Netsmart

Utilization Review Nurse, Full-Time (9a-9p EST), Remote

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Kansas

Responsible for utilization review work for emergency admissions and continued stay reviews

Required: Current and unrestricted RN license At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 2 years utilization management experience in acute admission and concurrent reviews Intermediate level experience with InterQual and/or MCG criteria within the last two years Proficiency in medical record review in an electronic medical record (EMR) Experience in Microsoft Suite including Office and basic Excel Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs Passing score(s) on job-related pre-employment assessment(s) Preferred: At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 3 years utilization management experience within the hospital setting Bachelor's of Science in Nursing (BSN) Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC) Expectations: Comfortable with remote work arrangements and virtual collaboration tools Physical demands include extended periods of sitting, computer use, and telephone communication

Review and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteria Apply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resources Participate in telephonic discussions with emergency department physicians relative to documentation and admission status Enter clinical review information into system for transmission to insurance companies for authorization Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources

Morgan Stephens

Utilization Management Nurse – Behavioral Health Focus (Remote)

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Ohio

Job Title: Utilization Management Nurse – Behavioral Health Focus (Remote) Location Requirements: Candidates must be located in one of the following preferred states: Arizona (AZ), Florida (FL), Georgia (GA), Idaho (ID), Iowa (IA), Kentucky (KY), Michigan (MI), Nebraska (NE), New Mexico (NM), New York (NY – outside greater NYC), Ohio (OH), Texas (TX), Utah (UT), Washington (WA – outside greater Seattle), or Wisconsin (WI). Time Zone Preference: Eastern Time Zone is preferred, but not required. Work Schedule: Tuesday through Saturday, 8:00 AM – 5:00 PM EST Compensation: $40 per hour Position Type: Temporary to Permanent Position Summary: A Managed Care Organization is seeking a Utilization Management Nurse to review provider-submitted service authorization requests and evaluate medical necessity, with a primary focus on behavioral health services. This position plays a key role in ensuring members receive appropriate and timely care by performing prior authorizations and concurrent reviews.

Must-Have Requirements: Background in Behavioral Health services and/or experience with a Managed Care Organization (MCO) in Utilization Management Licensure Requirements: Active, unrestricted RN, LPN, LCSW, or LPC license in any U.S. state Required Education and Experience: Completion of an accredited Registered Nursing program (or equivalent combination of experience and education) 2 years of clinical experience, preferably in hospital nursing, utilization management, or case management Knowledge, Skills, and Abilities: Understanding of state and federal healthcare regulations Experience with InterQual and NCQA standards Strong organizational, communication, and problem-solving skills Proficient in Microsoft Office and electronic documentation systems Ability to work independently and manage multiple priorities Professional demeanor and commitment to confidentiality and compliance with HIPAA standards Team-oriented with the ability to build and maintain positive working relationships

Review provider submissions for prior service authorizations, particularly in behavioral health Evaluate requests for medical necessity and appropriate service levels Provide concurrent review and prior authorization according to internal policies Identify appropriate benefits and determine eligibility and expected length of stay Collaborate with internal departments, including Behavioral Health and Long Term Care, to ensure continuity of care Refer cases to medical directors as needed Maintain productivity and quality standards Participate in staff meetings and assist with onboarding of new team members Foster professional relationships with internal teams and provider partners

Morgan Stephens

Utilization Management Clinician – Behavioral Health (Remote)

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Washington

Job Title: Utilization Management Clinician – Behavioral Health (Remote) Location Requirements: Candidates must reside in one of the following states: Arizona (AZ), Florida (FL), Georgia (GA), Idaho (ID), Iowa (IA), Kentucky (KY), Michigan (MI), Nebraska (NE), New Mexico (NM), New York (NY – outside greater NYC), Ohio (OH), Texas (TX), Utah (UT), Washington (WA), or Wisconsin (WI). Licensure must be in Washington (WA), regardless of physical location. Time Zone Requirements: Pacific Standard Time (PST) hours required. Work Schedule: Monday–Friday or Tuesday–Saturday, 9:00 AM – 5:00 PM PST Position Type: Temporary to Permanent Compensation: Up to $45 per hour Remote Work: 100% Remote Required Equipment: In addition to a laptop, keyboard, mouse, and headset, candidates will need a monitor and docking station. Position Summary: A Managed Care Organization is seeking a Behavioral Health Utilization Management Clinician to support the review of inpatient and outpatient services, ensuring appropriate care and resource utilization. This role involves evaluating prior authorization requests and conducting concurrent reviews to determine medical necessity for behavioral health services.

Must-Have Requirements: Behavioral Health background Utilization Management experience Licensure in the state of Washington as one of the following: Licensed Independent Clinical Social Worker (LICSW) Licensed Professional Clinical Counselor (LPCC) Licensed Mental Health Counselor (LMHC) Marriage and Family Therapist (LMFT) Psychiatric Nurse Registered Nurse (RN) Preferred Experience: 2–4 years of clinical experience, ideally in hospital settings, utilization review, or case management Familiarity with InterQual criteria and NCQA standards Previous work within a managed care or health plan environment Knowledge, Skills, and Abilities: Excellent communication, critical thinking, and decision-making skills Ability to manage multiple priorities and work independently Knowledge of federal/state regulations and behavioral health utilization review protocols Proficiency with Microsoft Office and electronic medical record systems Commitment to ethical standards and professional conduct

Process utilization review cases across various levels of care Conduct prior authorization and concurrent reviews for behavioral health services Determine eligibility, benefits, and expected length of stay Collaborate with interdisciplinary teams to promote continuity of care Refer cases to medical directors as appropriate Maintain productivity and quality performance standards Participate in team meetings and contribute to onboarding of new clinicians Adhere to regulatory guidelines, organizational policies, and HIPAA compliance

Morgan Stephens

Case Manager II LTSS (REMOTE) - $50/hr

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

LPN/LVN

State License:

Virginia

This opportunity is with one of the country’s most respected managed care organizations, serving Medicaid and Medicare members through high-quality, community-based programs. The company focuses on improving member outcomes through person-centered care coordination, behavioral health integration, and social support services. Employees are mission-driven and committed to delivering compassionate care with measurable impact across underserved populations.

Case Manager II Location: Remote – Must reside in Virginia (Tidewater or Central regions) Pay: $50/hour Assignment Type: Temp-to-Perm Start Date: As soon as available Work Schedule: Monday – Friday, 8:00 AM – 5:00 PM EST (No weekends) Tax Work Location: Remote Benefits: Medical, dental, vision, and 401(k) with 50% employer contribution towards premiums Position Overview: The Case Manager II will serve members in Virginia’s Tidewater and Central regions, supporting individuals receiving Long Term Services and Supports (LTSS) under Medicaid. This position is remote but requires regular in-field visits to members' homes and nursing facilities to conduct face-to-face assessments. You will coordinate care plans tailored to the health needs and personal goals of members while collaborating with interdisciplinary teams to ensure comprehensive support.

Required Qualifications: Must reside in Virginia (Tidewater or Central region) 1–3 years of experience in case management, disease management, managed care, or in a medical or behavioral health setting Valid driver’s license, reliable transportation, and good driving record Strong computer and multitasking skills required (for system navigation, documentation, and member engagement) Home office with high-speed internet connectivity Required Education / Licensure One of the following is required: Completion of an accredited LVN or LPN program Bachelor's or Master’s degree in social science, psychology, public health, gerontology, social work, or related field Graduation from an accredited School of Nursing (BSN preferred) If licensure is required, it must be active, unrestricted, and in good standing

Complete clinical assessments of members within regulated timelines to determine care management eligibility Develop and execute individualized care plans in collaboration with members, families, healthcare providers, and support networks Conduct telephonic, face-to-face, or home visits as needed Monitor and adjust care plans to reflect progress, interventions, and changing member needs Maintain regular outreach and ongoing case load management Coordinate integration of behavioral health and long-term care services for enhanced continuity Support wellness programs, such as asthma or depression management initiatives Facilitate interdisciplinary care team (ICT) meetings and informal team collaborations Use motivational interviewing to engage, educate, and promote behavioral change Identify and address barriers to care, connecting members to appropriate resources Collaborate with RN case managers, supervisors, and peers to optimize support Travel locally (30% or more) within the Tidewater and Central Virginia areas; mileage is reimbursed

Morgan Stephens

Case Manager II – EHR Team (Emerging High Risk) - REMOTE - $50/hr

Posted on:

May 6, 2025

Job Type:

Contract

Role Type:

Case Management

License:

LPN/LVN

State License:

Virginia

This position is with a mission-driven managed care organization that specializes in Medicaid and Medicare services for underserved populations. Known for its community-based model of care, the organization focuses on empowering members to live healthier, more independent lives. Employees are part of a collaborative environment that values innovation, equity, and measurable health outcomes.

Case Manager II – EHR Team (Emerging High Risk) Location: Remote – Must reside in Virginia (Tidewater, Central, or Southwest region) Pay: $50/hour Assignment Type: Contract | Duration: May 12, 2025 – June 30, 2025 Work Schedule: Monday – Friday, 8:00 AM – 5:00 PM EST (No weekends) Tax Work Location: Remote ZIP Code: 23803 (central to Tidewater, Central, and Southwest VA regions) Benefits: Medical, dental, vision, and 401(k) with 50% employer contribution towards premiums Position Overview: The Case Manager II will work on the Emerging High Risk (EHR) team, supporting Medicaid members across Virginia. This position is remote with regular fieldwork to complete face-to-face assessments in members’ homes. You will help build care plans tailored to members' clinical and social needs while working alongside an interdisciplinary team to ensure coordination of care and ongoing member engagement.

