptitude and information research skills. Demonstrated ability to manage multiple tasks in accordance with regulatory requirements. The ability to remain flexible due to changing business needs.
Utilize effective claim management skills to plan, implement and execute the investigation of disputed claims; ensure timely and compliant appeal resolution. Identify and interpret relevant plan language and thoroughly investigate all claim issues to make an accurate and non-biased appeal determination. Evaluate medical, financial and other claim information in consultation with clinical/vocational professionals for the purpose of resolving disputes. Utilize proactive outreach to provide superior customer service to all internal and external customers. Identify legal and/or compliance scenarios that require additional research; facilitate resolution. Maintain current knowledge of all ERISA and Department of Labor guidelines. Independently prioritize workload based on individual and departmental deadlines. Readily share insights and learnings with claims colleagues.
At Guardian, you’ll have the support and flexibility to achieve your professional and personal goals. Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.
The Senior RN Clinical Consultant will work in partnership with Clinical and Vocational Leaders to provide ongoing coaching and oversight to Clinical Consultants and will serve as clinical subject matter expert in all lines of business (STD/LTD/Appeals) and products, action planning management, and Guardian systems. This incumbent will have a strong clinical and client focus to assist in ensuring the fair and accurate assessments of medically supported functional abilities. They will assist in cultivating talent and foster an environment of continuous learning. They will promote organizational excellence by demonstrating leadership, problem-solving behaviors, and viewing challenges as opportunities. This individual will work with the Clinical Team Manager to drive performance and ensure the team meets their goals. They will effectively communicate & explain departmental initiatives and changes as they relate to organizational goals & strategies. They will assist the Clinical Team Manager in managing and resolving issues that come up related to clinical processes, claim management activities, customer inquiries, and quality. You are: A highly motivated and reliable individual who can work with varying levels of supervision – independently or collaboratively. You are diligent and a decisive decision maker who can prioritize multiple tasks simultaneously with a positive attitude. Location: This is a remote position with occasional travel as needed for department meetings determined by the people leader.
A minimum of 3+ years of (STD, LTD, Appeals) claim experience, minimum of 2 years disability experience A minimum of 5 years in direct patient care settings RN REQUIRED, BSN and CCM preferred Demonstrated proficiency in verbal and written communication, as well as strong presentation abilities Ability to exercise independent & sound judgment in decision making Strong problem-solving, analytical, clinical, and information research skills Excellent time management & organizational skills Demonstrated ability to multi-task with the ability to manage continually changing priorities and the ability to prioritize work based on customer service needs and departmental regulations The ability to remain flexible due to changing business needs Proven track record to mentor and coach Proficiency in MS Word, Excel, PowerPoint, DCMS, Claim Facts, and iProcess
Train and mentor, all new Clinical Consultants Provide ongoing training, coaching and development to all Clinical Consultant members Organize and present at least one Clinical Training session for the Claims teams over the course of a year Work with Team Manager to delegate, distribute, and monitor workloads within the department to meet departmental regulations, improve efficiency and reduce or eliminate backlogs Assist Team Manager when needed to monitor caseloads, productivity, and participate in calibration sessions with our Clinical CMA and provide feedback to leadership and team members Oversee external vendor utilization within team Leverage knowledge and skills to flex and assist the overall team meet its goals, (i.e., assist with STD/LTD/ Appeals, flex and assist if needed) Collaborate with claims partners to resolve conflicts and establish procedures that promote clinical claim management accuracy and improved customer service Address escalated customer inquiries and formal complaints. Senior BHCM will also be first point of contact for SI or mental health crisis calls Support training initiatives by identifying knowledge gaps and providing ideas for improvement Support Clinicians in developing efficient desk & time management skills Collaborate with peers and leadership to ensure consistency with mentoring and coaching Co-facilitate team meetings to share best practices, workflow changes, trends, and insights in alignment with Group benefits strategies Provide desk coverage for leadership as needed
Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.
This remote work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOB Responsible for promoting continuity of care through a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates care options and services available to members through their benefit plan that meet the individuals' health care needs while promoting quality, cost effective outcomes. This job description is primary for case management functions but can assist with utilization management if a business need arises.
Required Work Experience 2 year(s) of experience in full-time equivalent of direct clinical care to the consumer Required Education Associate’s Degree in general field of study or Post High School Nursing Diploma or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D Required Licenses Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN. Required Certifications Within 4 years of hire as a Care Manager employee must hold a certification in case management from the following certifications; Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC). PREFERRED QUALIFICATIONS Preferred Work Experience 3 year(s) of experience in full-time equivalent of direct clinical care to the consumer (managed care CM experience preferred) 1-2 year (s) of experience working in a managed care organization Preferred Education Bachelor's Degree in Nursing or Health and Human Services related field of study Preferred Licenses N/A Preferred Certifications Active and current certification in case management from the following certifications; Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC). Required Job Skills: Intermediate PC proficiency Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones Intermediate skill in word processing, spreadsheet, and database software Required Professional Competencies: Maintain confidentiality and privacy Advanced and current clinical knowledge Practice interpersonal and active listening skills to achieve customer satisfaction Interpret and translate policies, procedures, programs, and guidelines Capable of investigative and analytical research Demonstrated organizational skills with the ability to priortize tasks and work with multiple priorities Follow and accept instruction and direction Establish and maintain working relationships in a collaborative team environment Apply independent and sound judgment with good problem solving skills Navigate, gather, input, and maintain data records in multiple system applications Required Leadership Experience and Competencies Conflict Resolution Represent BCBSAZ in the community PREFERRED COMPETENCIES Preferred Job Skills Advanced PC proficiency Knowledge of CPT 2018 and ICD-10 coding Preferred Professional Competencies Knowledge of managed care, utilization management, and quality management Working knowledge of McKesson InterQual, MCG, ASAM, or other nationally recognized criteria Knowledge of a wide range of matters pertaining to the organizations services and operations Knowledge of health and/or patient education and behavior change techniques Preferred Leadership Experience and Competencies N/A
Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan. Answer a diverse and high volume of health insurance related customer calls on a daily basis. Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc. Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests. Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director. Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries. Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines. Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements. Maintain complete and accurate records per department policy. Demonstrate ability to apply plan policies and procedures effectively. When indicated to assist with team/project functions: Collaborate with team to distribute workload/work tasks; Monitor and report team tasks; Communicate team issues and opportunities for improvement to supervisor/manager; Support/mentor team members. Participate in continuing education and current development in the field of medicine, behavioral health and managed care at least annually. The position has an onsite expectation of 0 days per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned.
A&G INFUSION SERVICES INC. is the most reliable and trustworthy Home Infusion service in Southern California — providing excellent home infusion solutions to patients who are dealing with injury or illness. We are committed to meeting all of your health needs, and go above and beyond to ensure you get the best care available. Our experienced medical professionals put your healing needs first. We are proud to provide a high-quality level of customer service, medical experience, and commitment to health and wellness to all our patients. Our goal is to make you feel better as quickly as possible.
We are seeking an experienced and compassionate IVIG Infusion RN to provide high-quality, in-home infusion therapy services. The ideal candidate will deliver safe, efficient, and patient-centered care while supporting patients with chronic conditions requiring IVIG and other specialty infusions.
Active RN license in CA. Minimum 1 year of experience in infusion therapy, including IVIG administration. Proficiency in peripheral IV insertion, central line management, and infusion protocols. Strong clinical assessment and patient education skills. Reliable vehicle and valid driver’s license required. Excellent communication and interpersonal skills. Work Location: On the road Employment Type: Contract, Per diem This is a remote position.
Administer IVIG, antibiotics, TPN, and other specialty medications in patients’ homes. Insert and manage peripheral IVs, PICC lines, port-a-caths, and other central lines. Perform blood draws and monitor patient response during infusion therapy. Provide patient education on self-administration, medication management, and infusion safety. Collaborate with the healthcare team to develop and follow individualized care plans. Maintain accurate and timely documentation of nursing interventions and patient progress.
Galileo is a team-based medical practice working to improve the quality and affordability of health care for all. Operating across 50 states, Galileo offers high-touch, data-driven, multi-specialty, longitudinal care to diverse and complex patients—on the phone, in the home, and everywhere in between. Regional and national health plans, employers, and Fortune 500 organizations trust Galileo as the leading solution to improve population health. Founded by Dr. Tom X. Lee, the healthcare pioneer behind One Medical and Epocrates, Galileo is a team of leading innovators from healthcare, technology, and human-centered design. Our mission is to apply that talent and scientific thinking to transform society by solving our largest, toughest healthcare problems, while at the same time bringing patient and provider closer.
Are you a Registered Nurse who thrives on connecting with patients and making a real difference in their health outcomes? Do you want to leave behind rigid, cookie-cutter systems and join a dynamic, patient-centered organization that values your creativity and clinical expertise? If you are passionate about improving patient outcomes and enjoy making meaningful connections, we want you to be part of our team at Galileo! At Galileo, we’re transforming healthcare by delivering personalized, comprehensive care to those who need it most—underserved patients and patients with complex medical needs. Our focus is on patient engagement and outcomes, and we’re looking for someone just like you to join our growing team of healthcare heroes. This is a remote, full-time position at 40 hours/week. We're currently hiring for a schedule of Monday-Friday from 10am-6:30pm ET, with one weekend per month.
About You: You’re a “people person”. You love to connect with others and have an innate ability to build rapport and quickly engage with new patients. Your curious nature and creativity comes through in conversations with others. You’re looking for a new environment where your natural ability can shine and you’re given the ability to thrive. We look for passionate Registered Nurses who are invested in solving complex problems that impact millions of lives and are excited about fixing what’s broken to improve care quality and health outcomes for everyone. We believe in a culture that fosters teamwork, excellence, and sound decision-making—one that is based on mutual respect and trust. We would love to hear from you if you have the following or equivalent experience: 2+ years of experience in case management in insurance organizations or VBC health care startups OR as a primary care RN with population health experience Engaging with Medicare and Medicaid populations with complex chronic conditions Nurse Licensure Compact (NLC) required Active RN license(s) in NY, NV, MI, MN, OR, CA, MA, CT and/or IL a plus Ability to leverage your motivational interviewing skills to encourage patients to make behavioral changes Excellent written and verbal communication skills Familiarity with Population Health and HEDIS quality gaps in care preferred Well versed with operating in an Mac iOS and Google Suite technology environment Physical Requirements: Employee must be able to meet the following requirements with or without a reasonable accommodation: This is primarily a sedentary position. Physical requirements may include lifting up to 10 pounds, manual dexterity, near/far visual acuity, keyboarding, the ability to hear, understand, and distinguish speech, sitting, standing, walking, and screen usage 8 or more hours per day.
Telephonic outreach, including cold calls, to patients for post discharge assessments of clinical symptoms, barriers to medication adherence, safety concerns, social needs Educate and coordinate preventative health screenings Perform chronic disease management and medication adherence education Navigate conversations with patients seeking insight on Galileo’s care model Facilitate the coordination of care between health care services, including hospital/ED care, pharmacies and community providers to improve patient outcomes Develop an understanding of various health plan contracts / goals, Galileo markets, and needs of various patient populations Be accountable to performance targets as an individual contributor Collaborate internally with Engagement and Population Health leadership to improve population outcomes
This course and practicum experience provide an opportunity for students to apply newly acquired knowledge and skills as they participate in the evaluation, treatment, and management of patients seeking primary care services. Although practicum experiences may include a variety of adult patients, there is a focus on caring for adolescent, young adult, and adult patients. Students apply the knowledge of advanced assessment and diagnostic reasoning to formulate treatment plans for primary care patients within the ages of adolescence through adult. Emphasis is placed on the identification of signs and symptoms of disorders, selecting treatments and pharmacological interventions, inclusive of health promotion, health restoration and maintenance, and evidence-based practice in primary care settings.
Reporting Relationships: Adjunct Faculty will report to an Academic Dean Responsibilities: Competency-Based Education (CBE) allows students to master content and skills within a course or program at their own pace and prioritizes the demonstration of student learning over time. Students are able to show what they know when they know it. CBE courses are broken into multiple modules that are self-paced. Each module has an assessment at the end of it that allows students to demonstrate their mastery of the material. CBE Combined Instructional/Assessment Adjunct Faculty model consists of one faculty member facilitating and grading student assignment submissions. Faculty are responsible for running a number of live sessions during the week based on student need. These live sessions will cover a variety of topics including help with submissions, open office hours, content delivery, and general success strategies. Grading is facilitated through the use of detailed rubrics and feedback.
Experience and Qualifications: Teaching experience preferred. (Minimum of 3 years’ experience in the field of study) Self-motivated, flexible, and able to work in a team environment with minimal supervision Strong interpersonal skills to interact with students, leadership, and peers. Excellent written communication and strong verbal communication skills in the English language. Online adjuncts will need regular access to a computer with the following system requirements Windows XP or greater Microsoft Office 2010 An internet connection Education, certifications and Licensures: Doctorate in Nursing Must hold active Minnesota RN License and certified AGNP 2-3 years experience as an AGNP Rasmussen University follows the requirements set by the Department of Education, accrediting agencies, and the states in which the campuses operate. Must be able to provide professional licenses/certifications required for specialized schools (Health Sciences, Nursing) before teaching. License must be active and unencumbered Must be able to provide official transcripts for each degree earned from an accredited institution before teaching. Location: This position is remote but not available to CO residents
The essential function of the position include, but are not limited to the following tasks, duties, and responsibilities consistent with the function. The employee is expected to perform all other duties as requested, directed, and/or assigned. Adjunct faculty will be assigned up to 3 work units per academic quarter. Teaching Effectiveness: Professionalism, Use of Technology, and Content Expertise Dynamic, Active Classroom Use of effective teaching strategies and multiple teaching techniques; teaching and modeling appropriate level learning skills and creating an environment conducive to learning Creating high levels of student engagement through activities, community building, and student-centered learning including the use of live classroom tools to hold synchronous learning sessions with students Clarity, relevance, and connection of class session objectives to course performance objectives Organized classroom and efficient use of class time Subject Matter Expertise Demonstrate mastery and ability to articulate and relate to students Play an integral role in the development and implementation of curriculum and assessment for their area of expertise Student and University Support and Professionalism: Faculty are responsible for creating a classroom presence in support of students in collaboration with their Dean Student support and outreach that supports the success of students is accomplished through faculty availability to students in all courses through synchronous or asynchronous communication and meetings to help students achieve the learning objectives for their course(s) Faculty Meetings and other responsibilities: Faculty will attend events, programmatic meetings, and committee work as agreed upon and/or designated by the Dean Appropriate behavior, language, professional communication, demeanor and dress will be exhibited at all times Professional Development Faculty must complete a minimum of six (6) Rasmussen Educational Units (REUs) annually or two (2) REUs per quarter for each quarter you teach (whichever is less) between the combined areas of Teaching Development and Development in Discipline on an annual basis as described in the faculty handbook
Compassion, Accountability, Relationships and Excellence are the core values for American Senior Communities. These words not only form an acronym for C.A.R.E., but they are also our guiding principles and create the framework for all our relationships with customers, team members and community at large. American Senior Communities has proudly served our customers since the year 2000, with a long history of excellent outcomes. Team members within each of our 100+ American Senior Communities take great pride in our Hoosier hospitality roots, and it is ingrained in everything we do. As leaders in senior care, we are not just doing a job, but following a calling.
American Senior Communities is now hiring a Community Nurse Liaison (LPN) Hours: Monday – Friday 4p – 8p and Weekends 9a – 6p Remote position but must live within reasonable driving distance to Indianapolis.
Minimum of three years of clinical experience in acute care or long-term care setting. Must be able to work weekends and evenings. Current LPN License
The Clinical Nurse Liaison provides patient evaluations, while collaborating with hospital personnel to determine patient’s clinical needs and appropriateness for admission to skilled nursing facility. This position works closely with our communities and healthcare partners. This position will also be checking benefits and payor sources.
An independent licensee of the Blue Cross Blue Shield Association, Highmark Inc., together with its Blue-branded affiliates, collectively comprise the fifth largest overall Blue Cross Blue Shield-affiliated organization in the country with approximately 7.1 million members in Pennsylvania, Delaware, West Virginia and western and northeastern New York. The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield; CPA/SEPA: Highmark Inc. d/b/a Highmark Blue Shield; Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield; West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield; Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield; Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield. All references to “Highmark” are to Highmark Inc. and/or to one or more of its affiliated Blue companies. We're proudly part of Highmark Health.
This job has primary ownership and oversight over a specified panel of members that range in health status/severity and clinical needs. The incumbent assesses health management needs of the assigned member panel and utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent will be supported by a multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent will manage an active case load of members in his/her panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but is not limited to developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial and functional) for the specified panel of members.
Required: High School Diploma/GED Substitutions None Preferred Bachelor's Degree in Nursing EXPERIENCE Required 7 years of any combination of clinical, case management and/or disease/condition management experience, provider operations and / or health insurance experience Preferred Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT) Experience working with the healthcare needs of diverse populations Understanding of the importance of cultural competency in addressing targeted populations LICENSES AND CERTIFICATIONS Required Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) or WV or DE or NY is required. Other RN license(s), if applicable, must be obtained within the first 6 months of employment. Preferred Certification in Case Management SKILLS Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion Broad knowledge of disease processes Understanding of healthcare costs and the broader healthcare service delivery system Proficiency in MS Excel and strong analytic skills with ability to interpret, evaluate and act on clinical and financial data, including analysis of statistical data Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization Ability to work in a high performing team environment that requires flexibility Demonstrated ability to handle multiple priorities in a fast paced environment. Excellent organizational, time management and project management skills Self-directed; self-starter, ability to work successfully with indirect supervision and moderate autonomy LANGUAGE REQUIREMENT (Other Than English) None TRAVEL REQUIREMENT 0% - 25% PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS Position Type Office-Based Teaches/Trains others regularly Rarely Travels regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (Sales employees) Does Not Apply Physical Work Site Required No Lifting up to 10 pounds Rarely Lifting 10 to 25 pounds Rarely Lifting 25 to 50 pounds Rarely
Maintain oversight over specified panel of members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support. For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment. Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved. Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards. Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization. Other duties as assigned or requested.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. As a growing and innovative organization, we operate with a high degree of agility. Employees are expected to adapt to evolving business needs, step in to support cross-functional initiatives, and contribute beyond traditional role boundaries when needed. This collaborative and flexible mindset is essential to our success. We encourage cross-training, ongoing development, and a commitment to learning across all areas of the business—ensuring we continue to grow and you continue to thrive as a high-performing, mission-driven team.
As an RN Case Manager, you will partner with clinical teams to provide complex case management and strengthen the connection between the patient, the primary care physician/medical practice staff, and the patient’s care team. The Registered Nurse (RN) Case Manager is responsible for a specific patient population experiencing complex medical conditions, socio-economic, and/or mental health co-morbidities. The RN Case Manager will optimize the patient’s health status through assessment, planning, implementation, coordination, monitoring, and evaluation of the options and services available to the patient. The RN Case Manager collaborates with their assigned Healthguides to achieve optimal quality, clinical, and financial outcomes. This is primarily a remote position that will require travel as needed (10%-15%) to clinical sites in the Atlanta, GA area.
Licensed Registered Nurse in good standing in the State of Georgia with a compact license. 3+ years of RN Case Management experience in an outpatient setting. Bachelor of Science in Nursing, preferred. Certification in Case Management, preferred. Strong problem-solving skills to diagnose, troubleshoot, and resolve barriers to patient care, workflows, and care plan progression. Ability to analyze complex healthcare challenges and implement effective solutions while maintaining compliance within a high-regulation healthcare environment. Ability to manage multiple priorities, meet deadlines, and work independently in a fast-paced environment, ensuring timely and efficient case management. Exceptional written, visual, and verbal communication skills. Ability to participate in virtual meetings with clear verbal communication, engaging effectively with healthcare teams, patients, and stakeholders. Exceptional conversational skills and the ability to precisely document patient interviews, leveraging software in real time. Strong interpersonal skills with a focus on empathy, patience, professionalism, and respect in all patient, team, and client interactions. Demonstrated competency and ability to independently navigate technology using multiple platforms, computer screens, and other technical components (i.e., Electronic Medical Records, care management analytics databases, phone dialing system, Microsoft Office). Ability to meet accreditation and quality standards, including but not limited to NCQA and HEDIS. Observance of patient confidentiality through the use of the provided headset during all conversations in a private home office without distraction. Compliance with all Guidehealth policies and procedures. What we'd love for you to have: BSN and Case Management certification preferred.
Conducting in-depth telephonic assessments to understand each patient’s medical, psychosocial, and social needs. Reviewing and updating medical histories—including medications, chronic conditions, and preventive care. Developing individualized care plans and guiding patients through their treatment goals and care options. Providing empathetic, evidence-based education on chronic disease management and preventive health. Monitoring progress by phone, adjusting care plans, and ensuring patients stay connected to their providers. Completing Medicare Annual Wellness Visits (AWVs) via telehealth under physician supervision. Partnering with Healthguides who support non-clinical needs such as scheduling, transportation, food assistance, and SDOH resources. Performing proactive outreach and timely follow-ups to maintain continuity of care and patient engagement. Advocating for patients, helping them access the right resources at the right time. Documenting clearly and accurately in the EHR and care-management systems during and after calls. Supporting quality outcomes (HEDIS, NCQA) by coordinating preventive services and managing chronic conditions. Participating in virtual meetings, ongoing education, and clinical training to stay current with care standards. Using multiple communication methods (phone, text, patient portals, email, AI-supported tools) to reach high-risk patients. Collaborating in AI-driven outreach programs that help connect with vulnerable populations. Protecting patient privacy in a secure, private home workspace. Performing additional responsibilities as needed to support patients and the care team.
Serving communities across Michigan and beyond, Henry Ford Health is committed to partnering with patients & members along their entire health journey. Henry Ford Health provides a full continuum of services – from primary and preventative care, to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care & other healthcare retail. It is one of the nation’s leading academic medical centers, recognized for clinical excellence in cancer care, cardiology and cardiovascular surgery, neurology and neurosurgery, orthopedics and sports medicine, and multi-organ transplants. Consistently ranked among the top five NIH-funded institutions in Michigan, Henry Ford Health engages in thousands of research projects annually. Equally committed to educating the next generation of health professionals, Henry Ford Health trains more than 4,000 medical students, residents and fellows every year across 50+ accredited programs. With more than 50,000 valued team members, Henry Ford Health is also among Michigan’s largest and most diverse employers. President and CEO Bob Riney leads the health system and serves a growing number of customers across more than 550 sites across Michigan. That includes: 13 acute care hospitals; 3 behavioral health facilities including two world-class addiction treatment centers; a state-of-the-art orthopedics and sports medicine facility; multiple cancer care destinations including the Brigitte Harris Cancer Pavilion, Henry Ford Health’s premier location in Detroit; & more options than ever for primary care for patients and families across the region.
Position: 36 hours per week Shift: Afternoons 12 Hour Shifts Every other weekend and Holiday Rotations Benefits: Full time benefit package MUST be within driving distance of Elijah McCoy building in downtown Detroit for purposes of ongoing training and if internet is down at remote location
Education/Experience Required: Bachelor's degree in nursing. Three (3) years of clinical experience. Experience facilitating InterQual reviews, admission process preferred. Experience with systems that support patient flow, admission, and transfer preferred. Ability to prioritize, meet deadlines and produce detailed and accurate work. Excellent clinical knowledge and assessment skills to evaluate and prioritize care issues. Ability to assess and handle highly sensitive and confidential matters with considerable discretion and independent judgment. Demonstrated positive work ethic and strong sense of teamwork/problem solving with co-workers. Understanding of Henry Ford Health policies and procedures preferred. Certifications/Licensures Required: Licensed as a Registered Nurse in the State of Michigan
Within the System Capacity Command Center (SC3) at Henry Ford Health, the Access Management Nurse operates under minimal supervision, to review and screen recommended admission cases at Henry Ford Health System Emergency Departments (ED). Utilizes clinical and regulatory knowledge and skills to reduce financial risk and exposure due to inappropriate admissions. Collaborates with ED physicians, attending physicians, and third-party payers regarding initial screening reviews. Facilitates throughput in the most cost-effective manner, through continuous assessments, problem identification, and education.
Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. We deliver goal-centered care focused on alleviating physical symptoms and emotional stress for individuals and their caregivers. Our interdisciplinary care teams reduce avoidable hospitalizations and improve quality of life wherever individuals call home. Through our leading-edge care model, Tuesday Health is shaping the future of community-based palliative care nationwide.
The Complex Care Navigator LPN plays a key role in delivering coordinated, compassionate care for members with serious illnesses. Working closely with nurse practitioners and registered nurses, the LPN administers clinical assessments and screenings throughout the care journey. They prioritize member needs based on assessment results and collaborate with the interdisciplinary team to develop and execute individualized care plans. The LPN ensures seamless communication, participates in care rounds, and leverages Tuesday Health’s electronic tools to optimize the member experience. Trust-building, empathy, and consistent member engagement are essential to the role, enabling a truly person-centered approach to care.