Required Qualifications: Must reside in Virginia within the Tidewater, Central, or Southwest region 1–3 years of experience in case management, disease management, managed care, or in a medical/behavioral health setting Strong computer and documentation skills are essential for managing systems and maintaining accuracy Home office setup with high-speed internet is required Valid driver’s license, clean driving record, and reliable transportation Required Education / Licensure One of the following: Completion of an accredited LVN or LPN program Bachelor’s or Master’s degree in a relevant field (social work, psychology, gerontology, public health, or social science) Graduate of an accredited School of Nursing (BSN preferred) Licensure (if required) must be active, unrestricted, and in good standing

Complete timely clinical assessments to determine case management eligibility Create and execute individualized case management plans with input from the member, their caregivers, physicians, and support network Conduct telephonic and in-home visits as needed, adhering to regulatory timelines Monitor care plans and document changes, interventions, and member progress Maintain an active case load and conduct regular outreach to assigned members Promote integration of services, including behavioral health and long-term support programs Participate in or facilitate interdisciplinary care team (ICT) meetings Utilize motivational interviewing techniques to support behavioral change Address barriers to care and connect members to needed services and supports Travel locally (30% or more) across assigned territory (Tidewater, Central, and Southwest VA); mileage is reimbursed

Morgan Stephens

Utilization Management (Remote) California License

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

California

A leading Managed Care Organization is seeking an experienced and detail-oriented Care Review Clinician II (RN or LVN) to join their Utilization Management team. This remote position plays a key role in reviewing clinical service requests, supporting continuity of care, and ensuring appropriate, cost-effective healthcare decisions are made in compliance with regulatory and clinical guidelines.

Required Qualifications: Active, unrestricted LVN or RN license in California 3–5 years of clinical experience (inpatient, outpatient, or hospital setting strongly preferred) Prior experience in Utilization Management, Concurrent Review, or Prior Authorization Strong analytical and critical thinking skills in a fast-paced, metric-driven environment Solid computer proficiency, including ability to toggle between multiple databases and tools Experience using InterQual or similar medical necessity criteria tools Knowledge of HIPAA and regulatory compliance standards Excellent verbal and written communication skills Preferred Qualifications: Experience in Managed Care, Health Plans, or payer-side healthcare operations Familiarity with NCQA standards Previous case management or care coordination experience Additional Information: Must provide your own secure and quiet workspace for remote work Equipment (laptop, monitors, etc.) will be provided by the organization Must be available to work 8-hour shifts during PST business hours, Monday–Friday

Perform clinical reviews of service requests including concurrent and prior authorization determinations Serve as clinical support to the Continuity of Care (COC) and Community Support teams Determine whether requests meet COC or community support criteria and escalate for MD review when needed Conduct provider outreach as appropriate to support authorizations and care coordination Utilize InterQual and other clinical guidelines to assess medical necessity and appropriate length of stay Ensure documentation meets compliance, quality, and turnaround standards Create and manage authorizations in accordance with established UM processes Participate in team meetings and collaborate with other departments to support member care

Morgan Stephens

Utilization Review Nurse – LTSS (Contract-to-Perm) - REMOTE

Posted on:

May 6, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

This is your chance to join one of the nation’s most respected Managed Care Organizations, known for its commitment to delivering high-quality, cost-effective healthcare to underserved populations. With a culture of compassion and innovation, this organization is recognized for prioritizing patient outcomes and creating opportunities for professional growth across the country.

Utilization Review Nurse – LTSS (Contract-to-Perm) Location: Remote however Candidates must reside in one of the following states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY, OH, TX, UT, WA, or WI Schedule: Monday–Friday | 8:00 AM – 4:30 or 5:00 PM EST Pay Rate: $42.00 per hour + Full Health Benefit Plan Offered Contract-to-Hire Opportunity Position Overview The Utilization Review Nurse (LTSS) supports the Utilization Management team and is responsible for reviewing long-term services and supports (LTSS) provider requests, primarily by evaluating clinical documentation to ensure appropriateness of care, cost efficiency, and compliance with state and federal regulations. The role plays a critical part in ensuring members receive the right care at the right time, particularly under Virginia Medicaid guidelines.

Active, unrestricted RN license in Virginia or Compact State (required) Completion of an accredited Registered Nursing program 0–2 years of clinical practice experience (hospital, utilization management, or case management preferred) Experience with LTSS highly preferred Familiarity with Virginia Medicaid is a strong plus Knowledge of InterQual, Milliman, or other medical necessity tools Experience with NCQA standards and utilization review policies Comfortable working independently in a fully remote environment Strong written/verbal communication and organizational skills Proficient with Microsoft Office products; experience with clinical systems a plus Work Environment & Schedule: 100% Remote Candidates must be available to work EST business hours

Review LTSS provider service requests against case management documentation Conduct prior authorization and concurrent reviews in accordance with clinical guidelines and organizational policy Complete reviews within turnaround time (TAT) expectations Identify member eligibility, applicable benefits, and appropriate levels of care Collaborate with internal care teams, including Behavioral Health and Long-Term Care Refer cases to medical directors when needed for clinical decision-making Participate in staff meetings and cross-functional collaboration Provide mentorship to new team members as assigned Maintain documentation standards, compliance, and productivity benchmarks Ensure HIPAA and regulatory compliance at all times

IntellaTriage

Remote Hospice Triage RN- PT 2 shift 3:30p-12a + rotating Sat & Sun 7:30-4 CST

Posted on:

May 6, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

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

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

IntellaTriage

Remote Hospice Triage RN- PT 2 shift 3:30p-12a + rotating Sat & Sun 7:30-4

Posted on:

May 6, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

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

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

Avery Telehealth

Registered Nurse - Remote

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Now Hiring: Bilingual (Spanish/English) Telehealth Registered Nurses Location: Remote Must be licensed in California, Illinois, and Nevada (All 3 single states required) Compact License (NLC) required Avery Telehealth is expanding our team and actively seeking dedicated, bilingual Registered Nurses to deliver high-quality virtual care. If you're fluent in Spanish, hold licenses in California, Illinois, and Nevada, and have a Compact License, we want to hear from you.

Must have an active license in the states of California, Illinois and Neveda (REQUIRED). A Compact License (NLC) is required. Bilingual (English/Spanish) required – candidates must be fluent in both English and Spanish to be considered for this role. Strong communication skills and a friendly, outgoing personality. Enjoy working with patients and providing top-notch care, especially to seniors and underserved communities. Graduate of an approved school of nursing. Minimum of one (2) year of experience as an RN. Experience in telehealth is a significant plus. Demonstrated honesty, loyalty, and leadership. Telehealth Registered Nurse (RN) - Physical Requirements: Ability to read, write, hear, and speak English as required by job duties. Ability to work remotely using various telehealth technologies.

Conduct visits via virtual and telephonic platorms. Follow a script and checklist while using clinical judgment during calls and virtual visits. Maintain accurate and thorough documentation for assessments. Ensure all required forms are completed by patients. Cascade necessary information to physicians promptly. Provide excellent patient interaction, specifically with the senior and underserved populations, via phone and virtual methods. Perform other duties as requested and qualified.

EXL

Skilled Nursing Facility (SNF) Auditor III

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New York

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world's leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 55,000 employees spanning six continents. For more information, visit http://www.exlservice.com. About EXL Health We leverage Human Ingenuity and domain expertise to help clients improve outcomes, optimize revenue and maximize profitability across the healthcare ecosystem. Technology, data and analytics are at the heart of our solutions. We collaborate closely with clients to transform how care is delivered, managed and paid. EXL Health combines deep domain expertise with analytic insights and technology-enabled services to transform how care is delivered, managed, and paid. Leveraging Human Ingenuity, we collaborate with our clients to solve complex problems and enhance their performance with nimble, scalable solutions. With data on more than 260 million lives, we work with hundreds of organizations across the healthcare ecosystem. We help payers improve member care quality and network performance, manage population risk, and optimize revenue while decreasing administrative waste and reducing health claim expenditures. We help Pharmacy Benefit Managers (PBMs) manage member drug benefits and reduce drug spending while maintaining quality. We help provider organizations proactively manage risk, improve outcomes, and optimize network performance. We provide Life Sciences companies with enriched data, insights through advanced analytics and data visualization tools to get the right treatment to the right patient at the right time.

Are you passionate about healthcare auditing? Do you have a keen eye for detail and a deep understanding of Skilled Nursing Facility (SNF) billing and reimbursement? If so, EXL wants you on our team as an Auditor III – SNF/RUG! Remote Opportunity – Work from Home! At EXL, we bring together sharp, innovative professionals eager to make an impact in healthcare. In this role, you'll apply your clinical expertise to review claims, validate charges, and ensure compliance—all while working in a dynamic, collaborative environment.

Required: LPN or RN (Associate’s or Bachelor’s degree preferred). 3+ years of skilled nursing experience (RAC certification, reimbursement, or MDS coordinator experience a plus!). Familiarity with PDPM, RUG, Medicaid 48 grouper reimbursement, and HIPPS codes billing. Skills That Set You Apart: Strong analytical and problem-solving skills. Excellent written and verbal communication. Effective time management and ability to prioritize work. Proficiency in Excel, Word, and OneNote. A collaborative, team-oriented mindset with the ability to work independently.

Conduct in-depth clinical reviews to verify skilled nursing facility (SNF) billing accuracy. Analyze claims paid under PDPM, RUG, and per diem payment models to identify overpayments. Apply ICD-10 coding guidelines to validate diagnoses on Minimum Data Set (MDS) assessments. Document audit findings clearly and concisely using EXL tools, CMS guidelines, and payer policies. Stay up to date on changes in clinical guidelines, reimbursement trends, and regulations. Meet or exceed productivity and quality goals in a remote, independent work environment.

EXL

Skilled Nursing Facility (SNF) / Resource Utilization Group (RUG) - Auditor III, Healthcare

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

New York

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world's leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 55,000 employees spanning six continents. For more information, visit http://www.exlservice.com. About EXL Health We leverage Human Ingenuity and domain expertise to help clients improve outcomes, optimize revenue and maximize profitability across the healthcare ecosystem. Technology, data and analytics are at the heart of our solutions. We collaborate closely with clients to transform how care is delivered, managed and paid. EXL Health combines deep domain expertise with analytic insights and technology-enabled services to transform how care is delivered, managed, and paid. Leveraging Human Ingenuity, we collaborate with our clients to solve complex problems and enhance their performance with nimble, scalable solutions. With data on more than 260 million lives, we work with hundreds of organizations across the healthcare ecosystem. We help payers improve member care quality and network performance, manage population risk, and optimize revenue while decreasing administrative waste and reducing health claim expenditures. We help Pharmacy Benefit Managers (PBMs) manage member drug benefits and reduce drug spending while maintaining quality. We help provider organizations proactively manage risk, improve outcomes, and optimize network performance. We provide Life Sciences companies with enriched data, insights through advanced analytics and data visualization tools to get the right treatment to the right patient at the right time.

Are you passionate about healthcare auditing? Do you have a keen eye for detail and a deep understanding of Skilled Nursing Facility (SNF) billing and reimbursement? If so, EXL wants you on our team as an Auditor III – SNF/RUG! Remote Opportunity – Work from Home! At EXL, we bring together sharp, innovative professionals eager to make an impact in healthcare. In this role, you'll apply your clinical expertise to review claims, validate charges, and ensure compliance—all while working in a dynamic, collaborative environment.

LPN or RN (Associate’s or Bachelor’s degree preferred). 3+ years of skilled nursing experience (RAC certification, reimbursement, or MDS coordinator experience a plus!). Familiarity with PDPM, RUG, Medicaid 48 grouper reimbursement, and HIPPS codes billing. Skills That Set You Apart: Strong analytical and problem-solving skills. Excellent written and verbal communication. Effective time management and ability to prioritize work. Proficiency in Excel, Word, and OneNote. A collaborative, team-oriented mindset with the ability to work independently.

Conduct in-depth clinical reviews to verify skilled nursing facility (SNF) billing accuracy. Analyze claims paid under PDPM, RUG, and per diem payment models to identify overpayments. Apply ICD-10 coding guidelines to validate diagnoses on Minimum Data Set (MDS) assessments. Document audit findings clearly and concisely using EXL tools, CMS guidelines, and payer policies. Stay up to date on changes in clinical guidelines, reimbursement trends, and regulations. Meet or exceed productivity and quality goals in a remote, independent work environment.

EXL

Telephonic Utilization & Case Management RN

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world's leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 55,000 employees spanning six continents. For more information, visit http://www.exlservice.com. About EXL Health: We leverage Human Ingenuity and domain expertise to help clients improve outcomes, optimize revenue and maximize profitability across the healthcare ecosystem. Technology, data and analytics are at the heart of our solutions. We collaborate closely with clients to transform how care is delivered, managed and paid. EXL Health combines deep domain expertise with analytic insights and technology-enabled services to transform how care is delivered, managed, and paid. Leveraging Human Ingenuity, we collaborate with our clients to solve complex problems and enhance their performance with nimble, scalable solutions. With data on more than 260 million lives, we work with hundreds of organizations across the healthcare ecosystem. We help payers improve member care quality and network performance, manage population risk, and optimize revenue while decreasing administrative waste and reducing health claim expenditures. We help Pharmacy Benefit Managers (PBMs) manage member drug benefits and reduce drug spending while maintaining quality. We help provider organizations proactively manage risk, improve outcomes, and optimize network performance. We provide Life Sciences companies with enriched data, insights through advanced analytics and data visualization tools to get the right treatment to the right patient at the right time.

Are you passionate about ensuring patients receive the care they need? Join our team as a Utilization Management & Complex Case Management Nurse, where you will play a crucial role in reviewing and approving authorization requests for appropriate care and provide comprehensive case management services for beneficiaries with multiple or complex conditions. You will follow established guidelines and policies, and when necessary, forward requests to the appropriate stakeholders. You'll also use your clinical knowledge, communication skills, and collaborative spirit to help our beneficiaries regain their optimum health or improve their functional capabilities. This involves performing comprehensive assessment, care planning, implementation, monitoring, and evaluation activities via telephonic contact and digital outreach. Our team works diligently to ensure that beneficiaries progress toward desired outcomes with quality care that is medically appropriate and cost-effective. Our goal is to assist beneficiaries in regaining their optimal health or improved functional capability, support effective self-care management, and promote access to healthcare services and community resources. Work schedule Monday - Friday 5 days x 8 hours Shift time for remote telephonic work is aligned to state of residence and time zone: Pacific Time Zone 9 am - 6 pm PT Mountain Time Zone 10 am - 7 pm MT Central Time Zone 11 am - 8 pm CT Eastern Time Zone 11 am - 8 pm ET

Required: Current, unrestricted RN license in of residence with multi-state privileges (an active compact state license), or the ability to obtain multi-state privileges in the state of residence. 3+ years of experience as a nurse in a clinical setting. 2+ years’ experience performing the utilization review for a health plan or inpatient facility. 1+ year of experience as a case manager for a health plan or inpatient facility. Strong technical proficiency with MS Office Suite Word, Excel, Power Point, Microsoft Teams and SharePoint and ability to navigate multiple systems under periods of high volume. Must hold United States Citizenship status. Ability to obtain Federal Security Clearance required. Current DOD Security Clearance preferred. Secure, private home office work environment. Preferred: Bachelor’s degree in nursing from an accredited college, university, or school of nursing. Experience working in a NCQA and URAC accredited program. Previous experience in Hospital Acute Care, Prior Auth, Utilization Review / Utilization Management and knowledge of InterQual and/or MCG guidelines. Health Plan experience working with large carriers. Previous Federal government plan program experience such as Tricare, Medicare Medicaid and commercial health insurance experience. Active, Certified Case Management Certification (CCM). Experience working remotely.

Review authorization requests using clinical judgment and evidenced-based clinical decision support criteria to ensure medical necessity and appropriate level of care. Assesses services for beneficiaries to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Identifies appropriate benefits and eligibility for requested treatments and/or procedures. Conducts authorization reviews to determine financial responsibility for the payer and its beneficiaries. Approve services or refer cases to internal stakeholders based on findings. Makes appropriate referrals to other clinical programs. Refers appropriate authorization requests to and collaborates with Medical Directors. Educate providers on utilization and medical management processes. Enter and maintain clinical information in various medical management systems. Make evidenced-based independent decisions regarding work methods, even in ambiguous situations, with minimal direction. Analyzes clinical service requests from beneficiaries or providers against evidence based clinical guidelines. Processes requests within required timelines. Collaborates with multidisciplinary teams to promote the care model. Adheres to all UM policies and procedures, federal, state and regulatory guidelines. Conduct a comprehensive assessment with beneficiaries and analyze assessment findings to identify and prioritize clinical, psychosocial, and behavioral concerns and potential gaps in care. Develop and document a case management care plan in direct collaboration with the beneficiary, the beneficiary's family or significant other(s), the primary physician and other health care providers. Identify and include key concerns, needs, and preferences of the beneficiary and family/caregiver. Document identified issues, prioritized and individualized goals (long & short term), evidence-based interventions, collaborative approaches and resources, anticipated time frames, and barriers to achieving goals in the care plan. Coordinate and implement the activities specified in the care plan to provide optimal benefits coverage as well as promote continuity of care and integration of services for the beneficiary across care transitions. Collaborate and communicate with the beneficiary, family, significant other(s), physician, and other health care providers to accomplish the goals on the care plan. Monitor and continually evaluate the care plan on a scheduled basis to ensure it remains effective and to determine if desired outcomes are met and the goals are achieved. Revise and update the care plan as needed in collaboration with the beneficiary and the health care team. Collaborate with beneficiaries and their support system/caregivers, providers, the multi-disciplinary team, and health care and community resources throughout the case management process. Be familiar with and understand the scope of professional licensure and carry out case management activities consistent with the scope of this licensure.

Community Health Systems

Remote Denial Coordinator - Registered Nurse (RN)

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Tennessee

The Denial Coordinator is responsible for reviewing, tracking, and resolving denied claims, ensuring that appropriate appeals are submitted, and working closely with payers, internal departments, and revenue cycle teams to identify and address denial trends. This role plays a critical part in the denials management process, supporting efforts to improve claims resolution, reduce future denials, and ensure compliance with payer guidelines. This position requires a valid Registered Nurse (RN) license.

Qualifications: H.S. Diploma or GED required Associate Degree or higher in Healthcare Administration, Business, Finance, or a related field preferred Valid Registered Nurse (RN) license 1-3 years of experience in denials management, insurance claims processing, or revenue cycle operations required Experience in revenue cycle processes in a hospital or physician office required Experience with payer appeals, claim resolution, and healthcare billing systems preferred Knowledge, Skills And Abilities: Strong understanding of payer guidelines, claim adjudication processes, and denial management strategies. Proficiency in Artiva, HMS, Hyland, BARRT, and other revenue cycle applications. Excellent problem-solving skills, with the ability to analyze denial trends and recommend corrective actions. Strong written and verbal communication skills, with the ability to engage effectively with payers, internal teams, and leadership. Detail-oriented with strong organizational and documentation skills, ensuring compliance with payer appeal deadlines. Ability to work independently and manage multiple priorities in a fast-paced environment.