Active and unrestricted licensed practical nurse license in the State of Massachusetts without any board action Experience in clinical/medical setting preferred Experience in a multi-disciplinary care model working across network providers, health plan care management support, and employed clinicians Strong communication and organization skills Ability to multitask and work under pressure without sacrificing a positive member experience Ability to know when to escalate and potentially act professionally in an emergent situation Strong technical skills to navigate different documentation systems and tools; as well as ability to learn new systems as the company grows and evolves Strong written skills Ability to drive during daytime, nighttime, or inclement weather Valid driver's license with safe driving record State minimum automobile insurance coverage Comfort with change and ambiguity; you understand that rapid changes to the business, strategy, organization, and priorities will come with rapid evolution of our business
Administer multiple assessments and screening tools within the clinical model at different times throughout the care timeline with the support of nurse practitioners and registered nurses Prioritize needs based on assessment results and task interdisciplinary care team Be accountable for care plan development within the multidisciplinary care team Participate in internal and joint rounds to ensure the member experience is optimal and coordinated Learn the Tuesday Health electronic systems, tools, technology, to deliver a coordinated approach to ensure the members have a unique experience Build a strong, trusting relationship with every member, where listening and empathy are the foundation of every interaction Serve as the quarterback of the multidisciplinary team transforming care for members with serious illness
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
This role provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. EMERGENCY DEPARTMENT SUPPORT UNIT This is a remote role supporting our California Health Plan. The role is remote, but candidates must have an active and valid CALIFORNIA RN license and must be willing to work the Pacific Time Zone shift hours as posted. 3-12 SHIFT 7:00 AM - 08:30PM PACIFIC HOURS, schedule will rotate Must commit to working every other weekend and 4 Molina recognized holidays per year. This role will be on a provider-facing phone queue for the entirety of the shift, excluding breaks and lunches.
At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Ability to prioritize and manage multiple deadlines. Excellent organizational, problem-solving and critical-thinking skills. Strong written and verbal communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications: Certified Professional in Healthcare Management (CPHM). Recent hospital experience in an intensive care unit (ICU) or emergency room.
Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. Processes requests within required timelines. Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. Requests additional information from members or providers as needed. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote the Molina care model. Adheres to utilization management (UM) policies and procedures.
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care.
Highlights of the skills and qualifications needed for the Medical Review Nurse: Registered Nurse with a compact/multi-state license Must be willing to work a schedule within the Central Time Zone, Monday - Friday Have at least 2 years of clinical experience as a nurse Have at least 1 year of experience in the following areas: utilization review, medical claims review, claims auditing, medical necessity review and/or coding experience Excellent skills working with Microsoft Office Suite Confidence in having multiple screens open and toggling between them to complete necessary forms and documentation REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. Preferred Qualifications: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience.
Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols.
CareOregon is a nonprofit, mission-driven health plan, focused on providing care to low-income Oregonians. The CareOregon family includes Columbia Pacific CCO, Jackson Care Connect, Housecall Providers and our work as part of Health Share of Oregon. We also support recruitment for the Oregon Health and Education Collaborative.
The Registered Nurse – Utilization Management I is responsible for supporting specific utilization management (UM) program functions within the Clinical Operations department. UM program functions include Benefit Management, Benefit Review, Appeals and Grievances and Health Related Services (HRS). Together they support the healthcare needs of members, determine the best medically appropriate services, and apply clinical-based criteria for decision-making while managing medical expenses. Estimated Hiring Range $100,350.00 - $122,650.00 Bonus Target Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.
Experience and/or Education: Current unrestricted Oregon RN license Minimum 2 years RN experience [OR 1 year RN experience AND 3 years’ experience in healthcare setting role(s) such as billing, coding, medical assistant, etc.] Preferred: More than 1 year RN experience Healthcare utilization management experience in the functional focus area (Appeals and Grievance, Benefits Review or Benefit Management) Experience with Medicaid and/or Medicare utilization management Knowledge, Skills And Abilities Required Knowledge Knowledge of Medicaid health plan and Medicare benefits Knowledge of applicable DMAP rules and regulations Knowledge of ICD-10, CPT, and HCPCS codes Familiarity with the principles of utilization management Familiarity with healthcare documentation systems Skills And Abilities: General computer skills including use of Microsoft Office applications and internet search functions Ability to use review criteria in accordance with departmental policies Ability to adhere to HIPAA regulations e.g., maintaining confidentiality of protected health information Ability to interpret and apply complex policies and procedures Ability to review work for accuracy Ability to independently prioritize work Ability to use critical thinking and problem-solving skills Strong spoken and written communication skills Strong interpersonal and customer service skills Ability to work effectively with diverse individuals and groups Ability to learn, focus, understand, and evaluate information and determine appropriate actions Ability to accept direction and feedback, as well as tolerate and manage stress Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day Ability to hear and speak clearly for at least 3-6 hours/day Working Conditions: Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person Hazards: May include, but not limited to, physical and ergonomic hazards. Equipment: General office equipment Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used. Work Location: Work from home
Communicate with members and/or providers in a professional manner and in accordance with State and Federal requirements as needed to complete requests. Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards. Refer members to care coordination per policies and procedures. Maintain accurate and complete documentation. Collaborate with Medical Directors to determine medical necessity and appropriateness of care for benefits requested and/or rendered. Work with clinical support staff to ensure service requests, authorizations and/or grievances are managed in accordance with state and federal guidelines. Identify and refer potential quality of care issues for peer review. Ensure that authorization decisions are based on organizational policy and state and federal coverage rules. Gather and submit documents for third party case review; this includes all documentation and follow-up activities. Issue denial notices based on established unit protocols and state and/or federal requirements. Assist with periodic audits, general quality management and improvement activities, and other regulatory activities as needed. Foster collaboration with teams across the Clinical Operations department to ensure work and goals are met. Meet or exceed department production, timelines, and quality standards established for level I. May participate in departmental workgroups or projects as assigned. Support testing for system updates and implementations as assigned. May help train new staff and teammates as assigned. Cross train in additional functional focus areas as assigned. Duties Specific To Functional Focus Area Benefit Management Review provider pre-service requests and determine benefit coverage according to Medicare, Medicaid and/or organizational guidelines Benefit Review Determine appropriate level of care and length of stay for inpatient members to include hospitals, skilled nursing facilities, long term acute care hospitals, inpatient rehabilitation hospitals, and respite care programs. Review inpatient admission for re-insurance clinical reporting. Appeals and Grievance Assemble evidence and build clinical cases for administrative hearings or Independent Review Entity (IRE) reviews. Function as a CareOregon representative in administrative hearings. Assist with the analysis and summary of data for written reports and public presentations as needed. Communicate with members, providers, health plan administrators to manage grievances and appeals and provide case status updates as needed. Investigate and use clinical judgement to identify quality of care or safety issues and present findings to an oversight committee. Health Related Services Review provider and member submitted HRSN and Flexible Services requests and determine benefit eligibility according to Medicaid and/or organizational guidelines. Organizational Responsibilities Perform work in alignment with the organization’s mission, vision and values. Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals. Strive to meet annual business goals in support of the organization’s strategic goals. Adhere to the organization’s policies, procedures and other relevant compliance needs. Perform other duties as needed.
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
We're making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Telephone Case Manager RN with UnitedHealth Group, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Apply today! The Telephonic Case Manager RN Behavioral Health will identify, coordinate, and provide appropriate levels of care. The Telephonic Case Manager RN Behavioral Health is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. This is high volume, customer service environment. You'll need to be efficient, productive and thorough dealing with our members over the phone. Solid computer and software navigation skills are critical. You should also be solidly patient-focused and adaptable to changes. This is a full-time, Monday - Friday, 8am-5pm position in your time zone. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Required Qualifications: Current, unrestricted Compact RN license in the state of residence 1+ years of experience with mental health/behavioral health/substance use focus Proficiency in Microsoft Office Tools and Systems (Outlook, Word, Excel, Teams) Access to high-speed internet (DSL or Cable) Dedicated work area established that is separated from other living areas and provides information privacy Preferred Qualifications: BSN Certified Case Manager (CCM) 3+ years of experience with a mental health/behavioral health/substance use focus Case management experience Experience or exposure to discharge planning Experience in a telephonic role Background in managed care Bilingual in English and Spanish All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.
Make outbound calls and receive inbound calls to assess members current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self-management Make referrals to outside sources Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
This Case Manager RN position is 100% remote, no travel is expected with this position. Normal Working Hours: Monday through Friday, 8 hour shift between 7am to 5pm Arizona time The Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management activities with members from our Federal Plans. The Case Manager is responsible to evaluate the medical needs of the member in order to facilitate and promote the member’s overall wellness. The Case Manager develops a proactive course of action to address issues presented to enhance the member's short and long term outcomes.
Required Qualifications: Must have active, current and unrestricted RN licensure in state of residence and have the ability to be licensed in all non-compact states. Must be willing and able to work Monday through Friday, 8 hour shift between 7am to 5pm Arizona time Must live in either PST, MST, or Arizona Time zones 3+ years of clinical practice experience required 1+ years of experience utilizing MS Office suites Preferred Qualifications: Case management experience preferred Case Manager Certification Education: Associate's degree required BSN preferred
Apply data driven methods of identification of members to fashion individualized case management programs and/or referrals to alternative healthcare programs. Conduct comprehensive clinical assessments. Evaluate needs and develop flexible approaches based on member needs, benefit plans or external programs/services. Advocate for patients to the full extent of existing health care coverage. Promote quality, cost effective outcomes, and make suggestions to improve program/operational efficiency. Identify and escalate quality of care issues through established channels. Provide an expected very high level of customer service. Utilize assessment techniques to determine member’s level of health literacy, technology capabilities, and/or readiness to change. Utilize influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health.
Private Health Management (PHM) supports people with serious and complex medical conditions, helping them obtain the best possible medical care. We guide individuals and families to top specialists, advanced diagnostics, and personalized care. Trusted by healthcare providers and businesses, PHM offers independent, science-backed insights to help clients make informed decisions and access the best care.
As an Associate Clinical Director at PHM, you’ll help patients in their deepest moment of need to challenge the status quo and go beyond the standard of care to achieve the best possible health outcomes. Working from your home office, you’ll serve as the lead clinician and engagement manager collaborating with team members through our process to uncover opportunities to improve your client’s care. Team members may include additional clinicians, PhD scientists who mine the medical literature to identify data-supported care options, and care coordinators who manage care-related logistics. You will utilize your clinical expertise and curiosity along with your tenacious problem-solving skills to ascertain the key issues that must be addressed, identify and engage with top experts, and guide patients to optimized care plans. In collaboration with your personal care team colleagues, you will explore specialized diagnostics to better define the underlying mechanisms and array of treatment options beyond the current standard of care. Cutting through the barriers inherent to our chaotic healthcare system, you enable patients to access an unrivaled level of personalized care and attention while guiding them to the best possible treatment plan available.
Active NP or PA license in your home state A “Do what it takes to get the job done” attitude Five years of clinical experience managing complex medical issues in an oncology and/or hematology environment where careful assessment and critical thinking are required Exceptional client-facing skills including: Executive written & verbal communication, impeccable attention to detail and organization, and a highly professional demeanor under pressure. An insatiable clinical curiosity. You’re never satisfied by “the obvious answer” you think creatively, solve complex problems, and work successfully with others. Technically savvy and feel comfortable navigating various tech platforms to efficiently document your work and communicate with your colleagues Significant bonus points for oncology experienced mixed with another complex discipline.
What You’ll Accomplish: Building Strong Client Relationships. You’ll become the trusted guiding hand through a client's healthcare journey by managing complex medical issues, coordinating their care, facilitating best diagnostic and therapeutic treatment options available world-wide, and navigating being their guide to the healthcare system Demonstrating Strong Clinical Acumen. You’ll offer high level clinical management and education to clients and families in a caring, compassionate manner. Bring Together the Best Minds: Work closely with clinical and research team members at PHM to identify latest therapies and deliver comprehensive information on medical conditions, medications, treatments, and clinical trials Articulating needs for collaboration with external care providers, interdisciplinary team resources, and internal team rounding Networking with key opinion leaders to invite collaboration and build relationships that facilitate our ability to help our clients achieve best care Managing other clinical staff as it relates to a particular case or service line
Private Health Management (PHM) supports people with serious and complex medical conditions, helping them obtain the best possible medical care. We guide individuals and families to top specialists, advanced diagnostics, and personalized care. Trusted by healthcare providers and businesses, PHM offers independent, science-backed insights to help clients make informed decisions and access the best care.
As a Nurse Advisor, Member Engagement, you’ll engage in a newly created role designed to bring clinical credibility and empathy into the earliest moments of a member’s journey to the best of what’s possible in medicine with PHM. This role serves as the first clinical touchpoint for members, helping them understand PHM’s value and guiding them toward the best steps in their care journey. In the role you’ll focus on outbound engagement, including proactive outreach, trust-building, and guiding members towards engaging with PHM’s service. Additionally, this role will offer support for inbound triage and member needs, helping ensure members receive timely guidance and are directed appropriately in coordination with the broader team. You’ll remove friction from the current process and create a seamless transition into PHM services for members facing cancer and other serious and complex illnesses, helping them get the absolute best of what medicine has to offer.
Required: Registered Nurse (RN) license with strong clinical judgment. Candidates with PA-C and Nurse Practitioner licensure will be considered as well. Proven ability to build trust quickly in phone-based or virtual interactions High emotional intelligence with the ability to navigate sensitive or skeptical conversations Comfort with outbound calling and engaging unfamiliar members Strong communication, active listening, and discovery skills Strong organization and ability to manage multiple interactions effectively Ability to operate in ambiguity with evolving workflows and expectations Nice to Have: Ability to work intermittent weekend days and/or cover Pacific & Mountain Time Zones Experience in outreach, engagement, or proactive communication roles Background blending clinical work with customer-facing or business responsibilities Experience in telehealth, call center, or remote care environments Experience in ER, triage, or case management settings
What You’ll Accomplish: Increase conversion from outreach to case opening through trust-based, clinically grounded conversations through direct outreach to eligible members Improve member responsiveness, including higher answer rates and sustained engagement Strengthen progression from initial contact to active case participation Build trust and credibility with employer partners through a high-quality engagement experience How You’ll Spend Your Days Outbound Member Engagement: Conduct outbound calls to eligible members, introducing PHM as a free and confidential benefit Establish trust quickly by clearly explaining privacy protections, independence, and value Navigate skepticism and emotional resistance with empathy and confidence Guide members toward a clear next step, including case initiation Maintain consistent outreach and thoughtful follow-up to drive engagement Support Triage RNs with by responding to inbound inquiries as needed Clinical Judgment & Member Navigation: Apply clinical credibility to strengthen engagement conversations Recognize when situations require escalation versus continued engagement Support smooth transitions into care teams Cross-Functional Collaboration: Partner with engagement, triage, and clinical teams to refine workflows and handoffs Contribute to the evolution of this role in a fast-changing environment
WNS Healthhelp, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries, including Banking and Financial Services, Healthcare, Insurance, Shipping and Logistics, and Travel and Hospitality. We bring together deep domain excellence - WNS’ core differentiator - with AI-powered platforms and analytics to help businesses innovate, scale, adapt and build resilience in a world defined by disruption. Our purpose is clear: to enable lasting business value by designing intelligent, human-led solutions that deliver sustainable outcomes and a differentiated impact. With three global headquarters across four continents, operations in 13 countries, 65 delivery centers and more than 66,000 employees, WNS combines scale, expertise and execution to create meaningful, measurable impact.
RN graduate from an accredited school of nursing (BSN preferred) Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent) Two (2) years of experience in an acute care setting, required Two (2) years of inpatient clinical nursing, utilization management, concurrent experience required Experience with InterQual or similar evidence-based clinical decision support criteria, preferred Willingness to complete and maintain InterQual certification and ongoing competency requirements Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements Knowledge of insurance terminology Experience working with state and federal regulatory and compliance standards, preferred Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required Good organizational and time management skills Excellent written and verbal communication skills Ability to utilize critical thinking skills Highly motivated, self-starter who can work efficiently and independently, or as a team member
Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including Admission reviews Continued stay reviews Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital) Related follow-up activities and documentation updates Engage in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions Facilitates resolution of escalated cases that may require special handling Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes Maintains written documentation according to HealthHelp’s documentation policy Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs Complies with URAC & NCQA standards or other requisite regulating bodies Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management Keeps current with regulation changes as provided by Compliance Department and Nursing Management Functions as subject matter expert to support Compliance Department initiatives and updates Collects and enters confidential information ensuring the highest level of confidentiality in all areas Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines Appropriately identifies and refers quality issues to UM Leadership Collaborates with client personnel to resolve customer concerns Provides quality customer service through interaction with providers, administrative staff, and others Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy Participates in the HealthHelp Quality Management Program, as required Performs other related duties and projects as assigned to meet business needs
Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus.
Position: Contingent Shift: Afternoons Every other weekend and Holiday Rotations MUST be within driving distance of Elijah McCoy building in downtown Detroit for purposes of ongoing training and if internet is down at remote location
EDUCATION/EXPERIENCE REQUIRED: Bachelor's degree in nursing. Three (3) years of clinical experience. Experience facilitating InterQual reviews, admission process preferred. Experience with systems that support patient flow, admission, and transfer preferred. Ability to prioritize, meet deadlines and produce detailed and accurate work. Excellent clinical knowledge and assessment skills to evaluate and prioritize care issues. Ability to assess and handle highly sensitive and confidential matters with considerable discretion and independent judgment. Demonstrated positive work ethic and strong sense of teamwork/problem solving with co-workers. Understanding of Henry Ford Health policies and procedures preferred. CERTIFICATIONS/LICENSURES REQUIRED: Licensed as a Registered Nurse in the State of Michigan
Within the System Capacity Command Center (SC3) at Henry Ford Health, the Access Management Nurse operates under minimal supervision, to review and screen recommended admission cases at Henry Ford Health System Emergency Departments (ED). Utilizes clinical and regulatory knowledge and skills to reduce financial risk and exposure due to inappropriate admissions. Collaborates with ED physicians, attending physicians, and third-party payers regarding initial screening reviews. Facilitates throughput in the most cost-effective manner, through continuous assessments, problem identification, and education.
Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus.
Position: 24 hours per week Shift: Midnights Every other weekend and Holiday Rotations Benefits: part time benefit package MUST be within driving distance of Elijah McCoy building in downtown Detroit for purposes of ongoing training and if internet is down at remote location
EDUCATION/EXPERIENCE REQUIRED: Bachelor's degree in nursing. Three (3) years of clinical experience. Experience facilitating InterQual reviews, admission process preferred. Experience with systems that support patient flow, admission, and transfer preferred. Ability to prioritize, meet deadlines and produce detailed and accurate work. Excellent clinical knowledge and assessment skills to evaluate and prioritize care issues. Ability to assess and handle highly sensitive and confidential matters with considerable discretion and independent judgment. Demonstrated positive work ethic and strong sense of teamwork/problem solving with co-workers. Understanding of Henry Ford Health policies and procedures preferred. CERTIFICATIONS/LICENSURES REQUIRED: Licensed as a Registered Nurse in the State of Michigan
Within the System Capacity Command Center (SC3) at Henry Ford Health, the Access Management Nurse operates under minimal supervision, to review and screen recommended admission cases at Henry Ford Health System Emergency Departments (ED). Utilizes clinical and regulatory knowledge and skills to reduce financial risk and exposure due to inappropriate admissions. Collaborates with ED physicians, attending physicians, and third-party payers regarding initial screening reviews. Facilitates throughput in the most cost-effective manner, through continuous assessments, problem identification, and education.
Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus.
This is a great place to work where you can use your clinical knowledge and experience to support the medical necessity of our patients being admitted to the hospital. You fight for the services that were performed and what should be appropriately paid for. We currently are working remotely. Yes sometime this could change but as of now it is remotely.
EDUCATION AND EXPERIENCE: Registered Nurse with a valid, unrestricted, State of Michigan License required. Minimum 3-5 years of clinical experience required. Bachelor of Science Nursing required or three years Denial/Appeal/Utilization Management experience. Knowledge of hospital billing and payer regulations, including criteria for patient status determination, and tools/software used for determination.
Under minimal supervision, this RN specializes in follow-up of denied and rejected claims from all commercial, contracted and non-contracted payers, including preparing appeal letters. Working within a centralized department, reviews all denials for medical necessity and appeal ability utilizing clinical judgment and applying appropriate medical necessity criteria. Provides clinical utilization management expertise to provide education, formal and informal and facilitates denial management strategies. Serves as a liaison to key customers that include, hospital ancillary departments, physicians, and payers.
Serving communities across Michigan and beyond, Henry Ford Health is committed to partnering with patients & members along their entire health journey. Henry Ford Health provides a full continuum of services – from primary and preventative care, to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care & other healthcare retail. It is one of the nation’s leading academic medical centers, recognized for clinical excellence in cancer care, cardiology and cardiovascular surgery, neurology and neurosurgery, orthopedics and sports medicine, and multi-organ transplants. Consistently ranked among the top five NIH-funded institutions in Michigan, Henry Ford Health engages in thousands of research projects annually. Equally committed to educating the next generation of health professionals, Henry Ford Health trains more than 4,000 medical students, residents and fellows every year across 50+ accredited programs. With more than 50,000 valued team members, Henry Ford Health is also among Michigan’s largest and most diverse employers. President and CEO Bob Riney leads the health system and serves a growing number of customers across more than 550 sites across Michigan. That includes: 13 acute care hospitals; 3 behavioral health facilities including two world-class addiction treatment centers; a state-of-the-art orthopedics and sports medicine facility; multiple cancer care destinations including the Brigitte Harris Cancer Pavilion, Henry Ford Health’s premier location in Detroit; & more options than ever for primary care for patients and families across the region.
Position: 36 hours per week Shift: Midnights 12 Hour Shifts Every other weekend and Holiday Rotations Benefits: Full time benefit package MUST be within driving distance of Elijah McCoy building in downtown Detroit for purposes of ongoing training and if internet is down at remote location
Education/Experience Required: Bachelor's degree in nursing. Three (3) years of clinical experience. Experience facilitating InterQual reviews, admission process preferred. Experience with systems that support patient flow, admission, and transfer preferred. Ability to prioritize, meet deadlines and produce detailed and accurate work. Excellent clinical knowledge and assessment skills to evaluate and prioritize care issues. Ability to assess and handle highly sensitive and confidential matters with considerable discretion and independent judgment. Demonstrated positive work ethic and strong sense of teamwork/problem solving with co-workers. Understanding of Henry Ford Health policies and procedures preferred. Certifications/Licensures Required: Licensed as a Registered Nurse in the State of Michigan
Within the System Capacity Command Center (SC3) at Henry Ford Health, the Access Management Nurse operates under minimal supervision, to review and screen recommended admission cases at Henry Ford Health System Emergency Departments (ED). Utilizes clinical and regulatory knowledge and skills to reduce financial risk and exposure due to inappropriate admissions. Collaborates with ED physicians, attending physicians, and third-party payers regarding initial screening reviews. Facilitates throughput in the most cost-effective manner, through continuous assessments, problem identification, and education.
An independent licensee of the Blue Cross Blue Shield Association, Highmark Inc., together with its Blue-branded affiliates, collectively comprise the fifth largest overall Blue Cross Blue Shield-affiliated organization in the country with approximately 7.1 million members in Pennsylvania, Delaware, West Virginia and western and northeastern New York.
This job has primary ownership and oversight over a specified panel of members that range in health status/severity and clinical needs. The incumbent assesses health management needs of the assigned member panel and utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent will be supported by a multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent will manage an active case load of members in his/her panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but is not limited to: developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial and functional) for the specified panel of members.
Required High School Diploma/GED Substitutions None Preferred Bachelor's Degree in Nursing EXPERIENCE Required 7 years of any combination of clinical, case management and/or disease/condition management experience, provider operations and / or health insurance experience Preferred Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT) Experience working with the healthcare needs of diverse populations Understanding of the importance of cultural competency in addressing targeted populations LICENSES AND CERTIFICATIONS Required Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) or WV or DE or NY is required. Other RN license(s), if applicable, must be obtained within the first 6 months of employment. Preferred Certification in Case Management SKILLS Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion Broad knowledge of disease processes Understanding of healthcare costs and the broader healthcare service delivery system Proficiency in MS Excel and strong analytic skills with ability to interpret, evaluate and act on clinical and financial data, including analysis of statistical data Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization Ability to work in a high performing team environment that requires flexibility Demonstrated ability to handle multiple priorities in a fast paced environment. Excellent organizational, time management and project management skills Self-directed; self-starter, ability to work successfully with indirect supervision and moderate autonomy LANGUAGE REQUIREMENT (Other than English) None TRAVEL REQUIREMENT 0% - 25% PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS Position Type Office-Based Teaches/Trains others regularly Rarely Travels regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (Sales employees) Does Not Apply Physical Work Site Required No Lifting: up to 10 pounds Rarely Lifting: 10 to 25 pounds Rarely Lifting: 25 to 50 pounds Rarely
Maintain oversight over specified panel of members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support. For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment. Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved. Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards. Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization. Other duties as assigned or requested.