Monitors assigned denial pools and work queues in Artiva, HMS, Hyland, BARRT, and other host systems, ensuring timely follow-up on denials and appeals. Conducts follow-up calls and payer portal research to track the status of submitted appeals and claim determinations, documenting all actions taken. Communicates with key stakeholders across revenue cycle, billing, and clinical teams to resolve denial trends and improve claim submission accuracy. Tracks and documents all denial and appeal activity, maintaining accurate records in system logs, account notes, and tracking reports. Ensures compliance with all payer guidelines and regulatory requirements, keeping up to date with policy changes and appeal submission rules. Manages BARRT requests (Outbound/Inbound) in a timely manner, ensuring that all required documentation and system updates are completed. Identifies root causes of denials and collaborates with internal teams to implement process improvements that reduce future denials. Prepares and submits appeal documentation, ensuring that all required medical records, forms, and supporting materials are included. Performs other duties as assigned. Complies with all policies and standards.

Atrium

Remote Oncology Nurse Navigator - 155068

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

The Remote Oncology Nurse Navigator will provide triage, support and education to members during their cancer journey via phone, email and video.

The Oncology Nurse Navigator must possess OCN. Must possess compact license and/or licensure in MI, NY or IL. Must have recent oncology navigation or oncology case management experience. Minimum 5 years of nursing experience, including 2 years in direct patient care experience in outpatient infusion or navigation. Education Requirements: Bachelor of Science in Nursing.

Establish trusting relationships with members and their care network as a Remote Oncology Nurse Navigator. Support members throughout their cancer care journey including screening, survivorship and end of life care. Assist members with care coordination, symptom management, nutritional support, discharge planning and provider referrals. Assist with urgent clinical escalations and provide clinical consult support.

First Stop Health

Pre-Certification/Utilization Management Nurse

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Illinois

First Stop Health provides care that people love® with our convenient, high-quality, and confidential virtual care solutions – Telemedicine, Virtual Mental Health, and Virtual Primary Care. We help our patients save time and money through compassionate care that’s available 24/7 via app, website, or phone. First Stop Health offers a comprehensive benefits package that includes various health and medical coverage options, dental and vision coverage, disability, and life coverage, making healthcare easily accessible. For those that choose to waive medical coverage a monthly medical waiver allowance will be provided. First Stop Health offers a remote-first work environment and flexible paid time off, including Summer Fridays. Furthermore, the employer match 401k plan and monthly phone stipend demonstrate the company's commitment to employee financial well-being. The First Stop Health membership benefit is another added perk for employees and provides Virtual Urgent Care, Virtual Mental Health, and Virtual Primary Care from their very first day!

The Utilization Management (UM) Clinician is a registered nurse responsible for conducting utilization and quality management activities for First Stop Health in accordance with Utilization Management policies and procedures. The position responsibilities include the management of medical costs through timely prospective, concurrent, and retrospective review activities. The UM Nurse is responsible for conducting clinical reviews and authorizing services based on established medical necessity criteria and benefit guidelines. Working independently, the UM Nurse evaluates inpatient and outpatient service requests to determine appropriateness and medical necessity using clinical judgment and standardized tools such as InterQual or MCG. The UM Nurse collaborates closely with Intake Coordinators, Case Managers, and provider offices to ensure timely determinations and seamless care coordination. This role requires strong attention to detail, working knowledge of CPT/HCPCS and ICD-10 codes, and the ability to manage multiple reviews while maintaining compliance with all regulatory and contractual requirements.

RN with a current, unrestricted license to practice as a health professional in a state or territory of the United States required. HCQM, HRM or similarly acceptable certification preferred. At least 2-3 years of experience in utilization review, quality assurance, discharge planning or other cost management programs and/or a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review preferred. Two (2) years’ experience in a hospital-based nursing required. Medical-surgical care experience preferred for positions in medical management areas. Strong communication, documentation, clinical and critical thinking skills essential. Working knowledge of utilization management/case management preferred. Strong problem solving and decision-making skills essential. Strong typing and computer skills essential.

Contributes to UM program goals and objectives in containing health care costs and maintaining a high-quality medical delivery system through the ongoing development and refinement of program procedures for conducting UM activities. Apply clinical guidelines (e.g., InterQual, MCG) to support decision-making for prior authorizations Maintain compliance with regulatory requirements, including NCQA, URAC, and HIPAA. Performs telephonic review for inpatient and outpatient services using First Stop Health approved medical review healthcare criteria and behavioral health criteria. Collects only pertinent clinical information and documents all UM review information using the appropriate software system. Identify and refer complex cases to Case Management or Medical Director when appropriate Promotes alternative care programs and research available options including costs and appropriateness of patient placement in collaboration with health plan clients. Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services. Communicates directly with the designated medical director/physician advisor regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues. Recommends, coordinates, and educates providers regarding alternative care options. Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital and health plan client discharge planners and social workers in the early identification of potential home care candidates or less restrictive level of care placement. Works collaboratively if Case Management is involved with member. Participates in UM program CQI (Continuous Quality Improvement) activities. Communicates all UM review outcomes in accordance with the health plan’s requirements. Follows relevant client time frame standards for conducting and communicating UM review determination. Maintains and submits reports and logs on review activities as outlined by the UM program operational procedures when directed. Identifies and communicates to the appropriate supervisory personnel all hospital, ancillary provider, physician provider and physician office concerns and issues. Identifies and communicates to the appropriate supervisory personnel all potential quality of care concerns and patient safety. Serves as liaison for provider staff and the health plan client. Maintains courteous, professional attitude when working with internal staff, hospital and physician providers, and health plan client. Identifies and communicates to health plan client and/or contracted ancillary providers all catastrophic and high-risk cases for case management referral. Actively participates in team and First Stop Health company meetings; and Performs other duties as requested by the appropriate supervisory personnel. Customer Services - Internal: Supports a positive working environment. Identifies and resolves potential personnel/peer problems and issues proactively, readily utilizing appropriate supervisors and team members as resources. Communicates to the appropriate supervisory personnel all problems, issues and/or concerns as they arise. Communicates to the appropriate supervisory personnel any issues or concerns related to quality of care. Maintains a courteous and professional attitude when working with all First Stop Health staff members and the management team. Readily available to non-clinical staff to answer questions and ensure that non-clinical administrative staff is performing within the scope of the non-clinical role. Actively participates in team meetings, as designated. Customer Services – External: Timely identifies and communicates to applicable practitioners, providers, and the health plan/client staff all issues and concerns related to the case at hand. Communicates to the client/health plan staff any issues or concerns related to quality of care, using First Stop Health policies/procedures. Works, communicates, and collaborates in harmony and in a courteous and professional manner with the patient, practitioner, provider, and multidisciplinary health care team members all issues, concerns and/or as the UM Plan is revised and/or new services are implemented/terminated. Serves as a liaison and patient advocate when deemed applicable for quality of care and cost outcomes; and Communicates appropriately and according to policy, and/or regulatory requirements with the practitioner(s), provider(s), patient/patient’s legally appointed representative any UM coverage determination(s).

CircleLink Health

On-Call Registered Nurse (RN) Remote 1099 Contractor

Posted on:

May 6, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

CircleLink Health is a company of passionate clinicians, technologists and business people 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.

We are seeking an experienced and dependable Registered Nurse (RN) to join our team in a remote, part-time, on-call capacity. This is a great opportunity for RNs who are passionate about supporting patient care, enjoy flexible scheduling, and want to work from home in a non-clinical role.

Fluent in English Self-directed, able to work independently with little supervision while meeting performance metrics Passion for nursing and improving patient outcomes Comfortable with technology and eager to learn new systems and platforms Excellent organizational and time management skills Strong communication and telephonic skills Strong critical thinking and problem-solving abilities Education and Experience: Current, unrestricted Compact Multi-State RN License (required) 3+ years of experience as a Registered Nurse (required) Case Management or Chronic Disease Management experience Proficiency with electronic health records and web-based applications Scheduling and Other Requirements: You must have a reliable, high-speed internet-connected computer (equipment not provided) Minimum of 20–25 hours of availability per week required This role cannot be held alongside a full-time position Shifts are scheduled in advance and must fall between 9:00 AM – 6:00 PM ET, Monday through Friday Evening and weekend hours are not available You will self-schedule your shifts using our scheduling software Must be available by phone for the full 8-hour on-call shift

As an on-call RN, you will be available to assist with complex cases that are escalated by case management care coaches (LPNs). This may include triage and taking over a patient call or subsequent follow-up directly with the patient.

Wellbox Health

LPN Remote Chronic Care Management: (Time zone: PST/MST)

Posted on:

May 6, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Compact / Multi-State

Wellbox is a rapidly growing healthcare company focused on empowering people to live healthier lives through comprehensive preventative care solutions delivered by an elite team of experienced nurses. We are currently seeking tech-savvy LPN Patient Care Coordinators to conduct monthly telephonic outreach to chronically ill patients, developing personalized care plans that address their health challenges.

We are seeking full-time LPN team members who can work 40 hours per week, between the hours of 8 am – 6 pm PST/MST, Monday – Friday.

Active Compact LPN License. Minimum two years of clinical experience; care coordination experience preferred. Proficient with Electronic Medical Records and Microsoft Office. Excellent communication and problem-solving skills. Candidates who reside in Mountain Standard Time (MST) or Pacific Standard Time (PST) are preferred; candidates that reside in Central or Eastern time zones will not be considered for this position.

Manage patients’ healthcare needs via virtual phone conversations. Document visits using technology platforms and EHRs. Develop personalized care plans addressing physical, mental, and preventative health. Coach patients on treatment plans, including nutrition and wellness. Connect patients with resources and prepare them for medical appointments.

UnitedHealth Group

APR-DRG CVA RN Auditor - National Remote

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Minnesota

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

In this position as a DRG CVA RN Auditor, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: nAssociate’s degree (or higher) Unrestricted RN (Registered Nurse) license CCS/CIC or willing to obtain certification within 6 months of hire 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies 2+ years of ICD-10-CM coding experience including but not limited to expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM) 2+ years of ICD-10-PCS coding experience including but not limited to expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers Preferred Qualifications: Experience with prior DRG concurrent and/or retrospective overpayment identification audits Experience working with Utilization Management Experience with readmission reviews of claims Experience with DRG encoder tools (ex. 3M) Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry Healthcare claims experience Managed care experience Knowledge of health insurance business, industry terminology, and regulatory guidelines Soft Skills: Ability to use a Windows PC with the ability to utilize multiple applications at the same time Ability to work independently in a remote environment and deliver exceptional results Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail Excellent time management and work prioritization skills Physical Requirements and Work Environment: Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computer Have a secluded office area in which to perform job duties during the work day Have reliable high – speed internet access and a work environment free from distractions *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification Utilize expert knowledge to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements Maintain and manage daily case review assignments, with a high emphasis on quality Provide clinical support and expertise to the other investigative and analytical areas Work in a high-volume production environment that is matrix driven

Molina Healthcare

Care Review Clinician, Inpatient Review (RN) Remote based in Arizona

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Arizona

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.

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. This position will support the Arizona state Plan. We are seeking a candidate with an Arizona RN licensure. The ideal candidate will have experience with UM and prior authorization with both inpatient and outpatient. Candidates with a Behavioral Health background are highly preferred. Further details to be discussed during our interview process. Remote position, must reside in Arizona. Work hours: Monday - Friday 8:30am- 5:00pm Mountain Time with some weekends and holidays.

JOB QUALIFICATIONS Required Education: Graduate from an Accredited School of Nursing. Required Experience: 3+ years hospital acute care/medical experience. Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. State Specific Requirements: Licensed within the appropriate state. Preferred Education: Bachelor's Degree in Nursing Preferred Experience: Recent hospital experience in ICU, Medical, or ER unit. Prior working experience with MCG and/or InterQual guidelines Prior experience in Behavioral Health and Physical Health Utilization Mangement reviews. Preferred License, Certification, Association: Active, unrestricted Utilization Management Certification (CPHM).

Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and 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 inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed. Processes requests within required timelines. Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner. Requests additional information from members or providers in consistent and efficient manner. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote Molina Care Model. Adheres to UM policies and procedures. Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

UnitedHealth Group

Nurse Practitioner - Part Time - FL Licensed - Telephonic After Hours Remote

Posted on:

May 5, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual’s physical, mental and social needs – helping patients access and navigate care anytime and anywhere. As a team member of our Senior Community Care (SCC) product, we work with a team to provide care to patients at home in a nursing home, assisted living for senior housing. This life-changing work adds a layer of support to improve access to care. We’re connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

The Home and Community Care (HCC) program is a longitudinal, integrated care delivery program. The HCC National On Call advanced practice clinician (APC) is responsible for providing telephonic care and direction to members and facility staff during various evening, overnight, weekend, and holiday hours. This role is responsible for the delivery of medical care services to a pre-designated group of enrollees. In this remote role you will provide afterhours virtual (primarily telephonic) care for aging residents in various settings. This excellent opportunity affords an autonomous role bringing enormous satisfaction in the care and comfort of our aging population. In this role you will have the ability to achieve work life balance. Optum is transforming care delivery with innovative and personal care. As one of the largest employers of APCs, Optum offers unparalleled career development opportunities. Scheduling: This is a full time, work from home position requiring variable shift coverage on weeknights, weekends, and holidays While your shift times can vary, we provide coverage to members: on weeknights from 5pm- 8am local time, and continuous weekend coverage from Friday at 5pm to Monday at 8am, and Holiday coverage beginning at 5pm of the end of the last business day to 8am of the resumption of business hours Weekday Shifts are 5PM-2AM or 11PM-8AM Weekend Shifts are 11AM-11PM or 1AM-1PM Holiday scheduling is completed at the beginning of the year for advanced planning Experience Preference: Candidates with recent experience in high-acuity geriatric care (e.g., SNF, LTACH, Hospitalist, ICU, Emergency) are preferred. Call Handling: You will receive about 4 after-hours calls per hour on average from Nursing Home Staff, RNs, DONs, Staff Typing Skills: Excellent typing skills are essential as you will need to enter notes live for each case If you have an active FL license, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Active Florida NP license or ability to obtain by start date. Licensure must be unencumbered, free of any open/unresolved disciplinary actions including probation or restrictions against privilege to practice Active ANCC or AANP national certification in Family, Geriatrics, Adult, Adult-Gerontology Primary Care, or Adult-Gerontology Acute Care certification, or the ability to obtain national certification and/or NP license in state of assignment by start date Current active DEA licensure or ability to obtain post-hire, per state regulations (unless prohibited in state of practice) Availability to work assigned weekends, weekdays, and pre-assigned holidays Preferred Qualifications: 2+ years of hands-on postgrad experience within Long Term Care Understanding of Geriatrics and Chronic Illness Understanding of Advanced Illness and end of life discussions Proficient computer skills, including the ability to document medical information with written and electronic medical records

Available on provided telephonic platform, both taking and placing calls to coordinate care for members between facilities, hospitals, and Optum field colleagues Utilize EMR proficiently to provide acute care to members during overnight and weekend and holiday hours Primary Care Delivery Manage both medical and behavioral, chronic, and acute conditions effectively, and in collaboration with a physician or specialty provider Responsible for ensuring encounter is documented appropriately to support the diagnosis at that visit Attend and complete all mandatory educational training requirements Care Coordination Monitor the needs of members and families while facilitating any adjustments to the plan of care as situations and conditions change Review orders and interventions for appropriateness and response to treatment to identify the most effective plan of care that aligns with the member’s needs and wishes Program Enhancement Expected Behaviors Regular and effective communication with internal and external parties including physicians, members, key decision-makers, nursing facilities, HCC staff and other provider groups Ability to meet shift scheduling requirements, and attendance expectations

UnitedHealth Group

APR-DRG CVA RN Auditor - National Remote

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Minnesota

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

In this position as a DRG CVA RN Auditor, you will apply your expert knowledge of the MS-DRG and APR-DRG coding/reimbursement methodology systems, ICD-10 Official Coding Guidelines, and AHA Coding Clinic Guidelines in the auditing of inpatient claims. Employing both industry and Optum proprietary tools, you will validate ICD-10 diagnosis and procedure codes, DRG assignments, and discharge statuses billed by hospitals to identify overpayments. Utilizing excellent communications skills, you will compose rationales supporting your audit findings. You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Associate’s degree (or higher) Unrestricted RN (Registered Nurse) license CCS/CIC or willing to obtain certification within 6 months of hire 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies 2+ years of ICD-10-CM coding experience including but not limited to expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM) 2+ years of ICD-10-PCS coding experience including but not limited to expert knowledge of the structural components of PCS such as selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers Preferred Qualifications: Experience with prior DRG concurrent and/or retrospective overpayment identification audits Experience working with Utilization Management Experience with readmission reviews of claims Experience with DRG encoder tools (ex. 3M) Experience using Microsoft Excel with the ability to create / edit spreadsheets, use sort / filter function, and perform data entry Healthcare claims experience Managed care experience Knowledge of health insurance business, industry terminology, and regulatory guidelines Soft Skills: Ability to use a Windows PC with the ability to utilize multiple applications at the same time Ability to work independently in a remote environment and deliver exceptional results Demonstrate excellent written and verbal communication skills, solid analytical skills, and attention to detail Excellent time management and work prioritization skills Physical Requirements and Work Environment: Frequent speaking, listening using a headset, sitting, use of hands / fingers across keyboard or mouse, handling other objects, long periods working at a computer Have a secluded office area in which to perform job duties during the work day Have reliable high – speed internet access and a work environment free from distractions *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification Utilize expert knowledge to identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance Apply current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations and demonstrate working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing Utilize solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment Write clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements Maintain and manage daily case review assignments, with a high emphasis on quality Provide clinical support and expertise to the other investigative and analytical areas Work in a high-volume production environment that is matrix driven

CVS Health

Case Manager, Registered Nurse (Remote)

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

Aetna is an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. We collaborate with members, providers, and community organizations in pursuit of quality solutions that address the full continuum of our members’ health care and social determinant needs. Dual Eligible Special Needs Plans (DSNP) members are enrolled in Medicare and Medicaid. Our Care Managers are frontline advocates for members who cannot advocate for themselves. Join us in this exciting opportunity as we grow and expand DSNP into new markets across the country.