At Harbor Health, we’re transforming healthcare in Texas through collaboration and innovation. We’re seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you’re ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!
Candidate should reside in Texas Harbor Health is seeking a dedicated Utilization Management (UM) LVN. The UM LVN supports prior authorization and utilization review activities to ensure timely and appropriate access to care. This role collaborates with the UM team, providers, and members to facilitate authorization processes, coordinate clinical information, support medical necessity determinations, and maintain regulatory compliance. The UM LVN also provides ongoing communication and coordination support for high-need and high-cost members to promote appropriate utilization and continuity of care. Shifts and Business Hours This position is fully remote Monday-Friday 8am - 5pm with the exception of Saturday coverage once every 5 weeks on rotation for 4 hours.
Desired Professional Skills & Experience: Current, unrestricted LVN license. Minimum of 2–3 years of clinical experience; prior Utilization Management or Case Management experience preferred. Knowledge of Texas social service programs for members in need both local and state-wide preferred Familiarity with NCQA processes and requirements Knowledge of CPT codes and prior authorization requirements. Familiarity with utilization review processes and medical necessity determinations. Strong organizational and workflow management skills. Excellent written and verbal communication skills. Ability to assess member needs, provide education, and escalate concerns appropriately. Proficiency in Google Workspace, EHR systems and electronic UM platforms Ability to manage multiple cases while meeting regulatory timelines Ability to work independently and within a team-based model to deliver excellent care.
Coordinate and manage prior authorization workflows in collaboration with the Utilization Management (UM) team. Monitor incoming authorization requests via fax and phone and ensure timely case entry into the designated tracking system and UM platform. Review submitted clinical documentation and verify CPT codes to determine prior authorization requirements. Prepare and submit applicable cases to the contracted utilization review (UR) vendor for medical necessity determinations. Maintain accurate case documentation and track status to ensure compliance with regulatory turnaround times. Draft provider, facility, and member notification letters based on determination outcomes. Coordinate mailing and faxing of approved determination letters to appropriate parties and ensure proper documentation. Obtain and coordinate concurrent clinical documentation from hospitals, post-acute facilities, and other treating providers. Communicate with providers and facilities regarding required or missing clinical information to facilitate timely review. Provide clear communication to members and requesting providers regarding authorization status and documentation needs. Support high-need and high-cost members through ongoing communication and coordination to promote appropriate utilization and continuity of care. Assist with transitions of care and post-discharge coordination as applicable. Perform all duties in compliance with organizational policies and applicable state and federal regulatory requirements. Provide direct support to members with chronic diseases, ensuring continuity of care across chronic care pathways. Communicate regularly with members to assess progress, resolve barriers to care, and promote adherence to treatment plans.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. As a growing and innovative organization, we operate with a high degree of agility. Employees are expected to adapt to evolving business needs, step in to support cross-functional initiatives, and contribute beyond traditional role boundaries when needed. This collaborative and flexible mindset is essential to our success. We encourage cross-training, ongoing development, and a commitment to learning across all areas of the business—ensuring we continue to grow and you continue to thrive as a high-performing, mission-driven team.
The RN Case Manager serves as a trusted clinical partner to patients, families, providers, and interdisciplinary teams, guiding individuals through complex health journeys with compassion, clinical excellence, and purpose. This is a primarily remote position with telephonic and virtual engagement and occasional in‑person participation as program needs require. This position blends strong nursing judgment with a whole-person approach to care management, addressing medical, behavioral, and social needs to support optimal health outcomes. The RN Case Manager is responsible for assessment, care planning, coordination, monitoring, and evaluation of services for a defined population, including members with chronic, complex, and high-risk conditions. Working closely with primary care providers, patient navigators, and other care team members, the Care Manager – Registered Nurse ensures safe, effective, equitable, and patient-centered care within a value-based care model.
Active, unrestricted IL state Registered Nurse (RN) license in good standing Minimum of 3–5 years of clinical nursing experience, including care management, case management, or chronic/complex condition management. Strong clinical assessment, critical thinking, and care coordination skills. Experience working collaboratively within interdisciplinary teams. Proficiency with EMRs and comfort learning multiple documentation and care management platforms. Excellent written and verbal communication skills, including the ability to engage patients telephonically and virtually. Ability to work independently in a remote environment while maintaining strong team engagement. WHAT WE'D LOVE FOR YOU TO HAVE: Bachelor’s degree in nursing (BSN). Specialty certification in care management (CCM, ACM) or willingness to obtain within a defined timeframe. Experience in value‑based care, population health, managed care, or outpatient care settings. Supervisory or informal leadership experience. Multilingual skills.
Clinical Care Management: Conducting comprehensive clinical, psychosocial, and functional assessments to identify patient needs, risks, and goals. Developing, implementing, and maintaining individualized, evidence‑based care plans in collaboration with patients, families, PCPs, and the interdisciplinary care team. Providing clinical interventions and nursing support aligned with care plan goals, protocols, and accreditation standards. Monitoring patient progress through ongoing outreach, data review, and reassessment; adjust care plans as indicated. Developing patient‑specific escalation plans with providers for acute but non‑emergent changes in condition. Care Coordination & Advocacy: Coordinating care across providers, settings, and services to ensure continuity, safety, and quality. Partnering with patient navigators and non‑clinical team members to address social determinants of health, including access to transportation, food, housing, and community resources. Serving as a clinical advocate, assisting patients in accessing services requiring nursing licensure, clinical expertise, or care management oversight. Facilitating referrals and follow‑up to ensure timely connection to recommended services and resources. Patient & Family Engagement: Building meaningful, trusting relationships with patients and families through empathetic, culturally responsive communication. Providing education on conditions, treatment options, self‑management strategies, and navigation of the healthcare system. Empowering patients to make informed decisions and achieve greater health autonomy. Quality, Compliance, & Documentation: Maintaining accurate, timely, and compliant documentation in electronic medical records and care management systems. Utilizing evidence‑based clinical guidelines, internal protocols, and defined quality metrics (e.g., NCQA, HEDIS). Participating in quality, utilization management, and performance improvement activities as applicable. Maintaining strict confidentiality and adhere to all regulatory, accreditation, and organizational standards.
Built around a mission to improve the lives of nurses and patients, IntellaTriage has been providing after-hours nurse triage for hospice and home health providers since 2008. Utilizing best-in-class technology, IntellaTriage provides round-the-clock direct access to licensed, registered nurses using client-customized protocols for patient-centered, compassionate care. We are growing rapidly and excited to support our clients’ nursing staff in the field by leveraging our remote team of nurses to manage after-hours care delivery. Our triage nurses become an extension of our clients’ care team, and they trust us to support them and their patients during their non-core hours.
We are seeking a compassionate registered nurse (RN) to join our growing team! In this role, you will provide critical after-hours support, triaging hospice patients and family needs over the phone wit professionalism and empathy. You will help ensure timely interventions and coordination of care for patients receiving hospice services.
Active multistate Registered Nurse (RN) license Hospice, palliative, or end-of-life care is strongly preferred Must be comfortable with technology and electronic medical records (EMR) utilized for documentation of calls Ability and comfort with typing documentation and notes in a fast-paced environment Must be able to handle stress and multitask when receiving calls (minimum of 5 calls per hour on weekdays, and up to 8 per hour on weekends) Strong communication and critical thinking skills Ability to work independently in a remote environment This is a remote position that requires consistent attendance, active communication, and reliable internet connectivity during all scheduled shifts to support timely patient care coordination
Provide telephone triage for hospice patients and families Assess patient conditions and determine appropriate next steps Collaborate with on-call teams to coordinate care and resources Accurately document all communications and interventions Maintain a calm and professional demeanor while handling urgent calls.
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
Here at UnitedHealth Group, you're expected and empowered to be your best, to grow and to develop your skills. Join us and help people live healthier lives while doing your life's best work. Be part of an exciting team within Optum where you can utilize your Operations experience to support multiple internal teams as well as providers and patients. Work Schedule: Must be able to work Monday - Friday with a set schedule of hours between 7am - 7pm CST. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: The Specialty Appeals Registered Nurse role fills an integral role in drafting and submitting appeals for specialty patients with acute and chronic disease states. In this role you will be preparing appeal letters for submission, obtaining support documents, following up on prior authorization outcomes, and addressing issues and handling concerns from other corresponding departments.
Required Qualifications: Active, Registered Nurse License Willingness to obtain Case Management Certification (CCM) once eligible 2+ years of clinical experience as a Registered Nurse 1+ years of experience working with prior authorization, pre-certification, utilization review, and / or appeals experience Understanding of clinical documentation from physician offices Proficiency with MS Word, Excel, SharePoint Proven ability to work independently (At home or office) Preferred Qualifications: Bachelor's degree RN licenses in multiple states (outside of compact states) Case Management Certification (CCM) PBM and / or Managed Care experience Prior Authorization/Appeal Experience Knowledge of healthcare insurance plans, denials, and appeal procedures Advanced computer skills; Experience in a paperless role
Communicate with providers, patients, and pharmacy staff to obtain necessary clinical documentation, prior authorizations, and appeal letters Facilitate appeals process between the patient, physician, and insurance company by requesting denial information and facilitates obtaining the denial letter from the insurance, patient or physician. Composes clinical appeals letters based off of specific denial reason and patients clinical presentation. Ensures all clinical information and documentation are obtained prior to appeal submission Accessing multiple Optum resources to check PA, insurance and appeal status and benefits. Utilization of and proficiency in multiple internal processing systems for record keeping and tracking of letter determinations Interpret and utilize clinical documentation from providers, and different pharmacy/computer systems Utilizing multiple platforms, researching clinical studies for points of argument for appeals Write and return assigned appeals to providers Utilization of and proficiency in multiple internal processing systems for record keeping and tracking of determinations Assign appeal requests to coworkers as needed (rotating schedule) Perform other related duties as assigned You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. This role will require the ability to work a on Saturday either in a traditional 5 day work week schedule or working 4-10 hour shift but MUST be able to work until 5pm in residing time zone.
Required Qualifications: Active, unrestricted RN license in state of residence 5+ years of clinical experience as an RN including in an acute, inpatient hospital setting Experience applying benefits and criteria to clinical review Utilization Management, pre-authorization, concurrent review or appeals experience Solid computer skills including proficiency in Microsoft Office Word, Outlook, and Internet applications Ability to access multiple computer platforms Access to install secure high-speed internet (minimum speed 5 download mps & 1 upload mps) via cable/DSL in home (wireless / cell phone provider, satellite, microwave, etc. does NOT meet this requirement) Designated quiet workspace in your home (separated from non-workspace areas) and able to be secured to maintain Protected Health Information (PHI) and/or Protected Information (PI) Ability to work a on Saturday either in a traditional 5 day work week schedule or working 4-10 hour shifts Ability to work until 5pm in residing time zone Preferred Qualifications: Medical Coding experience/knowledge Experience using Interqual Experience with the following systems: UNET, iCUE/HSR, ATS, ETS or Cirrus Experience analyzing medical records, benefit plans, medical policies and other various criteria Demonstrated ability to work independently with solid self-discipline and time management skills Demonstrated excellent communication, interpersonal, problem-solving, and analytical skills
Conducts reviews of member and provider appeals Analyzes claim adjustment and claim history Reviews history of previous reviews Reviews denied services in conjunction with policies and procedures, benefit plans, federal and state regulations, and clinical criteria to and renders approval when appropriate Extrapolates and summarizes medical information for review by Medical Director, as needed Balances the need to produce high quality work with meeting timeframes and production goals You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Please see requirements for the schedules.
Required Qualifications: Active, unrestricted RN license in state of residence 5+ years of clinical experience as an RN including in an acute, inpatient hospital setting Experience applying benefits and criteria to clinical review Utilization Management, pre-authorization, concurrent review or appeals experience Solid computer skills including proficiency in Microsoft Office Word, Outlook, and Internet applications Ability to access multiple computer platforms Access to install secure high-speed internet (minimum speed 5 download mps & 1 upload mps) via cable/DSL in home (wireless / cell phone provider, satellite, microwave, etc. does NOT meet this requirement) Designated quiet workspace in your home (separated from non-workspace areas) and able to be secured to maintain Protected Health Information (PHI) and/or Protected Information (PI) Ability to work Monday - Friday Ability to work until 5pm in residing time zone Preferred Qualifications: Medical Coding experience/knowledge Experience using Interqual Experience with the following systems: UNET, iCUE/HSR, ATS, ETS or Cirrus Experience analyzing medical records, benefit plans, medical policies and other various criteria Demonstrated ability to work independently with solid self-discipline and time management skills Demonstrated excellent communication, interpersonal, problem-solving, and analytical skills
Conducts reviews of member and provider appeals Analyzing claim adjustments and histories, and reviewing previous decisions Evaluate denied services in accordance with policies, benefit plans, federal and state regulations, and clinical criteria, rendering approvals when appropriate Summarize medical information for review by the Medical Director as needed You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Berkley Medical Management Solutions (BMMS) provides a different kind of managed-care service for W.R. Berkley Corporation. We believe focusing on an injured worker’s successful and speedy return to work is good for people and good for Berkley’s insurance operating units. BMMS was first started in 2014 by reimagining the relationship between medical need and technology to deliver the best outcome for injured workers and Berkley’s operating units. Our goal was clear: combine solid clinical practices, proven return-to-work strategies and robust software into one system for seamless management of workers’ compensation cases. To get it right, we started with a flexible technology platform that allowed for impressive customization without sacrificing the ability for expansion and continued innovation. We deploy integrated systems to give W.R. Berkley Companies recommendations and professional services for managing each individual case in an efficient and appropriate manner. The power of our technology takes medical bill-review services and clinical advisory services to a new level. Our unique marriage of technology, software platforms, data analytics and professional services ensures we provide Berkley’s operating units with reliable results, and reduced time and expenses associated with case management.
This is a part-time position scheduled for 20 hours per week, working 4 hours per day, Monday through Friday, within standard business hours between 8:00 AM and 5:00 PM. As a Telephonic Nurse Case Manager, you will assess, plan, coordinate, monitor, evaluate and implement options and services to facilitate timely medical care and return to work outcomes of injured workers.
Qualifications: Minimum 2 years of experience in workers compensation insurance and medical case management preferred Minimum of 4 years medical/surgical clinical experience required Exhibit strong communication skills, professionalism, flexibility and adaptability Possess working knowledge of medical and vocational resources available to the Workers’ Compensation industry Demonstrate evidence of self-motivation and the ability to perform case management duties independently Demonstrate evidence of computer and technology skills Oral and written fluency in both Spanish and English a plus Education: Graduate of an accredited school of nursing and possess a current RN license. RN compact license preferred, CCM preferred, Bachelor of Nursing preferred
Coordinate and implement medical case management to facilitate case closure Timely and comprehensive communication with with employers, adjusters and the injured workers. Assess appropriate utilization of medical treatment and services available through contact with physicians and other specialist to ensure cost effective quality care Review and analyze medical records and assess data to ensure appropriate case management process occurs while providing recommendations to achieve case progress and movement to closure Responsible for assigned caseloads, which may vary in numbers, territory and/or by state jurisdiction Acquire and maintain nursing licensure for all jurisdictions as business needs require Coordinate services to include home services, durable medical equipment, IMEs, admissions, discharges, and vocational services when appropriate and evaluate cost effectiveness and quality of services Document activities and case progress using appropriate methods and tools following best practices for quality improvement Reviewing job analysis/job description with all providers to coordinate and implement disability case management. This includes coordinating job analysis with employer to facilitate return to work. Engage and participate in special projects as assigned by case management leadership team Occasionally attend on site meetings and professional programs Foster a teamwork environment Maintaining and updating evidence based medical guidelines (such as Official Disability Guidelines, MD Guidelines and all required state regulated guidelines) in reference to the injured worker treatment plan and work status. Obtain and maintain applicable state certifications and/or licensures in the state where job duties are performed. Obtain case management professional certification (CCM) within 2 years of hire date Earn Continuing Education Units to maintain certifications and licensures
Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact. Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.
Acentra Health is looking for a Clinical Reviewer - LPN/LVN or RN (remote U.S.) to join our growing team. Job Summary: The purpose of this position is to utilize clinical expertise to review medical records against appropriate criteria in conjunction with contract requirements. ***This position is remote within the United States, but applicants must be clinically licensed for the State of Indiana or have a compact license.*** ***Work Schedule: Five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays***
Required Qualifications: Active, unrestricted LPN/LVN or RN license in the state of Indiana or a Compact state clinical license. Associate's degree (bachelor's preferred) or Practical/Professional nursing diploma/certificate from an accredited nursing school, college, or university. 2+ years of Utilization Review/Management (UR/UM) and/or Prior Authorization experience. 2+ years of medical necessity review experience. 1+ years of InterQual criteria and/or Milliman Care Guidelines (MCG) experience. Knowledge of medical records, medical terminology, and disease processes. Strong clinical assessment and critical thinking skills. Excellent written and verbal communication skills. Proficient in navigating multiple systems with the ability to switch between systems seamlessly and effectively. Flexibility and strong organizational skills. Ability to work five 8-hour shifts between 9:00 AM to 6:00 PM Eastern Time with alternating weekends and holidays. Preferred Qualifications: 3+ years of clinical experience in an acute, behavioral health, and/or med-surgical environment. Knowledge of current National Committee for Quality Assurance (NCQA) standards. Knowledge of Utilization Review Accreditation Commission (URAC) standards. Ability to work in a team environment. Proficient in Microsoft Office. Efficient time management, including the ability to prioritize tasks, and meet deadlines. Exhibit the ability to maintain confidentiality standards and ensure HIPAA compliance when assessing relevant issues.
Assures accuracy and timeliness of all applicable review type cases within contract requirements. Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department. In collaboration with Supervisor, responsible for quality monitoring activities. Maintains current knowledge base related to review processes and clinical practices. Functions as providers' liaison for customer service issues and problem resolution. Performs all applicable review types as workload indicates. Fosters positive and professional relationships with internal and external customers. Attends training and scheduled meetings for current/updated information. Cross trains to provide flexible workforce to meet client/customer needs. Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules. The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.
At Capstone Care Services, our telephonic case management service is designed to achieve effective medical management and facilitate timely return-to-work outcomes in accordance with established guidelines. Our team of professionals is committed to delivering superior service, focusing on achieving optimal outcomes, providing strong advocacy, and ensuring client satisfaction.
Certifications- Registered Nurse (RN)- Certified Case Manager (CCM)- Certified Rehabilitation Registered Nurse (CRRN), Worker Compensation Experience a plus. This is a 1099 role.
Comprehensive Case Assessment- Conduct thorough assessments to identify the unique needs of injured workers and develop tailored action plans to support their recovery and return to work. Telephonic Support- Provide expert guidance, coordination, and support exclusively via phone to ensure appropriate and timely care delivery. Resource Coordination- Connect injured workers with the right resources, bridging gaps between services and support networks to facilitate recovery Licensed Professionals- Ensure all registered nurses hold a Compact License, maintaining compliance and professionalism. Administrative Efficiency- Provide administrative support for referral assignments with a 3-day turnaround time to ensure prompt service delivery. Caseload Oversight- Manage and oversee caseloads to meet 5-day memo and monthly reporting guidelines, ensuring accountability and timely communication Technology Expertise- Utilize multiple case management software products, including ICMS, to streamline processes and enhance efficiency. Timely Initial Contact- Ensure initial 3–4-point contact with injured workers within the specified timeframe to initiate case management promptly.
We are a care management company based in New York City, dedicated to supporting older adults and their families through high-quality, personalized care coordination. Our concierge-style approach helps seniors maintain independence, improve quality of life, and remain safely at home. We value collaboration, clear communication, and thoughtful, client-centered care.
We are seeking an experienced Remote Nurse Care Manager to support daily care coordination for our geriatric clients. This role focuses on clinical coordination, communication, follow-up, and documentation. You will work closely with clients, families, physicians, and field-based providers to ensure care plans are implemented smoothly and client needs are addressed promptly. This is an ideal role for a nurse who enjoys care coordination, problem-solving, and building relationships.
Skills & Qualifications: Active Registered Nurse (RN) license Minimum 5 years of nursing experience, with at least 1 year in geriatric care management, home health, or a related setting Strong experience with care coordination and working with interdisciplinary teams Excellent organizational and time-management skills Clear, compassionate communication skills with clients and families Comfortable working remotely and managing multiple clients simultaneously Proficient with EHR systems and basic healthcare technology Core Competencies: Client-centered, compassionate approach to care Strong attention to detail and follow-through Ability to prioritize tasks in a fast-paced, remote environment Collaborative mindset and professionalism
Care Coordination & Client Support: Coordinate day-to-day care needs for elderly clients in collaboration with families, physicians, and care providers Support the development, implementation, and ongoing updates of individualized care plans Conduct follow-ups related to appointments, services, and care recommendations Communication & Collaboration: Serve as a consistent point of contact for clients and families Communicate care updates clearly and professionally with field nurses and other providers Escalate concerns or changes in condition appropriately and in a timely manner Documentation & Follow-Up: Maintain accurate, timely documentation in the electronic health record (EHR) Track care activities, outcomes, and next steps to ensure continuity of care Address issues identified during in-person visits and ensure proper follow-up Client Advocacy: Advocate for client preferences, safety, and quality of care Monitor outcomes and assist with adjustments to care plans as needed
You will often hear people call Partners a North Carolina local management entity/managed care organization or LME/MCO. We think of ourselves as an MCO…a Member Care Organization™. Partners manages Medicaid, state and local funds for mental health, intellectual/developmental disability, substance use disorder and traumatic brain injury services. The system of care we manage is shaped by the choices of our members and their families and designed to meet the unique needs of each of the communities we serve. Partners manages care in Burke, Cabarrus, Catawba, Cleveland, Davidson, Davie, Forsyth, Gaston, Iredell, Lincoln, Rutherford, Surry, Stanly, Union and Yadkin Counties.
This is a primarily remote position, but will require in-person training and travel to Gaston, Lincoln, Burke, and Catawba counties.** Competitive Compensation & Benefits Package! Position eligible for – Annual incentive bonus plan Medical, dental, and vision insurance with low deductible/low cost health plan Generous vacation and sick time accrual 12 paid holidays State Retirement (pension plan) 401(k) Plan with employer match Company paid life and disability insurance Wellness Programs Public Service Loan Forgiveness Qualifying Employer See attachment for additional details. Office Location: Primarily remote position, but will require in-person training and travel to Gaston, Lincoln, Burke, and Catawba NC counties. Projected Hiring Range: Depending on Experience Closing Date: Open Until Filled Primary Purpose of Position: The primary duty of this position is to provide formal training, education, and consultation to community organizations that may include Adult Care Homes, Family Care Homes, Nursing Homes, Adult Day Programs, Senior Centers, Faith Based Organizations, Home Health Agencies, Home Care Agencies, Meals on Wheels Programs, Veterans Affairs, Departments of Social Services, and Law Enforcement/Judicial System staff/caregivers that serve geriatric or adult residents with geriatric like needs that may have mental illness and/or Dementia. The goal is to build community awareness and skills for addressing the unique needs of these individuals. Goal of HEART Program: To increase the ability of people working in community agencies/organizations in providing services and support to older adults with mental health, substance use issues, and/or dementia.
Knowledge, Skills And Abilities: Extensive knowledge of behavioral health issues within geriatric and adult population, potential for crisis issues, confidentiality laws and program protocols/policies Extensive knowledge of N.C. Mental Health Laws, Regulations and of Partners operations Knowledge and understanding of managed care and tailored plan and impact on population served Knowledge of resource information and ability to identify ongoing training resources for caregiver staff Skill in quickly identifying needs and responding, particularly in crisis situations Skill in computer functions required for the position and standard office software Ability to provide training and education to staff and caregivers on topics relevant to younger adults with mental illness RN staff must have knowledge of current psychopharmacology utilization within geriatric population and whole person care Ability to establish and maintain effective working relationships with stakeholders, facility staff and other LME/MCO staff, and to provide individualized technical support and education as needed Education and Experience Required: Registered Nurse with three (3) Years of documented experience working with older adults with mental illness and various forms of dementia. Education and Experience Preferred: Masters Prepared therapist and three (3) Years of documented experience working with older adults with mental illness or Registered Nurse with three (3) Years of documented experience working with older adults with mental illness and various forms of dementia. Licensure/Certification Requirements: RN licensure with the appropriate professional board of licensure in the state of North Carolina
60% In-Service Training/Marketing: Provide training, education, consultations on Mental Illness and cognitive disorders (delirium, dementia). Marketing HEART trainings to stakeholders in order to obtain opportunity to train. HEART RN completes all requested medication trainings, and trainings tailored to Integrated Care and Tailored Plan. Only RN staff are permitted to provide these trainings. 15% Community Resources/Agency Collaboration: Will provide input into annual needs assessment. Will collaborate with community agencies as needed, including Department of Social Services, Senior Center, Life Enrichment, and other HEART Teams in N.C. Will participate in any requested MCO meetings or events as assigned by supervisor. 10% Continuing Education/Cooperative Efforts: Attendance at required LME/MCO training and annual updates, staff meeting and professional development classes. 15% Other Duties: Other duties as assigned, including maintenance and care of audio-visual equipment used for training, attendance at community meeting, assisting in ongoing updates to training materials. Will establish and maintain effective working relationship within the unit and demonstrate tact and diplomacy in working with contract providers and other community partners. Actively participates in local collaborative related mental health issues. Maintains documents for GAST program including monthly and quarterly reports.