Required Qualifications: Candidate must have active and unrestricted RN licensure in the state of Georgia or compact licensure in state of residence 3+ years of clinical experience 2+ years of case management, discharge planning and/or home healthcare coordination experience Preferred Qualifications: Certified Case Manager Excellent analytical and problem-solving skills Bilingual Effective communications, organizational, and interpersonal skills Ability to work independently Effective computer skills including navigating multiple systems and keyboarding Proficiency with standard corporate software applications, including MS Word, Excel, Outlook, and PowerPoint, as well as some special proprietary applications Education: Associate's Degree in Nursing (REQUIRED) with equivalent experience Bachelor’s Degree (PREFERRED) License: Active and unrestricted RN licensure in the state of Georgia or compact licensure in state of residence

Nurse Care Manager is responsible for assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness. Develops a proactive plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness. Uses clinical tools and information/data review to conduct an evaluation of member's needs and benefits. Applies clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning. Conducts assessments that consider information from various sources, such as claims, to address all conditions including co-morbid and multiple diagnoses that impact functionality. Uses a holistic approach to assess the need for a referral to clinical resources and other interdisciplinary team members. Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

CVS Health

Transition of Care Associate, Licensed Practical Nurse, Remote

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

LPN/LVN

State License:

Texas

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

This is a full-time telework position. **This position will require 8a-5p in the assigned market time zone.** Help us elevate our member care to a whole new level! Join our Aetna Team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Dual Eligible Special Needs Plan (D-SNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand D-SNP to change lives in new markets across the country. The Transition of Care Coach is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay. The TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by: Complete post-discharge questionnaire, which may be market specific. Providing comprehensive discharge planning Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications. Benefit education Provides clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports) Evaluation of health and social indicators Identifies and engages barriers to achieving optimal member health. Uses discretion to apply strategies to reduce member risk. Presents cases at case conferences for multidisciplinary focus to benefit overall member management. Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage. Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up. Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel. Updates the Care Plan for any change in condition or behavioral health status. Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality.

REQUIRED WORK EXPERIENCE: 2+ years LPN nursing experience Active and unrestricted LPN license in the state of residence Proficiency in Microsoft Word, Excel, and Outlook PREFERRED WORK EXPERIENCE: 3+ years LPN nursing experience Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses Discharge planning experience Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care. Effective verbal and written communication skills Bilingual a plus! EDUCATION: Required: H.S. or Equivalent - MUST be an LPN Preferred: Associate's Degree, Bachelor's Degree

Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines. Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions. Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community. Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions.

ChenMed

Registered Nurse, Telehealth (Fulltime)(Spanish Bilingual) - Remote

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Registered Nurse, Telehealth is responsible for providing telephonic triage directional patient care advice for general and specific illnesses, health related issues, client counseling, patient advocacy, health education and referral and resource management to ChenMed patients and their families. The incumbent in this role provides remote clinical advice and assessments within license and as possible given the technology and medium. He/She collaborates with primary caregivers and others on the interdisciplinary care plan team to provide a team approach of care. This role is a full time opportunity. Schedule: Monday - Friday 1630-0030 EST

KNOWLEDGE, SKILLS AND ABILITIES: Advanced-level business acuity In-depth knowledge and understanding of general/core Nursing-related functions, practices, processes, procedures, techniques and methods Broad nursing knowledge and understanding Ability and willingness to provide extraordinary customer service and professionalism to all customers Maintains current nursing knowledge and competency to stays abreast of budding nursing trends and best practices Excellent written and verbal communication skills through a variety of formats, tools and technologies Capable of building trust and professional relationships to deliver VIP care across the continuum Ability to demonstrate excellent clinical judgement Ability to problem solve Ability to prioritize and work under pressure Ability to provide constructive feedback Ability to effectively collaborate with physicians, patients, family members, colleagues and other team members in a courteous and professional manner Ability to effectively collaborate with a multidisciplinary team Proficient skill in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook; competent in other systems required for the position Ability and willingness to travel locally, within South Florida, to attend meetings and trainings up to 10% of the time; flexible and available to cover after-hours and to work weekends as needed Spoken and written fluency in English; bilingual (Spanish) required This job requires use and exercise of independent judgment EDUCATION AND EXPERIENCE CRITERIA: Associate Degree in Nursing required, Bachelor’s Degree in Nursing preferred Nurse Licensure Multistate Compact license required Michigan and Illinois Nurse Licensure required within 90 days of hire, ability to obtain additional licenses as requested by the organization within 90 days of hire Spanish fluency required Minimum of 2 years of Nursing experience in an ER or Emergency Triage setting required. Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required Minimum of 3 years acute clinical nursing work experience preferred Minimum of 1 year virtual care experience preferred

Connects with patients via phone or video call. Interviews and questions patients to collect health history and uses a computer system to record and store comprehensive and focused data relating to the health needs of patients and families. Provides health assessment and treatment solutions, monitors patient health and at-home care, aids in emergency scenarios and promotes patient wellness. Based on the technology available, monitors a patient’s oxygen levels, heart rate, respiration, blood glucose and other assessment measures. With the help of video chatting, identifies patient’s symptoms and conditions. Analyzes data to determine the appropriate health maintenance and identify appropriate outcome for the patient and family. Collaborates with on-call PCP as needed to support expected clinical outcomes. Implements the appropriate protocol to attain the expected outcome. Evaluates and documents progress toward the anticipated outcome. Assists in ensuring achievement of optimal patient outcomes through use of Telemedicine. Documents interventions in readable, understandable language. Aids in enhancing the quality and effectiveness of the organization’s telehealth practices and professional nursing practice through successful utilization and improvement of outcomes that demonstrate program effectiveness. Utilizes appropriate resources to plan and provide services that are safe, effective and fiscally responsible. Performs other duties as assigned and modified at manager’s discretion.

Aveanna Healthcare LLC

Remote Home Health RN Assistant Clinical Manager

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Wisconsin

The Assistant Clinical Manager – Home Health, will evaluate nursing activities to ensure patient care, staff relations, and efficiency of service within the team. Act as a resource and support for clinical staff and facilitate collaborative teamwork on the unit and with ancillary departments. Oversee the Quality Program for the clinic and ensure that all standards are met, and keep procedural manuals and other necessary equipment up to date. This individual will serve as a backup to the Clinical Manager. Looking for an experienced OASIS HH RN who has a compact license to support our branches remotely with HCHB workflow, reviewing documentation, approving orders, communicating with providers, reviwing on call documentation and process improvements.

Requirements: Active RN licensure in the state of the application Bachelor’s degree required Preferred: Medicare skilled nursing experience Basic understanding of OASIS RN experience in health care (home health)

Maintains clinical record documentation according to agency policy and procedures and state/federal regulation Ensures compliance with regulations and is available for federal and state licensure surveys Participates in Performance Improvement activities including but not limited to clinical record review, quality indicator monitoring, and quality management OASIS and/or coding experience is strongly desired Acts as a Preceptor to coordinate orientation and training for all RN Clinical new hires Provides ongoing training and educational opportunities for Clinical staff Serves as a senior member to all staff regarding quality improvement and documentation Oversees clinical orientation duties including documentation and quality improvement for all new health related employee Carry a caseload of patients, understand and perform the admission process plan of care Supervise RN, LPN, and HHA field staff as indicated.

Hanger, Inc.

ACP- Nurse Clinical Ops Consultant

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

With a mantra of Empowering Human Potential, Hanger, Inc. is the world's premier provider of orthotic and prosthetic (O&P) services and products, offering the most advanced O&P solutions, clinically differentiated programs and unsurpassed customer service. Hanger's Patient Care segment is the largest owner and operator of O&P patient care clinics nationwide. Through its Products & Services segment, Hanger distributes branded and private label O&P devices, products and components, and provides rehabilitative solutions to the broader market. With 160 years of clinical excellence and innovation, Hanger's vision is to lead the orthotic and prosthetic markets by providing superior patient care, outcomes, services and value. Collectively, Hanger employees touch thousands of lives each day, helping people achieve new levels of mobility and freedom.

The Nurse Clinical Ops Consultant will achieve partner growth and retention by establishing maximum value for our clients through successful implementation of ACP clinical programs and rehab technologies. The focus of this role will emphasize nursing integration of respiratory, cardiopulmonary, and other rehab clinical programs as part of interdisciplinary ACP programs in post-acute care settings. The Nurse Clinical Ops Consultant will be part of ACP Clinical Services team and will work closely with field ops, marketing, and product development teams. The Nurse Clinical Ops Consultant will report directly to the Director of Clinical Services. Southeast Region, Georgia & Florida areas preferred

Minimum Qualifications: BSN or MSN Nursing Degree Licensed Registered Nurse 10 years of nursing experience with at least 5 years in leadership and/or operational role Deep knowledge of post-acute care (PAC) settings, healthcare systems, and regulatory environment Certifications: RAC-CT or similar certification is preferred Must have, or be eligible to obtain, a valid driver’s license and driving record within the standards outlined within Hanger’s Motor Vehicle Safety Policy and Procedures. Additional Success Factors: Extensive experience developing or implementing Clinical Programs in Post Acute Care settings including skilled nursing facilities. Strong familiarity with respiratory and pulmonary nursing care in post-acute care settings with command of the clinical, operational, and regulatory dimensions. Excellent verbal and written communication skills, with strength in dynamic presentations to influence adoption of new and innovative technologies/practices. Leadership and Management skills leading and influencing nursing teams with impact on quality of patient care. Proactive, adaptive, solutions-oriented to drive measurable results. Ability to travel up to 50% to support field implementation of ACP programs. Working knowledge of Microsoft Teams, Outlook, PowerPoint, Work, and Excel. Excellent customer service and public relations skills. Foster open collaboration and constructive dialogue with everyone around you. Continuously innovate new solutions, influencing and responding to change. Focus on superior outcomes and calibrate work processes for outstanding results. Act with integrity in all ways and at all times, remaining honest, transparent, and respectful in all relationships. Keep the patient at the center of everything that you do, building lifelong trust. Foster open collaboration and constructive dialogue with everyone around you. Continuously innovate new solutions, influencing and responding to change. Focus on superior outcomes, and calibrate work processes for outstanding results. #LI-Remote

Install ACP Respiratory/Cardiopulmonary program within ACP partner facilities where nursing team in collaboration with interdisciplinary team drive successful adoption of technology. Collaborate with members of Clinical Services, field Ops on the development of successful ACPlus Respiratory Assessment nursing workflow for respiratory assessment and treatment Promote nursing role in implementation of ACP rehab technologies and interdisciplinary clinical programs by: Collaborating with Clinical Services, Product Development, and Marketing teams to identify new opportunities. Advancing the development of ACP products and services with focused on optimal integration of nursing department/staff. Conducting webinars, training activities, and technology demonstrations for internal and external stakeholders with particular emphasis on nursing role. Contribute to nursing CE content development in collaboration with Clinical Content and Innovation team. Serve as a liaison to Remote Clinical Services addressing nursing clinical, regulatory, and operational inquiries supporting ACP core clinical programs within ACP partner facilities. Mentor ACP field team to navigate complex post-acute care settings and gain in-depth understanding of nursing role in successful technology and clinical program implementation. Be a resource for field operational leaders to support business review meetings for existing and prospective partners to strategize around business growth.

Elevance Health

LTSS Service Coordinator - RN

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

New York

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

LOCATION: This is a field designated role for the areas of Erie and Niagara Counties. New York residency is required. When you are not traveling, you will work virtually from your home. HOURS: Standard business hours, Monday through Friday. TRAVEL: Travel is required within the above areas visiting members in their homes or in a care facility. This field-based role enables associates to primarily operate in the field, traveling to client sites or designated locations as their role requires, with occasional office attendance for meetings or training. This approach ensures flexibility, responsiveness to client needs, and direct, hands-on engagement. The LTSS Svc Coordinator RN-Clinician is responsible for overall management of member's case within the scope of licensure. The RN has overall responsibility to develop the care plan for services for the member and ensures the member's access to those services.

Required Qualifications: Requires a high school diploma or equivalent. Requires current, unrestricted RN license issued by the state of New York; and 3 years of experience in working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator, Case Management, or similar role; or any combination of education and experience which would provide an equivalent background. Preferred Qualifications: You must be comfortable visiting members and providing care in their homes or in a care facility. You must be computer proficient in Microsoft Office including Word and Excel. Very strong verbal and written communication skills are needed for this position.

Responsible for performing telephonic or face-to-face clinical assessments for the identification, evaluation, coordination, and management of member's needs, including physical health, behavioral health, social services, and long term services and supports. Identifies members for high-risk complications and coordinates care in conjunction with the member and the health care team. Manages members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health benefits. Obtains a thorough and accurate member history to develop an individual care plan. Establishes short- and long-term goals in collaboration with the member, caregivers, family, natural supports, physicians; identifies members that would benefit from an alternative level of care or other waiver programs. May assist with the implementation of member care plans by facilitating authorizations/referrals for utilization of services, as appropriate, within benefits structure or through extra-contractual arrangements, as permissible. Interfaces with Medical Directors, Physician Advisors, and/or Inter-Disciplinary Teams on the development of care management treatment plans. May also assist in problem solving with providers, claims or service issues. May direct or supervise the work of any LPN, LCSW, LMSW, or other licensed professionals than an RN, in coordinating services for the member. Travels to worksite and other locations as necessary.

Elevance Health

Care Management Manager, Foster Care (Rutherford Co.)

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

North Carolina

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

North Carolina residency is required! LOCATION: This is field position. When you are not in the field, you will work remotely from your home. You must reside within 20 miles of Rutherford County. HOURS: General business hours, Monday through Friday. TRAVEL: Some travel within your assigned area or region is required. The CFSP Care Management Manager (Manager I GBD Special Programs) is responsible for managing and overseeing assigned care managers and ensuring fidelity to the CFSP Care Management model which includes physical health, behavioral health, and social services.

For the State of North Carolina, in accordance with federal/state law, scope of practice regulations or contract, the requirements are: Requires an active and current license as an LCSW, LCMHC, LPA, LMFT, or RN issued by the state of North Carolina. Requires a MS/MA in social work, counseling, or a related behavioral health field, or a degree in nursing. Requires three (3) years of experience providing care management, case management, or care coordination to individuals served by the child welfare system. Preferred Qualifications: Knowledge of resources, supports, services and opportunities required for safe community living for populations receiving in-reach and transition services, including LTSS, Behavioral Health, therapeutic, and physical health services. Experience working with Children, Youth, and Families who are being served by Local Departments of Social Services through Foster Care and Adoptive Assistance programs is very strongly preferred. At least 2 years of management/supervisor experience (with direct reports) is needed for this position. Service delivery coordination, discharge planning or behavioral health experience in a managed care setting preferred. We are unable to accommodate LCSW-A, LCMHC-A or any other associate level licenses.

Manages resource utilization to ensure appropriate delivery of care to members, adequate coverage for all tasks and job responsibilities. Review all Care Plans and ISPs for quality control and provide guidance to care managers on how to address Members’ complex health and social needs. Ensure care managers provide Trauma-Informed Care and recognize the impact of ACEs on the CFSP population. Coordinates service delivery to include member assessment of physical and psychological factors. Participates in cross-functional workgroups created to maintain and develop program. Evaluates current processes of Special Program's support functions; recommends changes for increased efficiencies and improved outcomes. Develops and conducts training programs for staff involved in the program. Extracts and manipulates analytical data to present findings to relevant markets and stakeholders. Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Pope's Place

Nurse Case Manager-RN

Posted on:

May 5, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Washington

Pope's Kids Place is a nonprofit providing services and assistance in the Pacific Northwest for medically complex and fragile children. We offer individualized care for children and young adults with exceptional medical and behavioral needs, strengthening them, their families, and the community. Our dedicated and loyal staff provide skilled nursing care to our residents. We are located in Centralia, Washington.

This is a full-time remote role for a Nurse Case Manager-RN.

Experience in special needs/ complex care Nursing Skills in authorizations and appealing Excellence in Case Management Excellent communication and organizational skills Ability to work independently and remotely Experience in working with medically complex and fragile children is a plus Bachelor's degree in Nursing (BSN) and an active RN license CCM

The Nurse Case Manager-RN will be responsible for coordinating and managing patient care, including admissions, discharge planning, utilization management, and case management. Daily tasks will involve assessing patient needs, developing care plans, coordinating with healthcare providers, and ensuring patients receive appropriate medical and nursing care.

IntellaTriage

Remote Hospice Triage RN- PT 2 shift 3:30p-12a + rotating Sat & Sun 7:30-4p

Posted on:

May 5, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

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

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

Molina Healthcare

Manager, Clinical Quality Interventions - RN Required (Remote)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Nebraska

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.

Molina's Quality Improvement function oversees, plans, and implements new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs for members in accordance with prescribed quality standards; conducts data collection, reporting and monitoring for key performance measurement activities; and provides direction and implementation of NCQA accreditation surveys and federal/state QI compliance activities.

KNOWLEDGE/SKILLS/ABILITIES: The Manager, Health Plan Quality Interventions is responsible for developing, implementing, and monitoring the success of quality improvement interventions. The Manager works to coordinate resources and training within the health plan and identify barriers to established goals and timelines. Key activities include implementing, monitoring, and analyzing the effectiveness of a comprehensive intervention strategy; and facilitating stakeholder input and strategic direction from the interventions Joint Operations Committee that includes leadership from multi-functional areas. The Manager serves as the primary contact for health plan interventions and leads the interventions Joint Operations Committee representing the Molina Plan Senior Leadership Team. In all activities, the Manager works with the national and regional collaborative analytics and strategic team to present and evaluate intervention strategies. Required Education: Active, unrestricted RN License. Required Experience: 5+ years' experience in managed healthcare, including at least 2 years in health plan quality improvement or equivalent/related experience. 2+ years' management experience leading a healthcare quality team. Operational knowledge and experience with Excel and Visio (flow chart equivalent). Preferred Education: Master's Degree or higher in a clinical field, Public Health or Healthcare. Preferred Experience: 3+ years' experience with member/ provider (HEDIS) outreach and/or quality intervention or improvement studies (development, implementation, evaluation). Supervisory experience. Project management and team building experience. Experience developing performance measures that support business objectives. Preferred License, Certification, Association Certified Professional in Health Quality (CPHQ) Certified HEDIS Compliance Auditor (CHCA)

Plans and/or implements Quality interventions that meet state and federal intervention rules and are aligned with effective practices as identified in the healthcare quality improvement literature and within Molina plans. Develops and implements targeted interventions related to performance improvement, including member and provider outreach to improve care and service. Serves as operations and implementation lead for Molina Plan quality improvement interventions using a defined roadmap, timeline, and key performance indicators. Collaborates with the national intervention collaborative analytics and strategic teams to deliver proposed interventions for review and evaluation. Communicates with the Molina Plan Senior Leadership Team, including the Plan President, Chief Medical Officer, national intervention collaborative analytics and strategic teams about key deliverables, timelines, barriers, and escalated issues that need immediate attention. Presents concise summaries, key takeaways, and action steps about Molina plan intervention strategy to national, regional and plan meetings. Demonstrates ability to lead and influence cross-functional teams that oversee implementation of quality interventions. Possesses a strong knowledge in quality to implement effective interventions that drive change. Functions as key lead for interventions including qualitative analysis, reporting and development of program materials, templates, or policies. Provides on-going support to manage and maintain the integrity of established programs/processes and member/provider outreach initiatives. Supports provision of high-quality clinical care and services by facilitating/building strategic relationships with health care providers.