Join us as we transform immunology and deliver medicines that help autoimmune patients get their lives back. argenx is preparing for multi-dimensional expansion to reach more patients through a rich pipeline of differentiated assets, led by VYVGART, our first-in-class neonatal Fc receptor blocker approved for the treatment of gMG, and with the potential to treat patients across dozens of severe autoimmune diseases. We are building a new kind of biotech company, one that maintains its roots as a science-based start-up and pushes our commitment to innovate across all corners of our business. We strive to inspire and grow our company, our partnerships, our science, and our people, because when we do, we deliver more for patients.
The Nurse Case Manager (NCM) is the single point of contact for patients and their caregivers. They are aligned regionally and are responsible for educating patients, caregivers and families affected by generalized Myasthenia Gravis (gMG) about the disease and argenx’s products and support services. The NCM may provide resources to help patients better manage their disease and coordinate their treatment. The NCM is responsible for participating in one-on-one communications with patients and their caregivers. Location: Candidates must reside on the East coast.
Skills and Competencies: Demonstrated effective presentation skills; ability to motivate others; excellent interpersonal (written and verbal) skills – with demonstrated effectiveness to work cross-functional and independently Demonstrated ability to develop, follow and execute plans in an independent environment Demonstrated ability to effectively build positive relationships both internally & externally Demonstrated ability to be adaptable to changing work environments and responsibilities Must be able to thrive in team environment and willing to contribute at all levels with flexibility and a positive attitude Fully competent in MS Office (Word, Excel, PowerPoint) Flexibility to work weekends and evenings, as needed Participate in and complete required pharmacovigilance training Comply with all relevant industry laws and argenx’s policies Travel requirements less than 50% of the time Education, Experience and Qualifications: Current RN License in good standing Bachelor’s degree required 5+ years of clinical experience in home healthcare, hospital and pharmaceutical or biotech is required 2-5+ years of case management 2+ years of experience in pharmaceutical/biotech industry is required Reimbursement experience a plus
Provide direct educational training and support to patients and caregivers about gMG and prescribed argenx products Will manage patient cases across regions as coverage and volume requires Communicate insurance coverage updates and findings to the patient and/or caregiver Review and educate the patients and/or caregivers on financial assistance programs that they may be eligible for Coordinate logistical support for patients to receive therapy and manage their disease Collaborate with argenx Patient Access Specialist, Case Coordinator, and Field Reimbursement Manager teams to troubleshoot and resolve reimbursement-related issues Engage with patients and provider case coordinators to ensure appropriate support is being given on an individualized basis Provide patient-focused education to empower patients to advocate on their behalf Develop relationships and manage multiple and complex challenges that patient and caregivers are facing Ensure compliance with relevant industry laws and argenx’s policies Aligned regional travel will be required for patient education to support patient programs Must be an excellent communicator and problem-solver Demonstrated time management skills; planning and prioritization skills; ability to multi-task and maintain prioritization of key projects and deadlines
Mindlance is a global Talent, Teams, Projects, and Workforce Solutions partner, serving leading enterprises across industries since 1999. With a 5,000 strong footprint across multiple countries, we deliver scalable, AI native solutions that help organizations build, optimize, and transform their workforce.
100% Remote - ONLY 28 states North Carolina, Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming will be allowed to maintain their current residence and work remotely.
Required Skills: Computer Skills, Telephonic Nice to have Skills: Social worker utilization review (using MCG or internal policy that an insurance company would use for their review) prior off review, Skilled home health background Years of Experience: 3-5 years of experience. If they have not done managed care they need more years of experience Education/Certifications Required: Cert Case Manager Industry Specific Experience – required, ideal, necessary? Medicare, Home Health What is this role’s main focus for the 1st 90 days? Breakdown of Duties/Typical Day: Provider facing (ineracting with providers if they need to get additional information to review a case). Reviewing cases for medicial necessity and making authorization determination. Will log into the system to work cases throughout the day this will be specifically for Home Health. Will be doing all levels of care. Basically is the one deciding if BCBSNC will be the one to pay for the service Hiring Requirements: RN with 3 years of clinical experience or LPN with 5 years of clinical experience. For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience. Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.
Clinical Evaluation and Review Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME) Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations. Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards Provide notifications to member and/or provider, according to regulatory requirements. Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed. May coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines Collaboration and Documentation Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.
Health Advocate is the nation’s leading provider of health advocacy, navigation, well-being and integrated benefits programs. For 20 years, Health Advocate has provided expert support to help our members navigate the complexities of healthcare and achieve the best possible health and well-being. Our solutions leverage a unique combination of best-in-class, personalized support with powerful predictive data analytics and a proprietary technology platform to address nearly every clinical, administrative, wellness or behavioral health need. Whether facing common issues or an unprecedented challenge like COVID-19, our team of highly trained, compassionate experts work together to go above and beyond expectations, making healthcare easier for our members and ensuring they get the care they need.
Behavioral Health - Population Health Nurse Coach Drive Outcomes. Transform Lives. Elevate Care. At Health Advocate, Population Health is not a checklist—it’s a catalyst for transformation. We’re seeking a Population Health Nurse Coach—an RN with health coaching certification or demonstrated experience applying coaching methodologies in practice—who knows how to turn clinical expertise into meaningful, sustainable behavior change—especially in members navigating behavioral health challenges such as stress, anxiety, depression, and low engagement. This role is for a nurse who understands that real impact happens beyond education—it happens through trust, consistency, and coaching that actually shifts how people live. This role requires a deep understanding of the connection between mental, emotional, and physical health—and the ability to coach through resistance, ambivalence, and behavior patterns that impact outcomes. Reporting into Clinical Leadership, you’ll manage a panel of members with complex chronic and behavioral health conditions—guiding them toward sustainable health improvements while reducing risk, utilization, and gaps in care. If you’re energized by coaching, behavior change, and helping people take ownership of their health—we want to meet you. Your Mission: What Success Looks Like Your primary accountability is to improve member health outcomes by driving engagement, behavior change, and self-management across a diverse population. You will support members with complex medical and behavioral health needs, requiring a compassionate, proactive, and outcomes-driven approach. Many members you support will not struggle with knowledge—but with follow-through. Your role is to identify and address the behavioral and emotional barriers driving that gap. Member Engagement & Activation Build trust-based relationships that drive consistent participation in coaching programs Re-engage at-risk or disengaged members through proactive outreach and connection Meet members where they are—while guiding them toward where they need to be Health Outcomes & Behavior Change Improve clinical and behavioral outcomes through personalized coaching and care planning Support members in developing sustainable habits that reduce risk and improve quality of life Address root causes of non-adherence, not just symptoms Care Coordination & Continuity Ensure members experience seamless, coordinated care across providers and services Reduce gaps in care through proactive follow-up and navigation support Act as a consistent, trusted guide within a complex healthcare system Program Impact & Utilization Contribute to reduced hospitalizations, ER visits, and overall cost of care Drive measurable improvements in program engagement, adherence, and satisfaction Ensure members fully utilize available Health Advocate programs and resources
You’re not just a clinician—you’re a behavior change leader. You understand that knowledge alone doesn’t change outcomes. People do. You bring: 3–5+ years of experience in chronic condition management, population health, health coaching, or behavioral health A strong foundation in motivational interviewing, behavior change science, and the ability to coach members navigating behavioral health challenges (e.g., anxiety, depression, stress-related barriers) An active, unrestricted RN license (multi-state preferred) The ability to connect, influence, and build trust quickly in a virtual environment Strong clinical judgment paired with empathy and emotional intelligence Excellent communication skills—you can simplify complexity without losing meaning A proactive, ownership-driven mindset with strong problem-solving abilities Comfort working independently while collaborating within a multidisciplinary team You are comfortable working with members who are resistant, overwhelmed, or disengaged—and know how to guide them without judgment or control Preferred Experience Health Coach Certification and/or Certified Diabetes Educator (CDE) (or in progress) Required or strongly preferred: Experience supporting members with both chronic medical and behavioral health conditions, with a focus on behavior change and engagement Experience in telephonic or virtual care delivery models Mental and Physical Requirements This is a fully remote role requiring a HIPAA-compliant home workspace • Work is primarily sedentary with prolonged computer and phone use • Requires sustained focus, active listening, and continuous communication throughout the day • Ability to manage multiple members, priorities, and documentation requirements in a fast-paced environment
Member Coaching & Behavior Change Deliver high-impact telephonic and virtual coaching sessions using motivational interviewing and evidence-based strategies Help members translate clinical recommendations into realistic, sustainable daily actions Navigate behavioral health dynamics such as anxiety, avoidance, low motivation, and emotional overwhelm that directly impact follow-through Support lifestyle changes related to chronic conditions, mental health, and overall wellness Clinical Assessment & Care Planning Conduct comprehensive assessments across physical health, behavioral health, and social determinants Develop personalized, goal-driven care plans aligned to each member’s needs and readiness for change Continuously evaluate and adjust care plans based on progress, setbacks, and evolving conditions Care Coordination & Advocacy Coordinate care across providers, behavioral health specialists, and community resources Help members navigate healthcare systems, benefits, and available services Advocate for members to ensure they receive appropriate, timely, and effective care Proactive Monitoring & Risk Management Maintain consistent follow-up to monitor progress and reinforce accountability Identify early warning signs of deterioration or disengagement and intervene quickly Provide support following hospitalizations, ER visits, or critical health events Education & Empowerment Simplify complex medical information into clear, actionable guidance Equip members with tools, resources, and confidence to manage their health independently Engage caregivers and support systems to strengthen long-term success Outcomes Tracking & Documentation Accurately document all interactions, care plans, and outcomes in compliance with regulatory standards Track key metrics including engagement, adherence, and health outcomes Use data insights to continuously improve coaching effectiveness and program impact
Health Advocate is the nation’s leading provider of health advocacy, navigation, well-being and integrated benefits programs. For 20 years, Health Advocate has provided expert support to help our members navigate the complexities of healthcare and achieve the best possible health and well-being. Our solutions leverage a unique combination of best-in-class, personalized support with powerful predictive data analytics and a proprietary technology platform to address nearly every clinical, administrative, wellness or behavioral health need. Whether facing common issues or an unprecedented challenge like COVID-19, our team of highly trained, compassionate experts work together to go above and beyond expectations, making healthcare easier for our members and ensuring they get the care they need.
At Health Advocate, we are committed to providing our customers with services that improve the health, well-being and productivity of their employees. The Personal Health Advocates are a dedicated team of Registered Nurses who assist our members in navigating the healthcare system by facilitating access to healthcare providers, health and benefit information, health services and resources and entitled benefits coverage.
Minimum Qualifications Education- BSN or RN degree from an accredited college or university required Minimum three to five years clinical and/or medical management experience Active and unrestricted State or Multi-State RN License Understanding of medical terminology to assist in locating appropriate care options Strong Communication skills and phone etiquette Strong ability to explain complex issues to employees/retirees Highly effective listening skills Strong problem solving/issues resolution skills Excellent customer service and customer resolution skills Organizational and administrative skills Experience with Microsoft Word and Excel Ability to work in a team environment Mental and Physical Requirements- This position is a remote position. The employee will need to have a dedicated HIPPAA compliant work space. Have access to internet and router. The nature of the work in this position is sedentary and the incumbent will be sitting most of the time Essential physical functions of the job include fingering, grasping, pulling hand over hand, and repetitive motions to utilize general computer software/hardware continuously throughout the work day Essential mental functions of this position include concentrating on tasks, reading information, and verbal/written communication to others continuously throughout the work day
Receive calls from members in regards to various healthcare issues (e.g., infertility, disease, medication, etc.) and determine best course of action/s to assist the members while adhering to established policies, procedures, and key performance indicators (KPIs) (e.g. case close targets, abandon rates, member follow up, all quality indicators, etc.) Build relationships with members in order to collaborate and develop plans of action by going above and beyond members’ initial requests, taking responsibility for members’ case records, and encouraging members to call back with future issues/ questions. Assist and educate members in understanding their medical conditions, associated health testing, test result interpretation, and health options available to them. Provide members choices in medical care providers and services based on the members’ clinical needs, geographic locations and available benefit offerings. Research providers through credentialing, education checks and affiliations with notable medical centers within the member’s plan Facilitate communication among members, treating physicians, and insurance carriers, which may include assisting members with asking necessary health questions to physicians or clarifying insurance plan provision Take appropriate steps on behalf of members by assisting with scheduling health appointments, re-scheduling health appointments, facilitating record and information transfers, and researching and resolving various problems as applicable Document cases in the department’s case management system using approved processes and procedures Escalate cases appropriately and on a timely basis to supervisor or internal resources for review as applicable Keep up-to-date on patient care procedures which include diagnosis, pre-certification, prior authorization, pre-service and post-service denials Continuously stay up to date on various health issues and medical procedures necessary to offer top of the line feedback to members Intercede for the member to obtain an earlier appointment. Help members obtain prescriptions Help members with pre-service fee negotiations Place outbound follow up calls for issues that cannot be resolved during the initial call Respond to member cases in delegate box, answers and after hours calls Mentor new team members Team Interfaces/Customer Service Establish and maintain a professional relationship with internal/external customers, team members and department contacts Cooperate with team members to meet goals or complete tasks Provide customer service that exceeds customer expectation Treat all internal/external customers, team members and department contacts with dignity/respect Escalate work flow and communication issues to supervisor Related Duties as Assigned :The job description documents the general nature and level of work but is not intended to be a comprehensive list of all activities, duties, and responsibilities required of job incumbents Consequently, job incumbents may be asked to perform other duties as required Also note, that reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above Please contact your local Employee Relations representative to request a review of any such accommodations
At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.
Workers Compensation Nurse Case Manager Brighton Health Plan Solutions REMOTE – 100% FULL TIME Brighton Health Plan Solutions (BHPS) provides Utilization Review/Medical and Case Management services for Group Health and Workers’ Compensation and other Casualty clients. The Workers’ Compensation Nurse Case Reviewer collaborates with medical care providers, employers, employees, and at times, attorneys to support the appropriate return to work, the provision of necessary medical services, and the evaluation of coverage under the Plan. The Nurse Case Reviewer reports to the Casualty Department Manager.
Currently licensed Registered Nurse (RN).......NY State preferred....if not with ability to secure NY State license Must maintain current licensure(s) and specialty certifications that are relevant to this position; CCM is encouraged. Bachelor’s degree preferred. Minimum of 4 years’ experience in a clinical environment required. Previous workers’ compensation case management experience required. Previous experience in utilization review/medical management preferred. Strong skills in medical assessment/medical record review. Excellent customer service skills. Ability to define and solve problems, collect data, establish facts and make effective decisions a must. Must be detail oriented and have strong organizational and time management skills, and the ability to work independently Ability to work proficiently on a computer (PC) with working knowledge of Microsoft Office, especially Word, Excel and Outlook.
Collaborates with workers' compensation patients, employers, providers, and claims adjusters to coordinate medical and disability services for timely return to work. Provides utilization review, continued stay reviews, and utilization management based on clinical judgment and state WCB Medical Treatment Guidelines. Knowledgeable and compliant with New York State Workers’ Compensation Law, Medical Treatment Guidelines, ERISA, HIPAA confidentiality requirements, and NY Formulary Review process. Proven ability to anticipate claimant's treatment or recovery milestones. Provides Case Management services, including assessing barriers to recovery and determining treatment alternatives. Facilitates and expedites discharge planning as needed. Produces accurate electronic records of individual cases. Ensures timely, cost-effective medical care for injured workers' recovery. Answers provider calls and assists with Casualty Department workload as necessary. Kind, caring, and positive with all customers and fellow employees. Adheres to established quality assurance standards and MagnaCare policies and procedures. Participates in up to 10% of employed time in QA activities.
AlediumHR represents a rapidly growing national telehealth provider focused on modernizing hormone care and preventive health. This organization is built around performance-driven wellness, helping patients take control of long-term health through clinically guided hormone optimization. You’ll work strictly within hormone optimization and wellness, no urgent care or unrelated casework.
Flexible scheduling with both part-time and full-time options. 1099 structure with malpractice coverage included. You’ll have full support across admin, compliance, and technology—so your time stays focused on patient care. This opportunity is designed for Nurse Practitioners with real-world experience in hormone replacement therapy (HRT) who want to operate in a more focused, protocol-driven environment. This is a fully remote role in which you will deliver care through a structured virtual platform designed specifically for hormone management and preventive wellness. We are seeking experienced Nurse Practitioners with direct experience in HRT for both male and female patients
Active Nurse Practitioner licenses across multiple U.S. states (8–10 preferred) Priority given to candidates licensed in California, Texas, New York, and Colorado Active, unrestricted DEA license Ability to prescribe controlled medications in accordance with all regulations Experience: At least 1 year of hands-on HRT experience Experience treating both male and female patients Strong clinical knowledge of hormone optimization and preventative care strategies Comfortable managing ongoing lab work and adjunct therapies
Conduct virtual patient visits centered on hormone balance and overall wellness Analyze lab results and identify hormonal deficiencies or imbalances Develop and manage individualized treatment plans using established HRT protocols Prescribe and oversee therapies, including testosterone and estrogen-based treatments Track patient outcomes through ongoing lab monitoring and follow-up care Provide clear education on treatment plans, expectations, and long-term health impact Ensure accurate and compliant documentation within the telehealth system Work alongside clinical and operational teams to maintain a high-quality patient experience
X Benefit Group provides shared services that help businesses grow stronger, smarter, and more efficiently. From branding and marketing to HR, finance, operations, and technology solutions, we act as the operational backbone for a portfolio of forward-thinking companies. Our centralized approach creates efficiencies, reduces complexity, and allows our partners to focus on what they do best. We’re here to support sustainable growth, operational excellence, and long-term success.
Position Title: Virtual Primary Care RN/LPN Department: Clinical Services Reports To: Chief Medical Officer FLSA Status: Exempt Work Location: 100% Remote (Multi-State Licensure Preferred) Position Summary: The Virtual Primary Care RN/LPN supports longitudinal, relationship-based patient care through a secure telehealth platform. This role focuses on chronic disease management support, preventive care coordination, patient education, triage, and care navigation. The RN/LPN collaborates closely with physicians, advanced practice providers, and interdisciplinary team members to ensure high-quality, patient-centered virtual care delivery.
Knowledge, Skills & Abilities (KSAs)Knowledge Telehealth workflows and documentation standards. HIPAA and patient privacy regulations. Clinical protocols relevant to role scope. Chronic disease management standards. Preventive screening guidelines. Telehealth triage protocols. HIPAA and patient privacy regulations. Care coordination workflows in value-based models.Skills Clear patient communication. Efficient EHR documentation. Time management and prioritization. Clinical triage and assessment. Motivational interviewing. Clear patient communication. Care coordination and follow-up tracking.Abilities Ability to recognize and escalate clinical concerns. Ability to manage workload in virtual environment. Ability to adapt to evolving digital tools. Ability to manage panel-based patient populations Ability to identify care gaps. Ability to work independently in remote setting. Ability to escalate appropriately. Education & Experience Active professional license (RN/LPN where applicable). Medical Assistant certification preferred for MA roles. 1–2+ years relevant clinical experience preferred. Telehealth experience preferred. RN: Active, unrestricted RN license. Associate or Bachelor’s degree in Nursing. 2+ years primary care, population health, or care coordination experience preferred. LPN Active, unrestricted LPN license. 1–2+ years ambulatory or primary care experience preferred. Telehealth experience preferred.Working Conditions 100% remote work environment. Prolonged computer use. Flexible scheduling including evenings/weekends as needed. Performance expectations tied to quality and productivity. Secure workspace and reliable high-speed internet required.
Conduct virtual intake assessments and clinical screening. Perform telephonic/video triage in accordance with clinical protocols. Support chronic disease management (HTN, DM, HLD, obesity, behavioral health conditions). Reinforce care plans and medication adherence. Coordinate referrals, labs, imaging, and follow-up care.Patient Education & Engagement Provide virtual education regarding preventive screenings and wellness. Support remote patient monitoring workflows. Address patient questions regarding treatment plans. Promote patient activation and self-management.Documentation & Compliance Maintain accurate EHR documentation. Ensure HIPAA compliance. Support quality and population health metrics. Additional Responsibilities: Responsibilities are representative and not exhaustive. Additional duties may be assigned to support patient care delivery, operational needs, and regulatory compliance, consistent with scope of practice.Scope of Practice & Regulatory Compliance All duties shall be performed in accordance with applicable state scope of practice laws, organizational policies, and federal and state regulatory requirements.
CuraSenseAI connects healthcare professionals with high-quality remote and global opportunities across healthcare, life sciences, and AI-driven medical domains. We curate and share roles from leading organizations working in clinical research, healthcare operations, medical AI, and digital health—helping candidates access structured and reliable hiring pipelines worldwide. Our focus is on bridging top healthcare talent with forward-thinking teams building the future of healthcare.
Nursing Talent Network Remote · Contract · Immediate Start · Competitive rates Role Overview We are looking for nursing professionals to join our expert network and help advance AI systems in healthcare through real-world clinical expertise. If you think clinically, communicate clearly, and can apply nursing knowledge to structured problem-solving, this opportunity is for you.
Professional experience in patient care, monitoring, and medication administration Strong understanding of clinical documentation and care protocols Strong communication skills with the ability to explain clinical reasoning clearly Ability to work independently in a remote environment Preferred: Experience engaging with training, evaluation, or healthcare workflows
Contribute to training and evaluating AI models in nursing contexts Create tasks and deliverables based on real-world patient care scenarios Provide domain-specific feedback to improve AI system performance Support development of AI systems through applied clinical reasoning
FitCam Health is a leading digital health platform specializing in pain management. We work with pain clinics to offer comprehensive Remote Therapeutic Monitoring (RTM) programs, helping patients manage their pain through personalized home exercise programs and cognitive behavioral therapy (CBT) techniques.
We are currently seeking licensed Bilingual Registered Nurses (Arabic – Iraqi/Syrian) to join our remote team and provide monitoring services for our RTM programs. This is an excellent opportunity to be part of a cutting-edge digital healthcare service that enhances patient care while providing a flexible work schedule.
Prior experience in telehealth, pain management, or monitoring patients remotely is preferred. Tech-Savvy: Comfortable using digital health tools, apps, and telehealth platforms for patient monitoring and engagement. Strong Communication Skills: Ability to effectively communicate and engage with patients and care teams through various channels. Nice to Have: Experience as a Psychiatric Nurse, understanding the psychological aspects of chronic pain management, and mental health care. Benefits: Flexible Work: Choose part-time or full-time hours to suit your schedule. Competitive Pay: Hourly rates with the potential for performance-based bonuses. Remote Opportunity: Work from the comfort of your home, while still making a direct impact on patient care. Ongoing Training: Access to continuous professional development through FitCam Health's training programs. Apply Now
Monitor Patient Data: Track patients’ progress, including therapy adherence, pain levels, and overall health data reported through the FitCam Health Console. Patient Communication: Engage with patients via in-app messaging, phone, and video calls to answer questions, offer guidance, and ensure they are following prescribed treatment plans. Program Customization: Work closely with physicians and other healthcare providers to tailor patient programs based on real-time data, adjusting treatments to optimize outcomes. Patient Education: Provide information on managing pain through the FitCam platform, guiding patients on self-care techniques and therapy adherence. Documentation and Reporting: Maintain thorough patient records and ensure all RTM interactions meet regulatory requirements. Compliance: Ensure adherence to HIPAA regulations and clinic protocols during patient interactions. Qualifications: Licensure: Active Registered Nurse (RN) license in one or more of the following states: Compact License, Alaska, New Jersey, New York, Ohio, South Carolina, California.
Hi, we're Oscar. We're hiring a Complex Case Management Nurse to join our CCM Team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.
You will educate members on improving health outcomes, assist with transitions from care settings, participate in process improvement and other pilot programs as they arise, and work with support teams to ensure exceptional care for our members. You will report into the Associate Director, Clinical. Work Location: This is a remote position, open to candidates who reside in: Alabama; Arizona; Arkansas; Colorado; Connecticut; District of Columbia; Florida; Georgia; Idaho; Illinois; Indiana; Iowa; Kansas; Kentucky; Maine; Maryland; Massachusetts; Michigan; Minnesota; Missouri; Nevada; New Hampshire; New Jersey; New Mexico; North Carolina; Ohio; Oregon; Pennsylvania; Rhode Island; South Carolina; Tennessee; Texas; Utah; Vermont; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $39.28 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.
Requirements: Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license Ability to obtain additional state licenses to meet business needs 2+ years of clinical experience to include payer, hospital, outpatient or community based care management 1+ years of experience in Care Coordination and Navigation Bonus points: CCM Certification NCQA knowledge and accreditation experience Bilingual in spanish and or creole reading, writing, speaking BSN Working knowledge of Milliman Guidelines
Assist in the coordination of care across a variety of settings (inpatient, outpatient, post acute, ER, home care) Actively reach out to members undergoing difficult health challenges and develop care plans Proactively reach out to hospital case managers to assist with discharge planning Communicate with members via phone or secure messaging to provide education on health conditions, new medications, and procedures Ensure compliance with all CCM NCQA standards in day to day practice and workflows. Compliance with all applicable laws and regulations Other duties as assigned
Hi, we're Oscar. We're hiring a Care Navigation Nurse to join our Care Navigation team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.
This role requires extensive clinical knowledge and initiative to perform in-depth research, problem-solving, and decision-making to source and route to medically appropriate care, verify network gaps, escalate issues to appropriate stakeholders, guide the Care Navigation team in searches, and improve member experience. Additionally, you will provide ongoing clinical education to non-clinical teams to provide a strong foundation to be utilized in their workings with members. You will report into the Clinical Care Navigation Lead. Work Location: This is a remote position, open to candidates who reside in: Alabama; Arizona; Arkansas; Colorado; Connecticut; District of Columbia; Florida; Georgia; Idaho; Illinois; Indiana; Iowa; Kansas; Kentucky; Maine; Maryland; Massachusetts; Michigan; Minnesota; Missouri; Nevada; New Hampshire; New Jersey; New Mexico; North Carolina; Ohio; Oregon; Pennsylvania; Rhode Island; South Carolina; Tennessee; Texas; Utah; Vermont; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. Pay Transparency: The base pay for this role is: $39.28 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.
Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license Ability to obtain additional state licenses to meet business needs 3+ years of clinical experience to include hospital, outpatient or community based care management 3+ years of experience in Care Coordination and Navigation
Help coordinate care across a variety of settings (inpatient, outpatient, post acute, ER, home care) Actively reach out to members undergoing difficult health challenges and develop care plans Proactively reach out to hospital case managers to assist with discharge planning Communicate with members via phone or secure messaging to provide education on health conditions, new medications, and procedures. Compliance with all applicable laws and regulations Other duties as assigned
Founded in 2003, Omega Healthcare Management Services® (Omega Healthcare) is an AI-driven healthcare solutions company that partners across the healthcare ecosystem to deliver breakthrough results by reimagining and elevating revenue operations. Powered by the Omega Digital Platform®, our agentic AI engine leverages adaptive intelligence to drive automation, complemented by deep human expertise to help optimize performance and deliver sustained financial and clinical outcomes—while enhancing patient satisfaction. Omega Healthcare empowers organizations across provider, payer, and life sciences sectors to navigate today’s healthcare challenges while building the agility to adapt as healthcare and technology continue to evolve rapidly. Recognized by industry analysts, Omega Healthcare has consistently been ranked a leader in driving operational performance excellence.
The CDI RN Lead serves as a clinical subject matter expert and frontline leader for the Clinical Documentation Improvement program. This role is responsible for coordinating program elements, mentoring staff, and driving physician engagement to ensure documentation accurately reflects patient complexity, severity of illness, and risk of mortality. The Lead ensures to program aligns with compliance standards and organizational goals while fostering a culture of continuous improvement.
Key Success Indicators/Attributes: Ability to prioritize and multi-task in a multifaceted environment. Demonstrate strong organizational skills and be detail oriented. Demonstrate ability to self-motivate, set goals, and meet deadlines. Demonstrate mentoring and interpersonal skills. Demonstrate excellent presentation, verbal, and written communication skills. Ability to develop and maintain relationships with key business partners by building personal credibility and trust. Maintains courteous and professional working relationships with employees at all levels of the organization. Demonstrate successful leadership skills with the use of critical thinking, problem solving, and deductive reasoning required. Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred Work Environment This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones. Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus. Position Type/Expected Hours of Work This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work. Travel Minimal travel required; up to 5% Required Education and Experience Bachelor’s degree in nursing (BSN) or a healthcare related field. Active, unrestricted Registered Nurse (RN) license. 3-5 years of experience in a Clinical Documentation Improvement Program. Minimum of 3 years in a management, supervisory, or Lead role within a clinical quality or CDI environment. Deep understanding of Medicare Part A and B, DRG assignment, and MCC/CC impact. CCDS (ACDIS) or CDIP (AHIMA) preferred. Additional Eligibility Qualifications None required Security Access Requirements In addition to the specific security access required by the employee’s client engagement, the employee will have access to the Omega systems set forth in "Standard Field Employee” profile. Microsoft Office: E1 Level Access ADP: Standard Employee Level Access Oracle: Standard Level Access
Acts as a primary point of contact for the CDI team; coordinates and maintains all program elements to meet organizational goals and balanced scorecard metrics. Ensures timely, accurate and complete clinical documentation to support high-quality data for physician and hospital outcome reporting. Serves as a liaison between CDI and Coding professionals; proactively resolves discrepancies and facilitates a unified approach to clinical code assignment. Analyzes program data and key performance indicators; creates comprehensive reports to identify trends, gaps, and opportunities for documentation improvement. Develops and delivers education for CDI staff and physicians; provides ongoing mentorship to team members to enhance clinical knowledge and query proficiency. Maintains effective communication with stakeholders (e.g. Quality, Revenue Cycle, Physician Leaders) to build credibility and trust. Ensures all departmental activities comply with company policies, HIPAA regulations, and official coding guidelines.
Blue Sun Healthcare is a mobile wound care health group dedicated to achieving excellent patient outcomes and optimal healing. Driven by our mission—providing the right care, at the right time, in the right way—we strive to deliver compassionate and effective care to our patients. We are committed to improving the health and well-being of our patients through our specialized, proprietary wound care services across the country.
We are seeking a Licensed Practical Nurse (LPN) to join our team as a PRN Ultra-Mist Technician, delivering advanced wound care treatments across multiple facility types and within patient homes. This is an ideal role for an LPN looking for flexibility, autonomy, and a specialized clinical focus in wound care.
Licensed Practical Nurse (LPN) license and expertise in general Nursing practices Experience in Wound Care and the ability to utilize best practices for wound healing Demonstrated skills in Home Care and in delivering compassionate, patient-centered care Strong collaboration, communication, and documentation skills Ability to work effectively in a fast-paced, hands-on clinical environment, autonomously Commitment to continuous learning and professional skill development Familiarity with compliance standards in healthcare settings is a plus Experience in a similar role or relevant certifications in wound care are highly desirable
Responsibilities include providing wound care to patients via ultrasonic debridement machines, monitoring the healing progress, documenting care, and ensuring proper patient education on wound management. The technician will collaborate with clinical team leaders to ensure high-quality, compassionate care and adherence to evidence-based practices. Additional duties may include assisting with home care visits and maintaining compliance with medical standards.
Ways2Well is redefining the future of healthcare. As a leader in regenerative and preventive medicine, we empower patients to take control of their health through data-driven, personalized care. We’re breaking away from outdated models—leveraging cutting-edge technology, digital care platforms, and bold thinking to deliver high-impact healthcare at scale.
As a Nurse Practitioner, you will provide evidence-informed, patient-centered care via telemedicine. Your role involves conducting comprehensive health assessments, interpreting advanced lab results, designing personalized wellness and hormone optimization plans, and supporting patients through lifestyle and supplement-based interventions. You will collaborate with a multidisciplinary team in a fast-paced, fully virtual environment.
Required Qualifications: Active and unencumbered Nurse Practitioner license in at least 5 U.S. states (multi-state licensure required) National certification (e.g., AANP, ANCC) Active DEA Minimum of 2 years of NP experience, with exposure to functional, integrative, or hormone therapy preferred Strong knowledge of hormone replacement therapy (HRT) (testosterone, estrogen, thyroid), peptides, and targeted supplementation preferred Prior experience in a telehealth or digital health setting is strongly preferred Comfortable navigating EHRs, telemedicine platforms, and cloud-based tools Exceptional communication, patient engagement, and clinical documentation skills Work Environment & Physical Requirements: Primarily clinic/office-based setting for telehealth visits Remote work environment; home office or dedicated workspace required Must be able to work independently with minimal supervision Virtual meetings via video conferencing (camera on expected) Reliable high-speed internet connection required Must maintain a distraction-free, professional background for video calls Schedule: Monday – Friday, 8am–5pm Central
Conduct virtual consultations using both asynchronous and synchronous telehealth platforms Review and interpret functional and traditional lab results (e.g., hormone panels, micronutrients, inflammatory markers) Develop personalized care plans focusing on hormonal balance, metabolic health, nutrition, and preventive strategies Educate patients on treatment options, supplement protocols, and lifestyle modifications Document thoroughly and accurately in the EHR system (i.e., Charm or similar) Collaborate with clinical support staff, pharmacists, and health coaches to ensure continuity of care Adhere to state and federal telehealth regulations and best practices Participate in ongoing training, case reviews, and team huddles to support professional development and care quality
Insight Global is an international talent and consulting company that delivers business outcomes in an ever-changing world. We obsess over solving problems and building solutions that move our customers further, faster. With access to top talent in more than 50 countries, our tech-enabled recruiters can build teams quickly. Our technical experts across Cloud, AI, Data, Enterprise Operations, and Applied Engineering deliver solutions tailored to each customer’s needs. As those needs evolve, so do we. As we evolve, though, we stay true to our purpose: to develop people personally, professionally, and financially so they can be the light to the world around them. It shows up in everything we do, from investing in our people to delivering results for our customers to making a meaningful impact in our communities.
A client of Insight Global is hiring for Telehealth Nurses, for a contract through the end of 2026, with potential for extension. This role will be remote, 40/hr per week, with oppotunity for overtime if you would like.
Must be a Registered Professional Nurse with current licensure, with 2 years of professional experience Knowledge of OSHA, FDA, and HIPAA compliance Will be reviewing cases to assess the documentation needed follow-up based on client guidelines, also reviewing for accuracy. Review medical records and documentation received for accuracy and completeness Adding medical codes from the case clinical notes to define symptoms using MedDRA
Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees. Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals. We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health.
Sentara Health Plans is hiring for a Maternity Behavioral Health Care Coordinator/RN/LPC/LCSW/LMFT- Remote in Virginia Status: Full-time, permanent (40 hours/week) Standard Working Hours: 8 AM to 5 PM EST, M-F Location: Remote in Virginia. The role includes travel of approximately 3 to 4 times per year to attend baby showers through the outreach program in Virginia.
Education: Master’s degree in Counseling, Social Work, or Marriage and Family Therapy required. For Registered Nurses, a Bachelor of Science in nursing is REQUIRED Certification/Licensure REQUIRED license must be valid in state of practice. One of the following qualifies: Licensed Clinical Social Worker (LCSW) - State license - Virginia Department of Health Professionals (VADHP) OR Licensed Clinical Social Worker (LCSW) - State license - North Carolina Social Work Certification and Licensure Board (NCSWCLB) OR Licensed Professional Counselor (LPC) - State license - Virginia Department of Health Professionals (VADHP) OR Licensed Professional Counselor (LPC) - State license - North Carolina Board of Licensed Clinical Mental Health Counselors (NCBLCMHC) OR Licensed Marriage and Family Therapist (LMFT) - State license - Virginia Department of Health Professionals (VADHP) OR Licensed Marriage and Family Therapist (LMFT) - State license - North Carolina Marriage and Family Therapy Licensure Board (NCBMFT) OR Registered Nurse (RN) Single State - Nursing License - Virginia Department of Health Professionals (VADHP) OR Registered Nurse (RN) Single State - Nursing License - North Carolina Board of Nursing (NCBON) OR Registered Nurse (RN) Multi State - Nursing License - Virginia Department of Health Professionals (VADHP) OR Registered Nurse (RN) Multi State - Nursing License - North Carolina Board of Nursing (NCBON) Experience: 2 years of behavioral health REQUIRED 1 year of case management REQUIRED Experience in a Maternal Health (Labor & Delivery, Postpartum care, Mother and Baby, High Risk Pregnancy, Prenatal Care) and experience in Serious Mental Illness, Substance Abuse Disorder preferred.
This position will provide case management for members under Sentara Health Plans for Maternal Health (Labor & Delivery, Postpartum care, Mother and Baby, High Risk Pregnancy, Prenatal Care) and Behavioral Health (Serious Mental Illness, Substance Abuse Disorder).
Medix provides workforce solutions to clients and creates opportunity for talent in the Healthcare, Life Sciences, Engineering and Technology fields. Through our core purpose of positively impacting lives, we have earned our reputation as an industry leader by providing unsurpassed customer service and top quality professionals to our clients.
Now Hiring: Utilization Management Specialist (RN) Remote | Contract Opportunity (6 Months) with potential for hire We’re looking for a skilled Utilization Management Specialist (UMS) to join our growing team! This is a 6-month contract opportunity, open to candidates nationwide, making it a great fit for experienced RNs seeking impactful work. About the Role: The Utilization Management Specialist plays a critical role in determining appropriate levels of care using clinical criteria, Medicare guidelines, and payer requirements. This position partners closely with physicians, case management, revenue integrity, and payers to support accurate admissions, reduce denials, and ensure compliance. Schedule Monday–Friday: 8:00 AM – 4:30 PM EST (flexible start times available) Weekend rotation: Ideally every 3rd weekend (flexible options available) Additional Details: This is a 6-month contract role with potential hire If converted to permanent employment, eligibility is limited to candidates residing in: AZ, CT, FL, MA, ME, MD, MI, NJ, NH, NC, OH, PA, RI, TX, WI
Active RN license Graduate of an accredited nursing program (BSN preferred) 2+ years of utilization review with a hospital syste Strong knowledge of payer guidelines, medical necessity criteria, and utilization management practices Ability to work independently and collaborate across interdisciplinary teams Excellent communication and critical thinking skills
Review admissions for appropriate patient status and authorization compliance Apply clinical criteria and Medicare Inpatient Only List to determine medical necessity Collaborate with physicians, APPs, and case managers to recommend appropriate level of care Manage payer interactions, including denials and peer-to-peer (P2P) reviews Document clinical findings and authorization details in the medical record Partner with Revenue Integrity and Denials teams to support accurate billing and appeals Conduct admission, continued stay, and discharge reviews Identify trends and support quality improvement initiatives
Infinit-O empowers finance and healthcare organizations to thrive in a digital-first world by combining specialized industry expertise, innovative technology, and a commitment to process optimization. As a trusted partner, we navigate complex industry landscapes to drive transformative outcomes, helping businesses streamline operations, enhance customer experience, and achieve sustainable growth.
This role is built for working nurses who want to put their clinical skills to use on their days off — without picking up a second job that demands a second schedule. As a Telehealth Triage RN on our nurse advice line, you'll assess patient symptoms, provide evidence-based guidance, and support safe clinical decision-making — all from home, on your own time. There are no mandatory hours, no shift minimums, and no schedule commitments: you pick up available shift blocks when it works for you.
Requirements: Active Florida RN license in good standing — OR a multistate license (MSL) issued through an eNLC compact state (no additional Florida registration required for RNs under the enhanced Nurse Licensure Compact) Minimum 2+ years of acute care, emergency, or similar clinical experience — you should be comfortable making independent clinical assessments with confidence Tech-comfortable — able to learn and navigate a proprietary telehealth platform; onboarding and training are provided, but a baseline comfort with technology is expected Reliable high-speed internet connection and a quiet, private home workspace suitable for patient calls Active professional liability / malpractice insurance (required; as a 1099 contractor, you are responsible for maintaining your own coverage) Excellent verbal communication skills — calm, clear, and effective with patients under stress Nice to Have: Prior telehealth, nurse advice line, or call center triage experience AAACN Telehealth Nursing Certification (TNC) Emergency Department (ED) or ICU background Experience working with structured triage tools (e.g., Schmitt-Thompson protocols)
Conduct structured telephone and video triage assessments for patients presenting with a wide range of symptoms and concerns Apply evidence-based clinical protocols and decision-support tools to guide appropriate care pathways Advise patients on self-care, home management, or the appropriate level of care to seek (urgent care, ED, 911, etc.) Provide clear, accurate patient education tailored to each caller's situation and health literacy level Document all interactions thoroughly and accurately within the company's platform Escalate calls appropriately and efficiently when a patient requires emergency intervention Follow established escalation pathways and communicate with on-call clinical supervisors as needed Maintain patient confidentiality and adhere to HIPAA standards on every call Participate in required onboarding training and periodic protocol updates
Home Health Focus AI's mission is to help home healthcare professionals find meaningful opportunities that prioritize patient care. We are not a staffing firm or agency. Home Health Focus AI does not hire for these roles—we identify and verify them from care providers directly. Employer Industry: Healthcare Services
Why Consider This Job Opportunity Work from home opportunity after training (equipment provided) Paid time off and comprehensive medical, dental, and vision benefits 403b retirement plan with matching contributions Opportunity for growth within the organization Positive and supportive work environment focused on patient care
Active certification or license as LPN, CMA, RMA, or EMT Minimum of one year of experience in a clinical setting relevant to certification Ability to comply with applicable laws and regulations, including HIPAA, OSHA, and CLIA Strong documentation skills in electronic medical records (EMR) Excellent communication skills to effectively interact with patients and healthcare providers How To Stand Out (Preferred Qualifications) Experience in a call center or patient access role within a healthcare environment Familiarity with medical scheduling systems and patient management software Additional certifications related to healthcare access or patient care Proven ability to manage multiple tasks and prioritize effectively Strong interpersonal skills and a passion for patient care
Relay reviewed normal, expected, or abnormal results to patients as directed by providers Manage large volumes of inbound calls, documenting and communicating pertinent medical information Schedule appointments for patients according to office scheduling guidelines Verify and update patient demographic and insurance information Maintain effective communication with patients, providers, and other team members to resolve issues
1836 Wellness is a concierge telehealth practice built for high-performing executives who want more than standard care. Our clinical model centers on a 123-marker diagnostic panel across 12 health domains, more comprehensive than Function Health or Empirical Health, combined with three biological age algorithms, 10-Year and Lifetime ASCVD cardiovascular risk scoring, GLP-1 and peptide protocols, and fully personalized treatment plans. Every patient gets genuine clinical depth, real time with their provider, and a treatment experience that matches how seriously they take their health. We are building this practice from the ground up. The Nurse Practitioner (NP) we hire will have a direct hand in shaping clinical protocols, patient workflows, and the standard of care we deliver, not inheriting a system someone else built.
Location: Remote, 100% Telehealth (Houston, TX base preferred but not required for TX-licensed NPs) Type: Contract (1099), transitioning to W-2 at scale Compensation: $3,000/month retainer + per-patient compensation at volume. Equivalent to $36,000-$60,000+ annually depending on patient load. Performance bonus tied to patient outcomes and retention. Start Date: May 2026 (targeting June 2026 clinical launch) Reports To: Medical Director (physician oversight) and CEO (operations) THE ROLE You will be the primary clinical provider at 1836 Wellness. Working under a collaborative practice agreement with a board-certified Medical Director, you'll manage the full patient lifecycle: intake assessment, comprehensive lab interpretation, treatment planning, medication management, and ongoing monitoring, entirely via secure telehealth through Cerbo EHR. Mobile phlebotomy partners handle all blood draws at the patient's home or office.
REQUIRED QUALIFICATIONS Non-negotiable: Hands-on experience prescribing and managing GLP-1 medications (semaglutide, tirzepatide) for weight loss. Candidates without this will not be considered. Active Texas APRN license,FNP-BC or AGPCNP-BC 3+ years of NP practice experience Strong foundation in metabolic health, you understand obesity as a chronic, multi-system disease Comfortable interpreting comprehensive panels beyond standard CMP/CBC: hormones, inflammatory markers, advanced lipids including NMR LipoProfile, thyroid depth, kidney markers Familiarity with ASCVD risk assessment and cardiovascular risk communication DEA registration (or ability to obtain before launch) Clean professional record, no board actions or disciplinary history Telehealth-confident, you can build clinical rapport through a screen BONUS QUALIFICATIONS Experience in a cash-pay, direct-pay, or concierge practice setting Background in endocrinology, internal medicine, or obesity medicine Certification or coursework through the Obesity Medicine Association (OMA) Familiarity with peptide therapies, hormone optimization, or regenerative medicine Multi-state NP licensure (AZ, FL) or willingness to obtain Familiarity with Cerbo EHR or similar modern clinical platforms Experience in a startup or early-stage clinical environment
Conduct comprehensive telehealth assessments, medical history, contraindication screening, baseline lab review Interpret the 123-Marker Executive Panel covering metabolic health, cardiovascular risk, hormonal balance, organ function, inflammation, advanced lipids (NMR LipoProfile), thyroid depth, and complete urinalysis Review biological age scores (PhenoAge, KDM, 1836 Functional Bio Age) with patients and translate results into actionable clinical recommendations Calculate and communicate ASCVD 10-Year and Lifetime cardiovascular risk scores Prescribe and manage GLP-1 therapies (compounded semaglutide, tirzepatide) with individualized dosing and titration Develop personalized protocols including peptide therapies (BPC-157, CJC/Ipamorelin, Thymosin Alpha-1), hormone optimization, and metabolic support Provide ongoing monitoring through bi-weekly check-ins, medication adjustments, and side effect management Order and interpret follow-up labs at program milestones (Week 6, Week 12) Contribute to building clinical operations, intake workflows, documentation templates, and patient experience standards in Cerbo EHR
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 is a fully remote position. Candidates must hold an active New York State (NYS) RN licensure to be considered. The standard work schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m. EST, with the potential for weekend coverage based on business needs. Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care 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 concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned. Complies with all policies and standards.
Reimagine the infrastructure of cancer care within a community that values integrity, inspires growth, and is uniquely positioned to create a more modern, connected oncology ecosystem.
We’re looking for an Oncology Clinical Content contractor to join our clinical content services team, helping us accomplish our mission to improve and extend lives by learning from the experience of every person with cancer. This is a temporary contract role for up to 10 hours/week for a minimum six month contact role with the opportunity for an additional six month extension. Are you ready to be the next changemaker in cancer care?
You're a kind, passionate and collaborative problem-solver who values the opportunity to think beyond the way things are. In addition, you’re a creative problem solver with 2+ years of clinical oncology experience building and maintaining regimen content. You also have: An advanced degree in pharmacy, nursing, or physician assistant required (PharmD, RN, NP, PA) 2+ years working within an oncology setting required, either through a residency or practical experience Experience building and maintaining regimens in an EMR Familiarity with NCCN Chemotherapy Order Templates and oncology treatment protocols Ability to manage and maintain deadlines Highly detail-oriented and process-oriented Ability to review clinical content for completeness, quality, and compliance with established standards Excellent verbal and written communication skills Excellent organizational skills and ability to multitask
The Clinical Content Services Team is responsible for ensuring the safety and usability of Flatiron’s community oncology provider-facing software, initiatives, and workflows. The team is comprised primarily of oncology clinicians who are embedded directly within Flatiron’s Product and Engineering teams to develop safe, intuitive workflows in OncoEMR, Flatiron’s cloud-based electronic health record, and who develop and integrate oncology clinical content into Flatiron’s technology platform to make it useful for clinicians and patients. In this role you will work directly within OncoEMR (OE) to build, customize, and maintain clinical regimen content. Build, update, and perform quality assurance (QA) on Flatiron regimen content in OncoEMR based on NCCN Chemotherapy Order Templates Migrate and customize Flatiron regimen content for Flatiron customers as part of our new clinical content services offering designed to help practices keep their regimen libraries current and up to date with the latest evidence-based regimens Map Flatiron regimen content in Flatiron Assist, our oncology-specific clinical decision support platform Maintain up-to-date tracking and status of all regimen work Review project status with Clinical Oncology team management and colleagues as appropriate Adhere to all build and maintenance policies, procedures, and quality standards Proactively communicate challenges and escalate appropriately to ensure that assigned projects are completed in a timely manner
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. This role is 100% remote with no face-to-face contact with patients. Full-Time Monday – Friday, no weekends, rotational on-call twice per year on average
Requirements: Active Illinois License (LPN) Technical aptitude – Microsoft Office Suite Excellent written and verbal communication skills Plusses: Epic Experience Bilingual 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.
In the United States, one in five adults experience a mental health illness and over 12 million people have thoughts of suicide. Mental health crises can be some of the most difficult times in a person’s life, and over 17 million people seeking behavioral health care experience a delay in accessing care. Willow Health is on a mission to significantly improve this experience by expanding affordable access to high-quality, evidence-based, intensive behavioral health care. In 2023, we launched our virtual crisis care program that provides personalized, recovery-oriented care for people experiencing behavioral health crises. Willow Health offers patients immediate access to evidence-based virtual crisis psychotherapy, medication management, certified peer coaching, care management, groups, and around-the-clock crisis coverage, while working to connect patients to the most appropriate next level of care.
As a Crisis Care Nurse Practitioner, you will provide telehealth evidence-based behavioral health care including comprehensive clinical assessments, differential diagnosis, creating and implementing co-created clinical treatment plans, and medication management. You will work alongside our diverse and passionate multidisciplinary clinical team taking care of Willow Health’s patients and making an impact in our clinical program. Our clinical team includes psychiatrists, nurse practitioners, licensed clinical social workers, licensed mental health clinicians, certified peer specialists, case managers, and clinical operations. We are looking for a thoughtful, empathic, and skilled clinician to join our highly motivated team to help improve behavioral health crisis care. This is a fully virtual role. Working hours for the clinic are Monday - Friday from 10:30AM to 7:30PM. This role is a 32 hours, 4 day per week position.
Bachelor of Science in Nursing degree (or equivalent non-U.S. degree) Board Certification Master of Science in Nursing degree or a Doctor of Nursing Practice degree (or equivalent non-U.S. degree) Hold an active license to practice in New York Maintain all state requirements and continuing education requirements to provide behavioral health care Has experience with clinical assessments, developing differential diagnosis, creating and implementing clinical treatment plans, and psychiatric medication management Has at least 2 years of clinical experience of psychiatric medication management Has experience with clinical risk management, suicide risk assessment, and safety planning Has experience and is comfortable with using validated clinical tools to help enhance clinical care Has experience with and is comfortable with using technology Excellent written and verbal communication skills Excellent interpersonal skills and ability to work effectively in a multidisciplinary clinical team Experience working with an electronic medical record Nice-to-Haves: Post degree experience in providing emergency mental health services and/or urgent behavioral healthcare Psychiatric fellowship Comprehensive knowledge of substance abuse, mental health, and recovery issues and principles Has experience with using clinical outcomes to help enhance clinical care Has experience launching and iterating on a clinical care model, (preferred, not required) Experience in a start-up healthcare setting and/or an innovative healthcare program (preferred, not required)
Perform comprehensive clinical assessments and develop differential diagnosis Provide psychiatric medication management Build therapeutic alliance with patients Create and implement co-created personalized treatment plans with our multidisciplinary team Manage a caseload of patients who you will follow for 8 to 12 weeks providing medication management Conduct comprehensive risk assessment and safety planning Utilize validated clinical tools to aid in differential diagnosis Work across our multidisciplinary clinical team to facilitate comprehensive behavioral health crisis care Actively participate in multidisciplinary team meetings Maintain appropriate documentation of all patient-related care Engage with clinical supervision Work with our patients, their families, and their providers in the community to ensure comprehensive behavioral health care
Heartbeat Health is the leading virtual-first cardiovascular care company in the country, providing patients with convenient, high-quality heart care through a combination of telemedicine, diagnostics, and virtual care programs. By leveraging real-time data and AI-powered insights, Heartbeat Health empowers providers and patients with personalized treatment plans, reducing hospitalizations and improving long-term heart health outcomes. Heartbeat Health is redefining how cardiovascular care is delivered in the digital age, led by our medical group of cardiologists, advanced practitioners, nurses, and care coordinators.
We are seeking a skilled and compassionate Registered Nurse located in the Mountain Standard Time zone to provide remote consultation and expertise in the field of cardiology.
Must hold a current and unrestricted Registered Nurse (RN) license (Compact). At least 3+ years of experience in cardiology. Experience in telemedicine is a bonus. Excellent communication and interpersonal skills, especially in a virtual environment. Team-player is a must. Ability to effectively educate patients and collaborate with a multidisciplinary healthcare team, including cardiologists and advanced practitioners. Ability to work independently and make clinical decisions under appropriate supervision Proficiency in using telehealth platforms and electronic health records Commitment to patient-centered care and empathy for patients with chronic cardiology conditions Compassion and empathy when working with patients and their families, especially when delivering challenging diagnoses or managing chronic cardiac conditions.
Education and Counseling: This role is a remote, patient-facing role. As part of our RN team, you will provide education about a patient’s diagnosis, test results and treatment plan. Collaboration: Collaborate closely with cardiologists, PCPs and other healthcare professionals to ensure comprehensive and coordinated care for patients. Discuss complex cases and participate in multidisciplinary care teams. Utilize clinical decision making to escalate concerns to the care team. Documentation: Maintain accurate and detailed patient records, including patient interactions, medical histories, assessments, treatment plans, progress notes, and discharge summaries within scope of practice. Ensure compliance with legal and ethical standards. Follow-Up Care: Schedule and conduct follow-up virtual visits to monitor patients' progress and address any concerns or questions. Patient Advocacy: Serve as an advocate for patients' needs and preferences, ensuring that they receive appropriate care and support throughout their healthcare journey. Compliance: Adhere to legal and ethical guidelines, including patient confidentiality and telemedicine regulations, while providing virtual care. Prioritization & Triage: Efficiently triage incoming patient requests and manage patient panel by prioritizing patients based on need and client SLAs. Continuing Education: Pursue ongoing education and professional development in the field of cardiology to stay updated on the latest advancements and maintain relevant certifications. Quality Assurance: Participate in quality assurance programs to monitor and improve the quality of cardiology care provided within the organization.
Heartbeat Health is the leading virtual-first cardiovascular care company in the country, providing patients with convenient, high-quality heart care through a combination of telemedicine, diagnostics, and virtual care programs. By leveraging real-time data and AI-powered insights, Heartbeat Health empowers providers and patients with personalized treatment plans, reducing hospitalizations and improving long-term heart health outcomes. Heartbeat Health is redefining how cardiovascular care is delivered in the digital age, led by our medical group of cardiologists, advanced practitioners, nurses, and care coordinators.
We are seeking a skilled and compassionate Registered Nurse located in the Eastern Time zone to provide remote consultation and expertise in the field of cardiology.
Must hold a current and unrestricted Registered Nurse (RN) license (Compact). At least 3+ years of experience in cardiology. Experience in telemedicine is a bonus. Excellent communication and interpersonal skills, especially in a virtual environment. Team-player is a must. Ability to effectively educate patients and collaborate with a multidisciplinary healthcare team, including cardiologists and advanced practitioners. Ability to work independently and make clinical decisions under appropriate supervision Proficiency in using telehealth platforms and electronic health records Commitment to patient-centered care and empathy for patients with chronic cardiology conditions Compassion and empathy when working with patients and their families, especially when delivering challenging diagnoses or managing chronic cardiac conditions.
Education and Counseling: This role is a remote, patient-facing role. As part of our RN team, you will provide education about a patient’s diagnosis, test results and treatment plan. Collaboration: Collaborate closely with cardiologists, PCPs and other healthcare professionals to ensure comprehensive and coordinated care for patients. Discuss complex cases and participate in multidisciplinary care teams. Utilize clinical decision making to escalate concerns to the care team. Documentation: Maintain accurate and detailed patient records, including patient interactions, medical histories, assessments, treatment plans, progress notes, and discharge summaries within scope of practice. Ensure compliance with legal and ethical standards. Follow-Up Care: Schedule and conduct follow-up virtual visits to monitor patients' progress and address any concerns or questions. Patient Advocacy: Serve as an advocate for patients' needs and preferences, ensuring that they receive appropriate care and support throughout their healthcare journey. Compliance: Adhere to legal and ethical guidelines, including patient confidentiality and telemedicine regulations, while providing virtual care. Prioritization & Triage: Efficiently triage incoming patient requests and manage patient panel by prioritizing patients based on need and client SLAs. Continuing Education: Pursue ongoing education and professional development in the field of cardiology to stay updated on the latest advancements and maintain relevant certifications. Quality Assurance: Participate in quality assurance programs to monitor and improve the quality of cardiology care provided within the organization.
At AccentCare, our care is most compassionate when we empathize and engage with everyone, and we are at our best when we value diverse perspectives, foster open dialogue, and enact change. And we are stronger when each of us is empowered to grow, be our unique selves, and feel a sense of inclusion and belonging. AccentCare is proud of how we are building a culture and inclusive infrastructure to help elevate the voice of all our employees with a special focus on the underrepresented and marginalized. We offer equal employment opportunities regardless of a person’s race, ethnicity, sex, sexual orientation, gender identity or expression, religion, national origin, color, creed, age, mental disability, physical disability, or any other protected classification.
Remote RN Triage Nurse/Part-Time, Weekends Location: Remote Position: RN Triage Nurse/Part-Time, Weekends Position Type: Part-time Remote/Virtual Position: Yes, virtual Coverage Area: Nationwide Find Your Passion and Purpose as an RN Triage Nurse/Part-Time Salary: $32.00-$34.00 per hour, dependent on experience Schedule: Sat & Sun 7a-7p, one weeknight 4p-10p Reimagine Your Career in Home Health As a medical professional, you know that what you do impacts you as much as your patients and their families, and at AccentCare, we are united in our relentless drive to reimagine care because we want to provide the service we would seek for our own families. We think it’s really special to be a part of our patient’s health journey and create incredible memories while providing world-class patient care.
Graduated from an approved school of professional nursing Excellent customer service, assessment, and verbal communication skills Computer skills Required Certifications and Licensures: Licensed to practice as a registered nurse in the state of agency operatio
Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact. Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes - making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.
The purpose of this position is to review medical records against appropriate criteria in conjunction with contract requirements to determine medical appropriateness.
Required Qualifications: A minimum of 2 years of clinical experience. An active unrestricted RN in the South Carolina and/or Compact State clinical license per contract requirements. Preferred Qualifications: Bachelor’s Degree is preferred Knowledge of the organization of medical records, medical terminology, and disease process required. Strong clinical assessment and critical thinking skills required. Medical record abstracting skills required. Requires excellent written and verbal communication skills. Medical record abstracting skills required.
Assures accuracy and timeliness of all applicable review type cases within contract requirements. Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department. In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas. Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns. Performs all applicable review types as workload indicates. Fosters positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process. Attends training and scheduled meetings and for maintenance and use of current/updated information for review. Cross trains and perform duties of other contracts to provide a flexible workforce to meet client/customer needs. The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.
WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.
Our Clinical Manager is accountable to plan, organize, manage, and evaluate clinical operations for Medical Review. This includes developing Centers for Medicare & Medicaid Services (CMS) reports as well as managing activities to ensure accurate rendering of claim decisions. They collaborate with other business areas to ensure WPS and CMS goals and objectives are met utilizing cost-effective, timely, accurate, and innovative methods. This Clinical Manager is accountable to ensure compliance with regulatory and payor guidelines. Salary Range $100,000 ~ $120,000 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. Work Location: Remote OR Hybrid We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin **Employees living within 45 miles of WPS Headquarters (1717 W. Broadway in Madison, WI) will be expected to be able to come into the office 2 days a week on a regular basis.
Minimum Qualifications: Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN). Active RN license, applicable to state of practice in good standing. 5 or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.) 3 or more years in a leadership role. Extensive knowledge and understanding of CMS guidelines and regulations. Extensive knowledge and understanding of medical/clinical review processes. Strong analytical, problem-solving, and organizational skills that include: The ability to manage multiple cases simultaneously and meet strict deadlines. Excellent reading comprehension, written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely. Proficient in Microsoft Office tools with experience working in electronic health records. Preferred Qualifications: Experience working for a Medicare Administrative Contractor (MAC). Remote Work Requirements: Wired (ethernet cable) internet connection from your router to your computer High speed cable or fiber internet Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net) Please review Remote Worker FAQs for additional information
Can develop, implement, and maintain the Improper Payment Reduction Strategy (IPRS) for Medical Review. Enjoy leading people monitoring and maintaining Full Time Equivalents (FTEs), budget, and workload according to IPRS. Thrive when ensuring accurate and timely handling of Medical Review clinical decisions. Can monitor all results for Medical Review Accuracy Award Fee, providing follow-up, dispute, and education as indicated. Have coordinate with the Medical Review Operations Manager in preparation of the Monthly Status Report. Want to ensure effective and timely response to clinical concerns raised by CMS, other CMS contractors and other clinical areas. Can maintain detailed knowledge of all Medicare regulations and broad level knowledge of WPS business capabilities. Have ensured compliance within federal and state regulations, CMS guidelines, and company policies. Enjoy coaching and mentoring the Clinical Med Management team to ensure a culture of accountability and excellence; execute programs to drive employee engagement and satisfaction.
WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.
Our Policy Nurse Analyst supports the development and maintenance of Medicare healthcare policies by conducting research, collaborating with Medical Directors, and engaging with both internal teams and external provider communities. They ensure that published Medicare coverage guidelines remain current, evidence-based, and compliant with federal regulations. This Policy Nurse Analyst plays a key role in interpreting CMS mandates, synthesizing clinical evidence, and contributing to the continuous improvement of the policy development process. Salary Range 70,000 ~ $85,000 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. Work Location We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin Employees living within 45 miles of WPS Headquarters (1717 W. Broadway in Madison, WI) will be expected to be able to work in the office 2 days a week on a regular basis.
Minimum Qualifications: Bachelor’s Degree in Nursing (BSN) or equivalent combination of education and experience. Active Registered Nurse (RN) license in state of practice or a compact nursing license. 2 or more years of experience in healthcare, health policy, clinical research, or a related field; including familiarity with regulatory standards (i.e., CMS, Medicare, URAC). Knowledge of medical coding (e.g., ICD-10, CPT, HCPCS); Proven experience conducting research, analyzing information, and summarizing findings. Strong critical thinking, ability to work independently applying sound nursing judgement, creative problem solving, and clinical decision-making skills. Strong organizational skills with the ability to meet deadlines, manage competing priorities, and maintain quality standards. Strong written and verbal communication skills with the ability to communicate complex medical information clearly and concisely. Proficiency in Microsoft Office tools (outlook, Word, Excel, One-Note) and shared document environments. Preferred Qualifications: Certification in medical coding. Experience evaluating medical literature GRADE Methodology. A passion for research and investigating. Remote Work Requirements: Wired (ethernet cable) internet connection from your router to your computer High speed cable or fiber internet Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net) Please review Remote Worker FAQs for additional information
Can initiate, coordinate, and maintain healthcare policy development for the Medicare programs. Have responded to mandates from the Centers for Medicare & Medicaid Services (CMS) and ensure alignment with federal healthcare policy requirements. Enjoy assisting Contractor Medical Directors in the development and revision of healthcare policies. Would like to serve as a resource to internal departments, including Customer Service and Medical Review, regarding Medicare policies. Can maintain up-to-date knowledge of current medical practices and Medicare coverage guidelines. Enjoy communicating with external providers and the Contractor Advisory Committee (CAC) to support clarification and implementation of CMS requests. Thrive when conducting research to determine safety and efficacy of healthcare products and procedures and producing clear written summaries of clinical evidence. Like to collaborate with multidisciplinary teams to draft, review, and revise medical policies. Can support continuous improvement initiatives within the medical policy development process.
Cascadia was formed when partners from the skilled nursing and real estate development industry joined forces with a common purpose in mind – to provide a high level of care to patients and families within the region they call home. Our goal is to provide a motivating environment for our employees based on the values of quality work, empowerment and accountability. Cascadia is driven by honest hard work and we believe that strong partnerships and quality care are the outcome.
Support ethical, compliant, and high-quality clinical and regulatory practices across a multifacility organization. We are seeking an experienced and dynamic Compliance Clinical Specialist to join our Compliance team. This role partners closely with clinical, operational, and leadership teams to support regulatory compliance, quality outcomes, and ethical business practices across skilled nursing facilities (SNFs), assisted living facilities (ALFs), and Hospice agencies. The position requires regular travel and a field-driven, hands-on, focused hybrid approach to compliance. You are a licensed Registered Nurse with clinical experience in skilled nursing or post-acute care environments and a strong working knowledge of regulatory and compliance requirements. You thrive in a compliance role, partnering with operations and the field to identify risk, provide guidance, and drive sustainable, compliant practices. You bring credibility, integrity, and a solution-oriented mindset to complex regulatory challenges.
Education & Licensure: Active, unrestricted Registered Nurse (RN) license Experience: Minimum of five (5) years of clinical nursing experience in a Skilled Nursing Facility (SNF) or post-acute care setting Experience with Medicare Part A and Part B and other payors in multifacility or multistate environments Ability to work with all levels of staff and leadership on complex regulatory issues Prior compliance or quality experience preferred Certifications (Preferred) Certified Professional in Healthcare Quality (CPHQ) Key Competencies: Strong analytical and critical decision-making skills Excellent written and verbal communication skills High degree of credibility, integrity, and professionalism Ability to work independently in a home office environment Strong interpersonal skills and ability to build trust with the field Proficiency with Microsoft 365 tools Ability and willingness to travel approximately 60% of the time with overnight travel expected
Compliance Audits & Investigations: Conduct compliance audits and investigations related to clinical care, documentation, billing practices, HIPAA, and other identified risk areas or regulatory concerns Utilize analytical review, computer auditing tools, and statistical sampling methods Prepare clear, timely audit and investigation reports Follow up on corrective action plans (CAPs) to ensure regulatory compliance Regulatory Guidance & Education: Provide regulatory guidance related to nursing practice and clinical compliance requirements Conduct training and education for field teams, leadership, and internal resources Present compliance findings in a clear, practical, and understandable manner Program Development & Risk Management: Assist the Chief Compliance Officer with development, implementation, and evaluation of audit tools and compliance program effectiveness Participate in onsite and remote audits, investigations, meetings, and risk assessments Support compliance efforts related to new acquisitions Keep facilities and leadership informed of regulatory changes, audit outcomes, and investigation findings Collaboration & Field Partnership: Partner closely with operations and clinical leadership to support compliance, quality of care, and organizational outcomes Attend company and local meetings as requested Provide hands-on compliance support in a fast-paced, highly regulated environment
At Cottingham & Butler, we sell a promise to help our clients through life’s toughest moments. To deliver on that promise, we aim to hire, train, and grow the best professionals in the industry. We look for people with an insatiable desire to succeed, are committed to growing, and thrive on challenges. Our culture is guided by the theme of “better every day” constantly pushing ourselves to be better than yesterday – that’s who we are and what we believe in. As an organization, we are tremendously optimistic about the future and have incredibly high expectations for our people and our performance. Our ability to grow as a company, fuels investments in new resources to better serve our clients and provide the amazing career opportunities our employees want and deserve. This is why we are a growth company and why we are committed to being better every day.
Location: Onsite in Dubuque, IA. Also accepting remote applicants. Are you passionate about patient care and thrive in a fast-paced, professional environment? We are seeking a dedicated Utilization Management Assistant to join our healthcare team. We are looking for individuals with experience in a medical setting, including but not limited to a receptionist, scheduler, insurance verification, LPN, CNA, Medical Assistants, or individuals with a background in customer service who are looking to make a meaningful impact behind the scenes. If you are looking to get into a professional office setting with daytime office hours and weekends/holidays off, this is the role for you!
Preferred Skills Communication - Strong interpersonal skills to be able to connect with patients, doctors, internal team members, and providers Customer Service - Friendly demeanor and understanding to be able to relay sensitive information to members Detail Oriented - Accuracy and attention to detail when reviewing pre-certifications and plans Qualifications: CNA, LPN, or Medical Assistant preferred Background in patient health support or care 1+ years of experience within this field
The Utilization Management Assistant answers first level calls in Utilization Review for our Health & Wellness participants. They will evaluate certification requests by reviewing the group specific requirements and will also triage the call to determine if a Utilization Review Nurse is needed to complete the call. You will be responsible for reviewing medical records, coordinating with healthcare providers, and ensuring that patients receive appropriate, cost-effective care in accordance with clinical guidelines and insurance requirements.
By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance
We are looking to add 2 full time nurses to our Clinical Consultation Team. This class will start on June 1 - no exceptions. Please note: Training is 8:30 am to 4:30 pm CST, Monday through Friday for 4 weeks. Schedules after training are the following shifts (in CST): 12:00 pm - 8:30 pm, Monday through Friday 7:30 pm - 4:00 am, Friday, Saturday, Sunday and Monday PRIMARY PURPOSE OF THE ROLE: To triage calls to assess needs, giving appropriate care advice and disposition to appropriate level of care treatment while promoting cost-effective outcomes and safely facilitate return to work. ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. Apply your medical/clinical or rehabilitation knowledge and experience to assist in the management of complex medical conditions, treatment planning and recovery from illness or injury. Work in the best of both worlds - a rewarding career making an impact on the health and lives of others, and a remote work environment. Enjoy flexibility in your career path while advocating for the most effective and efficient medical treatment for injured employees in a non-traditional setting. Enable our Caring counts® mission supporting injured employees from some of the world’s best brands and organizations. Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. Celebrate your career achievements and each other through professional development opportunities, continuing education credits, team building initiatives and more. Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs.
EDUCATION AND LICENSING: Bachelor's degree in nursing (BSN) preferred. Active unrestricted RN compact licensure required along with two year (2) years of recent clinical practice experience. Should be proficient in multiple screens and multiple computer applications,. TAKING CARE OF YOU BY Seeks innovative customer solutions . Craves cutting edge opportunities. Wants dynamic company culture. Passion about creativity. Seeks ongoing learning as a person and professional. Thrives when solving challenging problems. Wants achievements to be celebrated. We offer a diverse and comprehensive benefits including medical, dental vision, 401K, PTO and more beginning your first day.
Applies all phases of the nursing process, i.e. assessment, planning, implementation and evaluation when triaging calls. Identifies the needs of caller by triaging, obtaining general health information and/or physician services referral. Evaluates need for alternative treatment through telephonic contact and assessment with service provider. Triages patient using defined triage protocols to obtain pertinent data; and enters data into computer system. Identifies life-threatening emergencies and recommends appropriate interventions. Refers issues requiring physician interventions to physician in a timely manner; directs patients to appropriate level of care including but not limited to the nearest emergency room, urgent care facility, primary treating physician or selfcare. Demonstrates effective verbal communications skills. Adheres to quality assurance standards. Serves as resource to triage team members.
By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance
RN Clinical Consultation - PART TIME We are looking to add 4 part-time nurses to our Clinical Consultation Team. This class will start on June 1 - no exceptions. Please note: Training is 8:30 am to 4:30 pm CST, Monday through Friday for 4 weeks. Schedules after training are the following shifts (in CST): 1:00 pm - 7:00 pm, Wednesday/Thursday/Friday 4:00 pm - 10:00 pm, Thursday/Saturday/Sunday 11:00 am - 5:00 pm, Friday/Saturday/Sunday 8:30 am - 6:00 pm, Saturday/Sunday PRIMARY PURPOSE OF THE ROLE: To triage calls to assess needs, giving appropriate care advice and disposition to appropriate level of care treatment while promoting cost-effective outcomes and safely facilitate return to work. ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. Apply your medical/clinical or rehabilitation knowledge and experience to assist in the management of complex medical conditions, treatment planning and recovery from illness or injury. Work in the best of both worlds - a rewarding career making an impact on the health and lives of others, and a remote work environment. Enjoy flexibility in your career path while advocating for the most effective and efficient medical treatment for injured employees in a non-traditional setting. Enable our Caring counts® mission supporting injured employees from some of the world’s best brands and organizations. Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. Celebrate your career achievements and each other through professional development opportunities, continuing education credits, team building initiatives and more. Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs.
EDUCATION AND LICENSING Bachelor's degree in nursing (BSN) preferred. Active unrestricted RN compact licensure required along with two year (2) years of recent clinical practice experience. Should be proficient in multiple screens and multiple computer applications,. TAKING CARE OF YOU BY Seeks innovative customer solutions . Craves cutting edge opportunities. Wants dynamic company culture. Passion about creativity. Seeks ongoing learning as a person and professional. Thrives when solving challenging problems. Wants achievements to be celebrated. We offer a diverse and comprehensive benefits including medical, dental vision, 401K, PTO and more beginning your first day.
Applies all phases of the nursing process, i.e. assessment, planning, implementation and evaluation when triaging calls. Identifies the needs of caller by triaging, obtaining general health information and/or physician services referral. Evaluates need for alternative treatment through telephonic contact and assessment with service provider. Triages patient using defined triage protocols to obtain pertinent data; and enters data into computer system. Identifies life-threatening emergencies and recommends appropriate interventions. Refers issues requiring physician interventions to physician in a timely manner; directs patients to appropriate level of care including but not limited to the nearest emergency room, urgent care facility, primary treating physician or selfcare. Demonstrates effective verbal communications skills. Adheres to quality assurance standards. Serves as resource to triage team members.
Comagine Health is a national, mission-driven, nonprofit organization that has engaged in health care quality consulting and quality improvement services for more than 50 years. We are leaders in assisting front-line providers and engaging health care partners to improve care delivery and patient outcomes. Our talented remote workforce spans the country and plays a vital role in our success. We go beyond merely providing a remote work option; we support and embrace it. We offer opportunities to make a difference from anywhere in the U.S. and enjoy better work-life balance. An annual stipend gives you the freedom to enhance your workspace with options that suit your needs.
Lead Clinical Reviewer DC Medicaid Contract The Clinical Review Lead is responsible for designing, implementing, and evaluating reviews by coordinating, delegating, and supporting the Clinical Review team This position serves as a subject matter expert for FFS reviews, as well as Long Term Care reviews for the DC Contract The Clinical Reviewer Lead plays a pivotal role in overseeing the clinical review process to ensure the highest standards of quality and compliance within healthcare services. This position is responsible for leading a team of clinical reviewers, providing expert guidance and support to ensure accurate and timely evaluation of medical records and claims. The role requires collaboration with cross-functional teams to develop and implement review protocols that align with regulatory requirements and organizational goals. The Clinical Reviewer Lead will analyze complex clinical data to identify trends, improve processes, and support decision-making that enhances patient care outcomes. Ultimately, this role ensures that clinical reviews are conducted with integrity, accuracy, and efficiency, contributing to the overall success of healthcare service delivery in the Washington DC area.
Skills: The Clinical Reviewer Lead utilizes strong clinical knowledge and analytical skills daily to assess complex medical records and ensure compliance with healthcare standards. Leadership and communication skills are essential for effectively managing and motivating the clinical review team, as well as collaborating with various stakeholders. Attention to detail and critical thinking are applied to identify discrepancies and recommend process improvements. Familiarity with healthcare regulations and documentation standards guides the development and enforcement of review protocols. Additionally, proficiency with clinical software and data analysis tools supports efficient review workflows and informed decision-making. Preferred Qualifications: Master’s degree in Nursing, Healthcare Administration, or a related discipline. Certification in Clinical Documentation Improvement (CDI) or Certified Professional Medical Auditor (CPMA). Experience with electronic health record (EHR) systems and clinical review software. Familiarity with Medicare, Medicaid, and other payer regulations. Experience working in a fast-paced healthcare environment with multidisciplinary teams.
Lead and mentor a team of clinical reviewers, providing training, performance feedback, and professional development opportunities. Conduct and oversee detailed clinical reviews of medical records, claims, and related documentation to ensure accuracy and compliance with established guidelines. Collaborate with healthcare providers, auditors, and internal departments to resolve discrepancies and improve review processes. Develop, update, and implement clinical review protocols and quality assurance measures to maintain regulatory compliance and enhance review effectiveness. Analyze clinical data and review outcomes to identify trends, recommend improvements, and support strategic decision-making.
Comagine Health is a national, mission-driven, nonprofit organization that has engaged in health care quality consulting and quality improvement services for more than 50 years. We are leaders in assisting front-line providers and engaging health care partners to improve care delivery and patient outcomes. Our talented remote workforce spans the country and plays a vital role in our success. We go beyond merely providing a remote work option; we support and embrace it. We offer opportunities to make a difference from anywhere in the U.S. and enjoy better work-life balance. An annual stipend gives you the freedom to enhance your workspace with options that suit your needs. We believe in an environment that allows you to thrive both personally and professionally.
We are seeking PRN Clinical Utilization Review Nurses (RN) to assess the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective utilization management reviews. This full-time, remote position supports high-quality, appropriate, and cost-effective care while ensuring compliance with clinical criteria, organizational policies, and contract requirements specific to Washington D.C. This position will fill in for employees that are on leave or on PTO so weekend and evening work is expected. Expected work hours up to 19 hours per week.
Education & Experience BA/BS in Nursing Equivalent combination of education and/or related experience may be considered depending on contract Minimum of 3 years of direct patient care (clinical) experience Licensure Current, active, unrestricted RN license Washington D.C. Required Skills & Competencies Experience with InterQual Criteria Strong proficiency in Microsoft Office Suite and familiarity with database systems Excellent written and verbal communication skills Strong organizational, analytical, and problem-solving abilities Ability to manage multiple priorities in a fully remote, team-based environment Work Environment PRN Must be licensed in Washington D.C. Reliable, secure internet connection required Must maintain licensure eligibility for assigned state contract Physical Requirements & Work Environment This position is primarily remote and performed in a home-based setting, requiring reliable internet access and a workspace free from significant distractions. The role involves frequent use of computers, phones, and virtual communication tools. Employees must be able to sit for extended periods, communicate effectively. Some positions may require operating a motor vehicle for business purposes; in such cases, employees must maintain a valid driver’s license and meet the organization’s driving eligibility requirements. Occasional travel may be required for meetings, training, or other work-related events. Reasonable accommodations will be provided to enable individuals with disabilities to perform essential functions.
Conduct prospective, concurrent, and retrospective utilization management reviews Apply clinical review criteria, organizational policies, guidelines, and screening tools (InterQual) Consult with physician/practitioner consultants when services do not meet medical necessity criteria Collaborate with internal teams and refer cases for additional review or escalation as appropriate Refer cases to management when required Provide clinical and utilization review subject matter expertise Respond to provider, customer, and stakeholder questions regarding determinations and processes Conduct outreach to providers, case managers, consultants, and community support coordinators to obtain additional clinical information Maintain accurate documentation and comply with all regulatory and contract standards
At AccentCare, our care is most compassionate when we empathize and engage with everyone, and we are at our best when we value diverse perspectives, foster open dialogue, and enact change. And we are stronger when each of us is empowered to grow, be our unique selves, and feel a sense of inclusion and belonging. AccentCare is proud of how we are building a culture and inclusive infrastructure to help elevate the voice of all our employees with a special focus on the underrepresented and marginalized. We offer equal employment opportunities regardless of a person’s race, ethnicity, sex, sexual orientation, gender identity or expression, religion, national origin, color, creed, age, mental disability, physical disability, or any other protected classification.
Remote RN Triage Nurse/Part-Time, Weekends Location: Remote Position: RN Triage Nurse/Part-Time, Weekends Position Type: Part-time Remote/Virtual Position: Yes, virtual Coverage Area: Nationwide Find Your Passion and Purpose as an RN Triage Nurse/Part-Time Salary: $32.00-$34.00 per hour, dependent on experience Schedule: Sat & Sun 7a-7p, one weeknight 4p-10p Reimagine Your Career in Home Health As a medical professional, you know that what you do impacts you as much as your patients and their families, and at AccentCare, we are united in our relentless drive to reimagine care because we want to provide the service we would seek for our own families. We think it’s really special to be a part of our patient’s health journey and create incredible memories while providing world-class patient care.
Be the Best Home Health Triage Registered Nurse You Can Be If you meet these qualifications, we want to meet you! Graduated from an approved school of professional nursing Excellent customer service, assessment, and verbal communication skills Computer skills Required Certifications and Licensures: Licensed to practice as a registered nurse in the state of agency operatio
At AccentCare, our care is most compassionate when we empathize and engage with everyone, and we are at our best when we value diverse perspectives, foster open dialogue, and enact change. And we are stronger when each of us is empowered to grow, be our unique selves, and feel a sense of inclusion and belonging. AccentCare is proud of how we are building a culture and inclusive infrastructure to help elevate the voice of all our employees with a special focus on the underrepresented and marginalized. We offer equal employment opportunities regardless of a person’s race, ethnicity, sex, sexual orientation, gender identity or expression, religion, national origin, color, creed, age, mental disability, physical disability, or any other protected classification.
Remote RN Triage Nurse/Part-Time, Weekends Location: Remote Position: RN Triage Nurse/Part-Time, Weekends Position Type: Part-time Remote/Virtual Position: Yes, virtual Coverage Area: Nationwide Find Your Passion and Purpose as an RN Triage Nurse/Part-Time Salary: $32.00-$34.00 per hour, dependent on experience Schedule: Sat & Sun 7a-7p, one weeknight 4p-10p Find Your Passion and Purpose as a Hospice Triage Registered Nurse Reimagine Your Career in Hospice As a medical professional, you know that what you do impacts you as much as your patients and their families, and at AccentCare, we are united in our relentless drive to reimagine care because we want to provide the service we would seek for our own families. We think it’s really special to be a part of our patient’s health journey and create incredible memories while providing world-class patient care. Offer Based on Years of Experience What You Need To Know Our Investment in You We are committed to offering comprehensive benefits and rewards to full-time employees who work over 30 hours per week and their families, including: Medical, dental, and vision coverage Paid time off and paid holidays Professional development Company-matching 401(k) Flexible spending and health savings accounts Company store credit for your first AccentCare-branded scrubs for patient-facing employees
If you meet these qualifications, we want to meet you! Graduated from an approved school of professional nursing Excellent customer service, assessment, and verbal communication skills Computer skills Required Certifications and Licensures: Licensed to practice as a registered nurse in the state of agency operation
Bozeman Health is an integrated health care delivery system serving an eleven-county region in Southwest Montana. As a nonprofit organization, governed by a volunteer community board of directors, we are the largest private employer in Gallatin County, with more than 2,900 employees, including 270 medical providers representing over 40 clinical specialties. It is our privilege to deliver expert, compassionate health and wellness services across the care continuum, designed to meet the diverse health care needs of the communities we serve.
This position can be remote. Please review the approved remote states below. Remote Work Approved States: Arizona Florida Georgia Idaho Iowa South Dakota Texas South Carolina Wisconsin North Carolina Michigan *If your state is not listed, you must relocate to Montana or one of the approved states above to be eligible for this position. Position Summary: The Nurse Navigator collaborates with providers and/or clinical areas to coordinate service and ensure quality of care for patients. This nurse interdependently assesses, evaluates and implements care delivered to patients and ensures a smooth transition of patients from clinic to procedural and outpatient treatment areas. The nurse navigator, together with the multidisciplinary team, facilitates timely scheduling of appointments, diagnostic testing, and procedures to expedite the plan of care and promote continuity of care. The registered nurse also plans and implements patient and family education.
Minimum Qualifications Required: Bachelors in Nursing from accredited nursing school Montana Licensure (Registered Nurse) American Heart Association BLS 1 year of direct patient care experience Preferred: Certification in specialty Experience in specialty 3 years of direct patient care experience Knowledge, Skills, and Abilities Demonstrates sound judgement, patience, and maintains a professional demeanor at all times Ability to work in a busy and stressful environment Creativity, problem analysis and decision making Ability to work varied shifts Exercises tact, discretion, sensitivity and maintains confidentiality Strong emotional intelligence, interpersonal and teamwork skills Schedule Requirements: This role requires regular and sustained attendance. The position may necessitate working beyond a standard 40-hour workweek, including weekends and after-hours shifts. On-call work may be required to respond promptly to organizational, patient, or employee needs. Physical Requirements: Lifting (Repeatedly – 50 pounds): Exerting force occasionally and/or using a negligible amount of force to lift, carry, push, pull, or otherwise move objects or people. Sit (Occasionally): Maintaining a sitting posture for extended periods may include adjusting body position to prevent discomfort or strain. Stand (Repeatedly): Maintaining a standing posture for extended periods may include adjusting body position to prevent discomfort or strain. Walk (Repeatedly): Walking and moving around within the work area requires good balance and coordination. Climb (Rarely): Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like using feet and legs; may also use hands and arms. Twist/Bend/Stoop/Kneel (Repeatedly): Twisting, bending, and stooping require flexibility and a wide range of motion in the spine and joints. Reach Above Shoulder Level (Repeatedly): Lifting, carrying, pushing, or pulling objects as necessary above the shoulder, requiring strength and stability. Push/Pull (Repeatedly): Using the upper extremities to press or exert force against something with steady force to thrust forward, downward, or outward. Fine-Finger Movements (Continuously): Picking, pinching, typing, or otherwise working primarily with fingers rather than using the whole hand as in handling. Vision (Continuously): Close visual acuity to prepare and analyze data and figures and to read computer screens, printed materials, and handwritten materials. Cognitive Skills (Continuously): Learn new tasks, remember processes, maintain focus, complete tasks independently, and make timely decisions in the context of a workflow. Exposures (Continuously): Bloodborne pathogens, such as blood, bodily fluids, or tissues. Radiation in settings where medical imaging procedures are performed. Various chemicals and medications are used in healthcare settings. Job tasks may involve handling cleaning products, disinfectants, and other substances. Infectious diseases are caused by contact with patients in areas that may have contagious illnesses. Emotionally challenging situations, such as dealing with distressed patients or difficult family interactions.
In addition to the essential functions of the job listed below, employees must have on-time completion of all required education as assigned per DNV requirements, Bozeman Health policy, and other registry requirements. Coordination of patients Actively participates as a team member by communicating with providers, schedulers, nursing, infusion, radiology, lab, and other departments Assist in tracking of incidental radiological/laboratory findings as needed. Contact patients if needed to assure appropriate follow up is done. Coordinate the ordering, scheduling, and performance of selected procedures and treatments as indicated. Collaborate with clinic team as well as other departments to ensure overall coordination of services and ensure positive interactions with providers from oncology, primary care, and specialty/procedural areas. Assist with Survivorship care planning as needed Counsel and educate patients to insure the patient is well informed of all portions of the plan of care Works with non-licensed staff to gather necessary medical records for review. Works with other co-workers to improve care processes in the department. Room patients - Gather patient data consistently and accurately, collect information on history of present illness or injury, obtain vital signs, review current medications and allergies. Document patient encounters in EMR. Triage and respond to patient phone messages in a timely manner according to clinic guidelines, collaborate with provider, act on provider response, and communicate with patient; document task communications in EMR/paper chart.
Shapely is transforming the weight loss industry through an innovative physician-led approach that makes weight loss care affordable for everyone. With evidence-based care, industry-leading support, and a seamless integrated app, we're pioneering a new approach in weight loss that helps patients achieve long-lasting, sustainable results. Join us in shaping a company that will help improve the most important thing in all of our lives: our health.
Shapely is transforming the weight loss industry through an innovative physician-led approach that makes weight loss care affordable for everyone. We are currently seeking an experienced full-time nurse practitioner or physician assistant to provide telehealth weight loss services across multiple states (including California, Texas, Florida, and New York) to help support our rapid growth and expansion. With evidence-based care, industry-leading support, and a seamless integrated app, we're pioneering a new approach to weight loss that helps patients achieve long-lasting, sustainable weight loss. We're steadfast in our mission to help millions of Americans along their weight loss journey.
Nurse practitioner or physician assistant with at least 2 years of post-graduate clinical experience. Primary care experience , particularly in adult outpatient settings. Experience in women’s health is a plus, especially managing midlife health concerns such as perimenopause, menopause, or related metabolic conditions. Ideally with at least 6 months of experience supporting patients with weight management, including prescribing or managing injectable medications such as Ozempic, Wegovy, or Mounjaro. Experience with compounded weight loss medications is not required. MUST be licensed in California (otherwise will not be considered). Additional licensure in Texas, Florida, and New York is a plus. We will provide a collaborating physician. Preference (not required) for Spanish-speaking providers to better serve our Spanish-speaking patients. Motivated self-starter with a genuine passion for helping people achieve their health and weight goals. Comfortable using telemedicine platforms, EHRs, and clinical documentation software. Strong communication skills and empathetic bedside manner, especially when caring for patients with overweight or obesity. Available to work full-time. Ability to work remotely from a quiet, professional environment with reliable high-speed internet. Must pass background check and be eligible for Medicare enrollment.
Conduct 12–24 telehealth consultations per day with new and returning patients. Apply clinical expertise from a primary care lens to assess and manage patients’ weight-related conditions and comorbidities. Provide evidence-based guidance on weight loss medications and lifestyle strategies. When relevant, address health concerns within the context of women’s health, including midlife transitions. Respond to patient messages in our care platform regarding their treatment plans and progress. Collaborate closely with our registered dietitians in weekly interdisciplinary rounds. Maintain full HIPAA compliance in all patient communications and records. Build strong rapport with patients, supporting them through compassionate and clinically sound care. Stay informed on clinical best practices related to obesity, chronic disease, primary care, and women’s health.
Explore opportunities at Atrius Health, part of the Optum family of businesses. We're an innovative health care leader and multi-specialty group practice, delivering an effective, connected system of care for adult and pediatric patients at 28 practice locations in eastern Massachusetts. Our entire team of providers (physicians, AP/NPs and ancillary clinicians) works collaboratively with a value-based philosophy within our group practice as well as with hospitals, rehab and nursing facilities. Be part of our vision to transform care and improve lives by building trust, understanding and shared decision-making with every patient. Join us and discover the meaning behind Caring. Connecting. Growing together.
As the Registered Nurse, you will be responsible for effective care delivery and management of patient care within a specialty, utilizing the nursing process and adhering to current standards of nursing practice. Communicates and coordinates effectively with all entities involved in the care of the patient to promote safe, high quality care. Making decisions reflecting critical thinking and evidence based nursing practice. If you are located in Massachusetts, you will have the flexibility to work remotely* as you take on some tough challenges. Position Details: Location: Telecom After Hours RN Department: Pediatrics Schedule: 32 hours weekly M-F 5PM- 11:30PM . Includes every other weekend 3PM-11:30PM
Graduate of a State-approved school of nursing Current, unrestricted, license to practice professional nursing in the Commonwealth of Massachusetts American Heart Association Basic Life Support (BLS) Computer experience required with the ability to use word processing and spreadsheet programs Electronic medical record (EMR) experience and/or aptitude to master the EMR based on other technology experience Demonstrated solid critical thinking, problem solving, interpersonal and patient interviewing skills Proven ability to interpret clinical information, assess the implication of treatment and develop and implement a plan of care Demonstrates ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands Demonstrates excellence in practice, documentation, and cost-effective care utilization. Maintains high patient satisfaction Up to date with current standard of nursing care in Specialty Preferred Qualifications: Bachelor of Science in Nursing (BSN) 2+ years of RN experience Pediatric experience All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Build therapeutic and supportive relationships with patients and families, providing education and managing care transitions Deliver patient care and follow-up in alignment with RN protocols, including medication administration and chronic disease management Conduct telephone triage, escalate concerns appropriately, and support the clinical team with ongoing care coordination Perform clinical procedures and manage acute conditions during patient visits, ensuring timely documentation in the EMR Contribute to quality improvement initiatives, mentor nursing staff, and uphold high standards of patient service and safety 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.
Taking care of government agencies and employees is at the heart of everything we do. Sedgwick Government Solutions helps people, restores property, and empowers performance through claims and productivity management solutions tailored to the needs of federal employees and government agencies. The company believes in a people first, tech forward, data driven approach, bringing together empathy, innovation and expertise to deliver results. We have decades of experience working with federal, state and local governments bolstered by the acquisition of award-winning federal government contracting firm Managed Care Advisors (MCA).
Are you looking to make a difference by providing high-quality care with a personal touch that impacts the lives of workers? Would you like to be part of a team focused on empowering and sustaining health by supporting the occupationally injured? Do you have the professional nursing, case management experience, and licenses necessary to help further establish MCA as a leading case management company? Do you have experience with workers' compensation? We believe in helping those with work-sustained illnesses and injuries to live their best life by providing care, health management, and support through our highly skilled team of home-based Medical Case Managers (MCM).
Unrestricted State Registered Nursing License 3+ years related clinical experience with at least 1 year in workers' compensation, utilization review, disability case management, occupational health, and/or comparable field Preference is given to Nurses with National Certification in case management or related fields. Attention to detail, timetables, and commitment to completing tasks Computer literacy, including MS Word, Excel, and Outlook Experience with Microsoft Windows and computer savvy Must be well organized, efficient, and able to work independently and within a team Responsible for having reliable High-Speed Cable or Fiber Optic Internet service and an Internet Router in an established home office Must have Excellent Communication Skills via Phone, email, Text, Verbal, and Documentation Skills, and provide 24-hour follow-up to all communication U.S. Citizenship Before hiring and training able to pass a preliminary credit and background check Upon hire, a federal security clearance will be required
As a Medical Case Manager, you will work independently in your home office setting while still being part of a supportive nationwide team. Through the application of a unique mix of experience and certification, you will support federal workers with diagnoses in the fields of occupational-related injuries and illness, emphasize timely facilitation and coordination of diagnosis, and be involved in the acute and chronic phases of treatment and support. Your broad responsibilities will include developing a case management plan for each injured worker throughout the various stages of recovery while tracking in a database patient improvement goals. You will implement integrated medical disability case management services to prevent, minimize, or overcome a disability, as well as provide medical expertise and serve as the critical communication link between the parties involved in any medical disability case.
Yoh delivers expertise, methodology, and momentum to keep work moving forward. From strategy to execution, we deliver bold ideas and big results through consulting, staffing, and enterprise solutions. Nearly a century after our founding, Yoh remains STEM-centered, collaborative, and committed to client success. Yoh is a proud member of the Day & Zimmermann family of companies.
Occupational Health Nurse Practitioner needed for a part-time, nights, weekend contract opportunity with Yoh’s client based out of Southern California. This is a fully remote position as part of a 24/7 Injury Care and Telemedicine Program supporting the employees of several organizations throughout California. You'll be providing assessment, triage, treatment, and education for employee health concerns. SHIFTS: Saturdays & Sundays between the hours of 6:00PM and 6:00AM. We are looking for 2 people to split the shift - so ideally 6:00PM to 12:00AM and then 12:00AM to 6:00AM coverage.
Active/unrestricted Nurse Practitioner (FNP/ANP) license in state of California Active/unrestricted Registered Nurse license in state of California Minimum (2) years' experience as a provider Prior experience in: Occupational/Employee Health, Emergency Medicine, Urgent Care, Corrections, Primary Care, Internal Medicine, or Family Practice type setting Workers' Compensation experience highly preferred What You Need to Bring to the Table: Nationally Certified (ANCC / AANP) NPI Computer skills with previous experience using EMR and MS Office (Outlook, Word, Excel, and PowerPoint) Interpersonal skills necessary to interview, teach and counsel patients and interact with clients/employers Strong clinical knowledge with the ability to be trained in case management and occupational health Work from home requirement: must live in a location that can maintain reasonable connectivity to power and Internet, free from background noise and distraction, must be able to meet privacy and HIPAA regulations, and more
Provide initial injury intake, follow-up, and case closures in accordance with policies and procedures Triage employees to appropriate level of care based on symptoms, history, photos, and clinical judgement Perform virtual physical assessments Complete workers' compensation forms and work status forms Prescribe or recommend treatments, including medications and therapies Order and interpret diagnostic tests to assess clinical conditions Provide employer and supervisor with updates regarding the nature and mechanism of injury as well as suggested level of care Counsel employees on reduction of risks associated with occupational and environmental hazards
Join our dynamic telehealth team as a Telehealth Nurse Practitioner, providing remote, high-quality healthcare services to patients across Arizona. This exciting role offers the opportunity to deliver comprehensive patient assessments, manage acute and chronic conditions, and coordinate care—all from the comfort of your home. Candidates must possess valid admitting privileges in Arizona and have experience working with diverse patient populations. If you are a motivated, detail-oriented nurse practitioner with a passion for innovative healthcare delivery, this is your chance to make a meaningful impact while enjoying flexible scheduling and professional growth.
Valid Arizona APRN license with active admitting privileges in good standing Extensive telehealth experience with proficiency in EHR systems Strong clinical skills across multiple specialties including emergency medicine, internal medicine, geriatrics, pediatrics, behavioral health, and hospice & palliative medicine Knowledge of medical coding systems such as CPT, ICD-10/ICD-9 for accurate documentation and billing Ability to perform comprehensive patient assessments involving vital signs, physiology knowledge, airway management, and physical examinations Familiarity with complex medical topics like infectious disease care, acute pain management, dialysis procedures, gastroscopy (gastric lavage), spinal tap procedures, and neurovascular assessments Strong communication skills for effective patient education and case management in a remote setting Knowledge of Workers' Compensation law and utilization review processes for diverse healthcare settings including inpatient, outpatient, nursing homes, assisted living facilities, and home care environments This role offers an engaging environment where your expertise can truly make a difference. We are committed to supporting your professional development through ongoing training opportunities in areas such as telehealth best practices and advanced clinical procedures. Join us to be part of a forward-thinking healthcare team dedicated to delivering compassionate care remotely while advancing your career!
Conduct thorough virtual patient assessments, including vital signs, medical history review, and physical examinations via telehealth platforms Manage acute and chronic health conditions by developing personalized treatment plans in collaboration with patients and healthcare teams Perform triage to determine urgency and appropriate level of care, ensuring timely interventions Document all patient interactions accurately within electronic health record (EHR) systems Prescribe medications and treatments remotely Provide health coaching and education tailored to individual patient needs, including geriatrics, pediatrics, behavioral health, and memory care Coordinate with specialists for referrals or further diagnostic evaluation, utilizing skills in diagnostic evaluation and medical documentation Ensure compliance with HIPAA regulations
At Geriatric Post-Acute Specialists (GPS), we’re more than just a healthcare group, we’re redefining continuity of care across Central Texas. Our team of board-certified physicians, nurse practitioners, and physician assistants works across hospitals, rehabilitation centers, assisted living communities, and even patients’ homes to ensure seamless transitions and compassionate outcomes.
We are seeking an Acute Care Nurse Practitioner/Physician Assistant to provide comprehensive overnight coverage across all company locations. This fully remote role is responsible for managing night call duties, performing admissions, and handling cross-coverage patient care needs. The provider will support continuity of care by evaluating acute issues, coordinating admissions, and ensuring appropriate overnight management of patients via telephone and telehealth video (tele cart) visits. This position requires close collaboration with administrative leadership to maintain high-quality, coordinated patient care. Join our dynamic healthcare team as a Night Shift Advanced Practice Provider (APP), working entirely remotely to deliver exceptional patient care during overnight hours. This vital role offers the opportunity to utilize your advanced clinical skills, critical thinking, and diverse medical knowledge to support a wide range of patient needs across various specialties. This position is perfect for motivated healthcare professionals seeking a flexible schedule while making a meaningful impact on patient outcomes. Schedule: 7 Days on / 7 Days off Shift: Nights – 7:00 pm-7:00 am Employment Status: Full Time or Part Time Texas License Required and DEA License
Licensures: (Must be current and in good standing) Acute Care Nurse Practitioner, Physician Assistant Texas License DEA ACLS/BLS Education: Graduate of an accredited Nurse Practitioner program (MSN or DNP) or Physician Assistant program (MPAS or MSPAS) Experience: Critical care experience in settings such as ICU or Level I Trauma Centers; hospital medicine or emergency medicine background preferred. Experience in a clinical setting, preferably including internal medicine, hospitalist, or post-acute care preferred Experience working with diverse populations including, adult, adolescence, and geriatric (geriatrics) Location: This position is fully remote Strong working knowledge of chronic disease management, medication reconciliation, and transitional care Proficiency with documentation, coding, and billing practices (Medicare and Medicaid experience strongly preferred) Demonstrated ability to work independently while collaborating effectively within an interdisciplinary care team Excellent clinical judgment, organization, and communication skills with a compassionate, patient-centered approach This role offers an exciting opportunity to leverage your extensive clinical expertise in a flexible remote environment while contributing to innovative healthcare delivery. We are committed to supporting your professional growth through ongoing training opportunities and fostering a collaborative team culture dedicated to excellence in patient-centered care.
Deliver remote, overnight patient care services including admissions, cross-coverage call management, and ongoing clinical support for Geriatric Post-Acute Specialists. Maintain full active privileges at the facilities where he/she sees patients for Geriatric Post-Acute Specialists. Follow Medicare and state guidelines and Employer policy and procedures when providing services and submitting charges into the EHR for billing of services. Complete all required documentation for billing and documentation of services rendered by established deadlines. Quality initiatives and metrics assigned by administration. Maintain all professional credentials and certifications. Attend all business and clinical meetings coordinated by the employer or its vendors
The Vivo Infusion team is focused on providing patients with the highest quality of care in a comfortable, safe, and convenient setting! Vivo is a national company with locations in 15 states, providing opportunities for growth and advancement as well as competitive benefits that support what matters most to you. Our highly trained medical professionals are dedicated to delivering a safe, comfortable, and affordable solution for our patients. We offer an array of advanced therapeutics and provide personalized care for every patient. We are passionate about providing high-quality patient care, relationships with our referring Providers, and nurturing our company culture!
Remote If you are a Registered Nurse or LPN/LVN looking to leverage your experience to make a difference in your patients' lives while working in a remote setting, we have an incredible opportunity for you! Vivo Infusion is looking for a Licensed Practical/Vocational Nurse (LPN/LVN) or Registered Nurse (RN) with a clinical eye. The Clinical Concierge Coordinator is the primary clinical and administrative anchor for the patient's journey into care. This role serves as the regionalized "communication hub" for referring providers, patients, and internal teams. The CCC is responsible for the end-to-end clinical intake process—from the moment a referral is received until the file is "Auth-Ready." By combining clinical expertise with proactive relationship management, the CCC ensures a seamless, "Patients First" experience while aggressively reducing referral turnaround times and mitigating financial risk. The Clinical Concierge Coordinator will work remotely from a home office with a secure network. Only candidates residing in the states below at the time of employment will be considered. Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, North Carolina, New Hampshire, New Jersey, Nevada, New York, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Wisconsin, Wyoming, Washington D.C.
Qualifications: Active Licensed Practical Nurse (LPN) or Registered Nurse (RN) required. Minimum of 3 years experience in a healthcare setting Prior experience in outpatient, infusion, specialty pharmacy, or intake/authorization environments preferred Demonstrated experience handling sensitive patient information with discretion and confidentiality Additional Qualifications: Must possess outstanding communication and interpersonal skills, be able to communicate professionally and effectively with other staff members, patients, vendors, and physicians, and is fluent in written and spoken English. Strong command of medical terminology, infusion therapies, and payer medical policy interpretation. Advanced Letters of Medical Necessity (LMN) writing capability. Proven ability to interpret complex medical conditions, diagnostic testing, and treatment criteria. Proficiency with EMR systems, Microsoft Office, and professional internet research tools.
Unified Intake & Clinical Assessment: Serve as the first point of clinical review for all new referrals. Assess incoming orders against FDA and payer-specific medical policy guidelines to ensure compliance and patient safety. Proactive Document Coordination: Act as the primary liaison with referring offices to secure missing clinical documentation (labs, physician notes, trial/fail dates). Use clinical judgment to "triage" what is needed to prevent insurance denials. Patient & Provider Rapport: Establish and maintain strong working relationships with assigned physicians, practice managers, and patients. Act as the patient's primary advocate and point of contact during the entire admissions process. Clinical Subject Matter Expertise: Research off-label medication uses and draft professional Letters of Medical Necessity (LMN). Educate referring staff on complex insurance coverage requirements and medical necessity guidelines. Tech-Enabled Workflow (Tennr): Master the use of AI intake tools to automate data entry and document categorization, ensuring all clinical data is entered into the EMR (WeInfuse) rapidly and accurately. Clinical Safety Oversight: Alert clinic staff of potential safety concerns or treatment inappropriateness identified during the initial assessment of a prescribed regimen. Additional duties and responsibilities: Assist Revenue Cycle department with diagnosis code review and clinical rebuttals for claim appeals. Maintain a high level of proficiency in Microsoft Office and internal EMR applications. Demonstrate independent problem-solving and critical thinking in a fast-paced, remote-capable environment.
One Medical is a primary care solution challenging the industry status quo by making quality care more affordable, accessible and enjoyable. But this isn’t your average doctor’s office. We’re on a mission to transform healthcare, which means improving the experience for everyone involved - from patients and providers to employers and health networks. Our seamless in-office and 24/7 virtual care services, on-site labs, and programs for preventive care, chronic care management, common illnesses and mental health concerns have been delighting people for the past fifteen years. In February 2023 we marked a milestone when One Medical joined Amazon. Together, we look to deliver exceptional health care to more consumers, employers, care team members, and health networks to achieve better health outcomes. As we continue to grow and seek to impact more lives, we’re building a diverse, driven and empathetic team, while working hard to cultivate an environment where everyone can thrive.
The One Medical Virtual Medical Team (VMT) is a leading provider of virtual clinical care, providing world-class, convenient, evidence-based virtual medical care to One Medical patients in concert with their primary care providers. Through advanced technology and a team-based approach, we care for patients 24 hours a day, 365 days a year. Our team is united by intellectual curiosity, inclusiveness, and a powerful mission: transforming healthcare and bringing world-class primary care to everyone. Employment type: Full time 40 hours including evenings and weekends
Completed an accredited FNP program with a national certification In the past 5 years, practiced as an Advanced Practitioner for at least: 2 years in an outpatient primary care setting seeing patients of all ages (0+), OR 2 years in an urgent care or emergency medicine setting seeing patients of all ages (0+) Currently licensed in MA with ability to obtain additional state licenses Ability to work weekday and weekend shifts (every other Saturday AND or Sunday required) Current shifts range from (6am-5pm EST, 7am-6pm EST, 8am-7pm EST, 11am-10pm EST, 1pm-12am EST) Excellent clinical and communication skills One Medical providers also demonstrate: A passion for human-centered primary care The ability to successfully communicate with and provide care to individuals of all backgrounds The ability to effectively use technology to deliver high quality care Clinical proficiency in evidence-based primary care The desire to be an integral part of a team dedicated to changing healthcare delivery An openness to feedback and reflection to gain productive insight into strengths and weaknesses The ability to confidently navigate uncertain situations with both patients and colleagues Readiness to adapt personal and interpersonal behavior to meet the needs of our patients This is a full-time virtual role.
Treating patients via tele-health visits, including telephonic triage calls, video visit appointments, and email follow-ups Continuous learning during weekly Clinical Rounds and through other modalities Ongoing collaboration with both virtual and in-office teammates via daily huddles Utilization of your specific clinical training and opportunities to give exceptional care to patients virtually
Trinity Health is one of the largest not-for-profit, Catholic health care systems in the nation. It is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians caring for diverse communities across 25 states. Nationally recognized for care and experience, the Trinity Health system includes 88 hospitals, 131 continuing care locations, the second largest PACE program in the country, 125 urgent care locations and many other health and well-being services. Based in Livonia, Michigan, its annual operating revenue is $20.2 billion with $1.2 billion returned to its communities in the form of charity care and other community benefit programs.
Employment Type: Part time Shift: 12 Hour Day Shift Description: Highlights: Remote Role Week 1: Sunday 645p-715a, Monday 445p-315a, Thursday 645p-715a Week 2: Monday 445p-315a, Saturday 645p-715a Day 1 benefits, no waiting period!Comprehensive benefit packages available including medical, dental, vision, paid time off and 403B Colleague Referral Program to earn cash and prizes Unlimited career growth opportunities Trinity Health offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday Position Summary: A variety of shared responsibilities in a busy practice. Utilizes nursing assessment skills and clinical protocol guidelines in a decision-making capacity to provide timely and efficient patient care.
Graduation from a NLN or AACN accredited school of nursing Enrollment in a Baccalaureate Degree in the Science of Nursing (BSN) Degree from an accredited school of nursing and completion required within 4 years of hire Valid Registered Nurse (RN) licensure authorized in the state of Michigan. Experience in a health care setting or enrollment in RN Residency Program Specialty credentialing preferred according to clinical nursing practice specialty area
Telephone triage Medication Refill New consult evaluation Patient education Performs clerical functions, all functions of a Medical Assistant, and environmental duties to support team objectives
The Center for Human Development (CHD) provides a broad range of high quality, community-oriented human services dedicated to promoting, enhancing, and protecting the dignity and welfare of people in need. At CHD we are celebrating differences, inclusion is not just a policy- it is a daily practice. Multicultural, multilingual, and fluent in sign language, CHD is a reflection of those we serve.
The Center for Human Development (CHD) is growing! We are currently seeking a Primary Care Registered Nurse to join our Primary Care practice that is uniquely integrated in our Outpatient Behavioral Health Clinic located in West Springfield, MA. Your role as the Primary Care Registered Nurse: The Primary Care Registered Nurse will be responsible for meeting with clients, conducting nursing visits, including medication administration, providing client education, reviewing medical records and lab results, facilitation pharmacy communication medication refills and prior authorizations managing client triage needs and other duties as seen fit by the program and providers. Schedule is Monday- Friday day shift position 8:00am-4:00pm. Home location in West Springfield. And be flexible to work out of our other primary care locations on an as needed only basis. The salary range is $85,000-$93,000 based on experience. This is a full-time on-site opportunity and is complemented with a phenomenal benefit package that includes, Dental, Health and Life insurance, a flexible schedule, paid time off, earned vacation time and paid holidays just to name a few.
Experience working with patients with serious mental illness required Comfort operating in fast-moving, unpredictable clinical environments Experience working with EHR Registered Nurse licensure A minimum of 2 years’ clinical experience. Reliable, registered & insured vehicle for travel between program locations. Approved driving record check Approved criminal background check (CORI) Valid BLS CPR Certification required Preferred: Bachelors or better. Licenses & Certifications Required: Registered Nurse
Our ideal Primary Care RN will join the team with a display of enthusiasm for the role. Our RN professionals should be proud to execute in a way that shows dedication to work with persons served to achieve medical and medication goals, objectives and interventions. Additionally, the RN will display excellent communication skills, and the ability to adapt to ever changing needs. Position requires someone who is self-motivated and thrives in an autonomous environment.
AON is an alliance of physicians and veteran healthcare leaders dedicated to ensuring the long-term success and viability of oncology diagnosis and treatment in community-based settings. We are the fastest growing network of community oncology practices delivering local access to exceptional cancer care. We partner with physicians and their practices to help them navigate the complex healthcare landscape, improve quality of care and elevate community oncology. That's Why We Focus On Enriching the patient experience. By supporting the delivery of true value-based care through participation in the Oncology Care Model and enhanced services, such as care management. Being 100% physician led and governed. Allowing for practice autonomy, where our partnership is collaborative and leveraged as a resource but, ultimately, what gets implemented in the practice is up to the physicians. Improving the lives of those who practice medicine. With over 35 years of proven practice management expertise and the enablement of new revenue streams by accessing additional service lines such as clinical lab, pathology and oral oncolytic pharmacy. AON serves its expanding network of partner practices by providing over 36 years of proven practice management expertise, dedicated end-to-end administrative support, and access to an extensive array of centralized ancillary support services. The AON Difference Practice diversification A partnership with AON enables practice growth and access to new revenue streams through centralized ancillaries such as clinical lab, pathology and oral oncolytic pharmacy. Economies of scale Our ability to aggregate size and scale helps us to provide practices with the most competitive and attentive vendor services and drug pricing.
Join American Oncology Network's Transition team! This position does require travel around the United States to our AON locations new and current! Travel: >75% Standard Core Workdays/Hours : Monday to Friday 8:00 AM – 5:00 PM. #LI-REMOTE
Education: Registered Nurse, Multistate License required and may be required to obtain other state licenses as applicable. Certifications/Licenses: Valid state Driver’s License for travel. Compliance with the company Driver Safety Operations and Motor Vehicle Records Check Policy is required. Current CPR & BLS certifications are required. OCN preferred Experience: IV Therapy experience required 3 years’ experience with hematology/oncology patients in a clinic or hospital is required. Strong knowledge of Electronic medical record (EMR) software required. Ability to assess patient needs and condition is essential. Must have strong critical thinking skills, as well as the ability to react calmly and effectively in emergency situations. Excellent oral and written communication skills is required. Former teaching/training/precepting/supervisory/acquisition experience preferred. Core Capabilities: Analysis & Critical Thinking: Critical thinking skills including solid problem solving, analysis, decision-making, planning, time management and organizational skills. Must be detailed oriented with the ability to exercise independent judgment. Interpersonal Effectiveness: Developed interpersonal skills, emotional intelligence, diplomacy, tact, conflict management, delegation skills, and diversity awareness. Ability to work effectively with sensitive and confidential material and sometimes emotionally charged matters. Communication Skills: Good command of the English language. Second language is an asset but not required. Effective communication skills (oral, written, presentation), is an active listener, and effectively provides balanced feedback. Customer Service & Organizational Awareness: Strong customer focus. Ability to build an engaging culture of quality, performance effectiveness and operational excellence through best practices, strong business and political acumen, collaboration and partnerships, as well as a positive employee, physician and community relations. Self-Management: Effectively manages own time, conflicting priorities, self, stress, and professional development. Self-motivated and self-starter with ability work independently with limited supervision. Ability to work remotely effectively as required. Must be able to work effectively in a fast-paced, multi-site environment with demonstrated ability to juggle competing priorities and demands from a variety of stakeholders and sites. Computer Skills: Efficient in MS Office Word, Excel, Power Point, and Outlook required. Knowledge of Workday
Documentation: Thorough and accurate documentation in OncoEMR of treatment rendered to patients. Ensure appropriate charges are captured by following guidelines for appropriate administration of all medications. Safely and accurately administer chemotherapeutic agents to patients as ordered by company physicians. Will use ONS standards and guidelines. Accurate and safe disposal of biohazardous waste, per OSHA and HRS guidelines. Teaching and Training: Educate patients and (when appropriate), family about medications, side effects and planned treatment course. Interact with patient and family in a caring, professional manner. Telephone triage: Includes prioritizing incoming calls and messages from patients, family members, hospitals, nursing facilities, pharmacies and physician offices from emergent to non-urgent. Must respond accordingly in an appropriate time frame. Dispensing equipment: Have working knowledge of dispensing medications via a secured system. Able to perform cycle count. Restock medications within appropriate time frame. Enters all appropriate patient charges into secured system. Analyze current processes and recommend training required on both a group and individual level. Prepare training materials and deliver such materials in on-site (live) sessions and webinar format. Evaluate training results and recommend additional resources to ensure successful transition. Provide on-going support and guidance for on-going success Perform any and all duties required to keep in compliance with state and federal regulatory agencies. Will follow the company I.D. policy and procedure with every patient encounter. Supplies: Includes assisting with inventory and re-stocking medical supplies, when called upon. Recommend purchase of new items as needed. Place stock in storage areas in a timely manner. Meetings: Attend annual Safety / OSHA training meetings and any applicable assigned educational materials. Attend all mandatory staff meetings as necessary. Maintain and ensure the confidentiality of all patient and employee information at all times. Lead all training efforts to onboarding and new employees to related job duties. Complies with all federal and state laws and regulations pertaining to patient privacy, patient’s rights, personnel law, safety, labor, and employment law. Adheres to company and departmental policies and procedures, including IT policies and procedures and Disaster Plan. Provide on-going support to merger staff/clinic and guidance for on-going success during and after transition. May be required to travel outside of transition to a company location to assist with training new employees and/or clinic coverage.
The MAXIS Group is an IT staffing company that has a long successful history providing quality staff to our clientele. MAXIS specializes in servicing Healthcare and State Government organizations.
Request ID: 83033-1 Job Title: Healthcare - Care Manager II-Large Managed Care Company Job Description: Location: Remote MI (living within Wayne County or Macomb County) Duration: 8 months-Potential for perm hire (5/4-12/28) What is the typical schedule/shift going to be (i.e., 8am – 5pm)? 8:30-5 EST Required Licensure / Education: RN, LBSW, LLMSW, LMSW Remote with Field Visits (mileage reimbursed)
Must Have Skills: Has worked within MI Choice waiver or HCBS waiver program in Michigan · Reliable transportation with insurance · Strong internet connection Required Years of Experience: At least 2 years health care experience, including at least 1 year of experience working with persons with disabilities/chronic conditions long-term services and supports (LTSS), and 1 year of experience in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience.
Provides support for care management/care coordination long-term services and supports specific activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care.
OpTech is a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work at OpTech, not only do you get health and dental benefits on the first day of employment, but you also have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! To view our complete list of openings, please visit our website at www.optechus.com.
We have a great employment opportunity for a RN Medical Case Manager! Location: Grand Rapids, MI Remote with some travel required to attend patient medical appointments; Distance: Up to 2 hour drive. Gas expense is reimbursed. ***MUST LIVE IN AND HAVE STATE OF MICHIGAN RN LICENSE*** Salary range: Up to $84k. Excellent employee benefits. Eligible for monthly performance bonuses! RESPONSIBILITIES: The Case Manager RN leads the coordination of a multidisciplinary team to deliver a holistic, person centric care management program to a diverse health plan population with a variety of health and social needs. They serve as the single point of contact for members, caregivers, and providers using a variety of communication channels including phone calls, emails, text messages and Our Client’s online messaging platform. The Case Manager RN uses the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the member’s health across the care continuum. They work in partnership with the member, providers of care and community resources to develop and implement the plan of care and achieve stated goals.
QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. OTHER SKILLS AND ABILITIES: Ability to think critically, be decisive, and problem solve a variety of topics that can impact a member’s outcomes Empathetic, supportive and a good listener Proficient in motivational interviewing skills Demonstrated time management skills Organizational skills with the ability to manage multiple systems/tools, while simultaneously interacting with a member Must have intermediate computer knowledge, typing capability and proficiency in Microsoft programs (Excel, OneNote, Outlook, Teams, Word, etc.) Must embrace teamwork but can also work independently Excellent interpersonal and communication skills both written and verbal EDUCATION AND EXPERIENCE: Nursing Diploma or Associates degree in nursing required Bachelor’s degree in nursing strongly preferred 3 years of clinical nursing experience in a clinical, acute/post-acute care, and community setting required 1 year of case management experience in a managed care setting strongly preferred Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred CERTIFICATES, LICENSES, REGISTRATIONS: Current, active, and unrestricted Michigan Registered Nurse license required Certification in Case Management (CCM) required or to be obtained within 18 months of hire Certification in Chronic Care Professional (CCP) preferred
Lead the coordination of a regionally aligned, multidisciplinary team to provide holistic care to meet member needs telephonic and/or digitally The multidisciplinary team is inclusive of Medical and Behavioral Health Social Workers, Registered Dietitians, Pharmacists, Clinical Support Staff and Medical Directors. Use the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the members’ health across the care continuum Assess the member's health, psychosocial needs, cultural preferences, and support systems Engage the member and/or caregiver to develop an individualized plan of care, address barriers, identify gaps in care, and promotes improved overall health outcomes Arrange resources necessary to meet identified needs (e.g., community resources, mental health services, substance abuse services, financial support services and disease-specific services) Coordinate care delivery and support among member support systems, including providers, community-based agencies, and family Advocate for members and promote self-advocacy Deliver education to include health literacy, self-management skills, medication plans, and nutrition Monitor and evaluate effectiveness of the care management plan, assess adherence to care plan to ensure progress to goals and adjust and reevaluate as necessary Accurately document interactions that support management of the member Prepare the member and/or caregiver for discharge from a facility to home or for transfer to another healthcare facility to support continuity of care Educate the member and/or caregiver about post-transition care and needed follow-up, summarizing what happened during an episode of care Secure durable medical equipment and transportation services and communicate this to the member and/or caregiver and to key individuals at the receiving facility or home care agency Adhere to professional standards as outlined by protocols, rules and guidelines meeting quality and production goals Continue professional development by completing relevant continuing education and maintaining Certified Case Manager (CCM)
OpTech is a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work at OpTech, not only do you get health and dental benefits, but you also have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! To view our complete list of openings, pleas e visit our website at www.optechus.com.
MUST HAVE: Experiencing managing a psych unit in a hospital Required Skills & Experience: Minimum five (5) years as Registered Nurse. Minimum of five (5) years of clinical experience in psychiatry. Minimum two (2) years of experience in a leadership role. Critical thinking, math, and computer skills; works as a team player. Monitors and facilitates the meeting of requirements of NYSDOH, JCAHO and other regulators. Knowledge of quality improvement philosophy models, processes and tools and their use in health care integrated settings. Maintains currency with state of the art and regulatory trends. Knowledge of methods for CQI, and Root Cause Analysis. Demonstrates respect and professionalism in all interactions. Demonstrates competence in leadership, budgetary and administrative skills. Demonstrates a commitment to continuing professional growth and development. Excellent oral and communication skills. Experience and demonstrated competency in applicable clinical specialty. Decision making and problem solving. Able to read, write, see and hear English. Ability to fully utilize BHMC's electronic record systems, equipment and healthcare and billing systems relevant to this position. Education: Required Education: Graduate of accredited Nursing school BSN. Preferred Education: Master’s Degree in Nursing. Required Certifications & Licensure: Licensed and currently registered as a Professional Nurse in New York State. Basic Life Support. ACLS. Crisis Management (PMCS, TRUST). Experience: Required Skills & Experience: Previous experience working with children ages six (6) weeks to six (6) years of age (paid or unpaid). Two (2) years of formal experience
Establishes and maintains positive relationships with patients, visitors, and other employees. Interacts professionally, courteously, and appropriately with patients, visitors, and other employees. Behave consistently by maintaining and furthering a positive public perception of Brookdale Hospital and its employees. Responsible for the implementation of hospital’s policies and procedures, as well as regulatory agencies codes and regulations as they pertain to the Department. Responsible for operations and management of the unit in collaboration with the Director. Has overall responsibility for the operation of the unit with all disciplines reporting to the Director. Coordinates all performance improvement activities so that it is truly an interdisciplinary process. Utilizes appropriate benchmarks. Assembles and prepares data relative to clinical activities as well as other statistical and special reports required by the NY State Office of Mental Health (OMH), the NY Department of Health (KOH), the NY City Department of Health and Mental Hygiene (DOHMH), and the Administration for Children’s Services (ACS). Reviews and monitors admissions and discharges to ensure appropriate clinical management and discharge planning. Responsible for gathering performance improvement data, gathering information and meeting compliance standards for regulatory agency surveys, including DOH and JCAHO. Other essential functions as deemed necessary such as budgeting, supply and inventory maintenance. Responsible for operational leadership on a 24h basis. Responsible for ensuring that all PCS Scope of service, Philosophy of Nursing and Ethical standards are met while delivering patient care. Oversees patient care area to ensure clinical needs & competencies are met. Provides administrative coverage for the Nursing Department as necessary. Participate in the system of continuing education to increase administrative and clinical knowledge and skills. Innovative and implements best practices in care. Assumes other responsibilities as assigned by the Director and/ or Sr. Vice President for Patient Care Services. Compliance with regulatory requirements. HCAPS: Development with team and service. Virtual interviews required
.svg)
.svg)
.svg)
.svg)