CareFirst BlueCross BlueShield

Clinical Advisor - (Registered Nurse) - (Remote)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Must live in MD, DC, VA PURPOSE: The Clinical Advisor's role is multifaceted from data analytics, client facing presentations, and solutions optimization. The Clinical Advisor will extract clinical and relevant data to educate clients, brokers, consultants, and internal stakeholders, showcasing the value of the organization's approach to managing care delivery. The Clinical Advisor will synthesize data and make individualized recommendations related to population health with a goal of improving outcomes and driving down cost in populations. The Clinical Advisor serves as key subject matter expert and strategic partner for the Sales team and will regularly attend onsite and virtual client meetings to review health outcomes and cost information.

QUALIFICATIONS: Education Level: Bachelor's Degree in Nursing, Pharmacy, Psychology, Behavioral Health, Social Work or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience Licenses/Certifications: RN - Registered Nurse - State Licensure And/or Compact State Licensure. Experience: 4 years experience working in a clinical setting. 2 years demonstrated experience with healthcare data analysis. Preferred Qualifications: Graduate degree such as MSN, MBA, MPH. Knowledge of health plan sales or account management. Experience working in a health plan environment in a business role. Knowledge, Skills and Abilities (KSAs): Ability to present onsite and virtually to both small and large audiences. An in-depth knowledge of current and emerging trends in care management. Ability to work closely with and influence people at all levels, including C-suite executives, vice presidents, directors, managers, and associates. Critical thinking and judgment with the ability to connect the dots, put the story together and then deliver to the client in a professional manner. Demonstrated ability to analyze and interpret data. Ability to lead/coordinate projects and function as a resource to other CareFirst departments. Ability to communicate effectively, both verbally and in writing. Ability to present and communicate in group settings in a professional manner. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for extended periods of time. Must be able to meet established deadlines and manage multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Analyzes population health data as well as clinical and financial trends, for existing and prospect customer accounts. Develops business case studies and next generation reports to demonstrate the value of care management and wellness approaches. Makes strategic recommendations for key accounts and their consultants/brokers to retain and grow business. Delivers presentations and demonstrates to external clients, customers and prospects the value proposition and return on investment of assigned solutions. Consults with key stakeholders regarding cost containment and quality improvement for their employee populations. Identifies gaps in care and make referrals to appropriate programs. As a clinical subject matter expert, reviews and analyzes member data to show value of care management programs. Collaborates with internal teams including wellness, pharmacy, and care management. Creates and executes upon a sales strategy for the assigned solutions to help customers meet their clinical goals. Present and demonstrate to external clients, customers and prospects the value proposition and return on investment of assigned solutions in a consultative approach. Consult about how to best control cost and improve quality for their employee populations. Using clinical knowledge, review and analyze member data to show the value of the organizations care management efforts; identify gaps in care and make referrals to appropriate programs.

Providence Service

Hospital at Home Command Center RN *Remote, .6 Day Shift*

Posted on:

May 4, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

Texas

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits.

**Hospital at Home Command Center RN *Remote, . 6 Day Shift Candidates residing in AK, WA, MT, OR, CA, TX or NM are encouraged to apply.** Interested in being on the cutting edge of innovation within nursing? Passionate about caring for patients but no longer want to work in the traditional Hospital setting? Enjoy working in a fast-paced and challenging environment? If so, then come join our team! Hospital At Home is a very dynamic model of care, where appropriate patients transfer to the virtual unit to complete their hospitalization. This program runs like a regular inpatient unit, it just happens to be set up in the patient’s home. The program provides medical equipment, meals, and diagnostics in the home setting. The Field RN will provide the ‘hands on’ care and be part of a team of clinicians which includes Command Center RNs, MDs, plus Field Therapists such as PT and OT. This role is very dynamic as, the Field RN will work closely with their virtual colleagues throughout the day to provide clinical care for our patients. Hospital at Home is a model of care where patients who meet inpatient criteria are clinically managed in their home. Data shows that patients cared for in a Hospital at Home model have better outcomes, higher patient/family satisfaction, fewer complications, and shorter lengths of stay. Staff who care for these patients virtually and in the home also report higher job satisfaction. The Field RN is an integral part of providing the best care possible for a subset of the patient population. The acuity of patients in our program are the same as a standard medical floor. And, while this care model isn’t appropriate for everyone, it is appropriate for those patients who meet specific, established criteria, and are deemed safe and appropriate to be hospitalized in their home versus the traditional setting. Strong candidates will have excellent clinical and communication skills, be comfortable with technology, and a willingness to flex as the day progresses. You will be joining a team of very supportive colleagues! Those hired into this role will be required to obtain nursing licenses for the balance of the states the department supports. Providence nurses are not simply valued – they’re invaluable. You will thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best nurses, we must empower them. Learn why nurses choose to work at Providence by visiting our Nursing Institute page. Join our team at Providence Strategic And Management Services as a Providence caregiver, you’ll apply your specialized training to deliver world-class health with human connection and make a difference every day through your extraordinary care.

Graduation from an accredited nursing program. Registered Nurse License from the state in which you reside, specifically one of our footprint states where we can hire: Texas Registered Nurse License upon hire, Or Washington Registered Nurse License (Vendor Managed) Or Alaska Registered Nurse License (Vendor Managed) Or California Registered Nurse License (Vendor Managed) Or Montana Registered Nurse License (Vendor Managed) Or Oregon Registered Nurse License (Vendor Managed) Or New Mexico Registered Nurse License (Vendor Managed) Or Texas Registered Nurse License (Vendor Managed) 1 year - Nursing experience.

UnitedHealth Group,

Behavioral Health Senior Clinical Admin RN - Remote

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

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

The Senior Clinical Admin Nurse will be responsible for providing individualized attention to UMR membership and covered families and serves to assist with navigation of the health care system. The purpose of the clinical liaison nurse is to help individuals live their lives to the fullest by supporting coordination and collaboration with multiple and external partners including consumers and their families/caregivers, medical, and other clinical teams. You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Hours: Monday – Friday 8:00 am – 5:00 pm.

Required Qualifications: Current and unrestricted RN compact license 2+ years of acute nursing experience 2+ years of behavioral health nursing experience Basic computer proficiency (i.e. MS Word, Outlook) Proven ability to function independently and responsibly with minimal supervision Preferred Qualifications: Bachelor’s degree in nursing CCM 2+ years managed care experience Critical care, pediatric, med-surg and/or telemetry experience Utilization management experience Adverse Determination experience Telecommute experience Soft Skills: Demonstrated excellent verbal and written communication skills Excellent customer service orientation Proven team player and team building skills Ability and flexibility to assume responsibilities and tasks in a constantly changing work environment

Provide members with tools and educational support needed to navigate the health care system and manage their health concerns effectively and cost efficiently Assist members with adverse determinations, including the appeal process Teach members how to navigate UMR internet-based wellness tools and resources Outreach to membership providing pre-admission counseling to membership Outreach to membership providing discharge planning to membership and caretakers Track all activities and provide complete documentation to generate customer reporting Accept referrals via designated processes, collaborate in evaluating available services, and coordinate necessary medical care and community referrals as needed Comply with all policies, procedures and documentation standards in appropriate systems, tracking mechanisms and databases Contribute to treatment plan discussions Other duties as assigned

SSM Health

RN - Clinical Documentation Specialist, First Reviewer | Remote

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Missouri

Must have prior and direct Clinical Documentation experience Job Summary: Performs concurrent analytical reviews of clinical and coding data to improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners. Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.

Preferred Qualifications: CCDS certification Proficiency with MS Office Tool - especially Excel. Prior experience reviewing PSI (patient safety indicator) or experience with Vizient specialized mortality reviews. Required Qualifications: 12 months of experience as a Clinical Documentation Specialist Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS) Two years' in an acute care setting or relevant experience Eligible Remote States Candidates are required to reside on one of SSM's approved States: Alabama, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, and Wisconsin. EDUCATION: Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS) Experience: Two years' in an acute care setting or relevant experience Physical Requirements: Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. Frequent keyboard use/data entry. Occasional bending, stooping, kneeling, squatting, twisting and gripping. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Rare climbing. Required Professional License And/Or Certifications State of Work Location: Illinois Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) Or Physician Assistant in Medicine, Licensed - Illinois Department of Financial and Professional Regulation (IDFPR) Or Physician - Regional MSO Credentialing Or Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Or Advanced Practice Nurse (APN) - Illinois Department of Financial and Professional Regulation (IDFPR) Or APN Controlled Substance - Illinois Department of Financial and Professional Regulation (IDFPR) Or Full Practice Authority APRN Control Substance - Illinois Department of Financial and Professional Regulation (IDFPR) Or Full Practice Authority APRN - Illinois Department of Financial and Professional Regulation (IDFPR) State of Work Location: Missouri Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) Or Physician Assistant - Missouri Division of Professional Registration Or Physician - Regional MSO Credentialing Or Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration Or Nurse Practitioner - Missouri Division of Professional Registration Or Registered Nurse Practitioner - Missouri Division of Professional Registration State of Work Location: Oklahoma Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) Or Acknowledgement of Receipt of Application for Physician Assistant - Oklahoma Medical Board Or Physician Assistant - Oklahoma Medical Board Or Physician - Regional MSO Credentialing Or Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) Or Advanced Practice Registered Nurse (APRN) - Oklahoma Board of Nursing (OBN) Or Certified Family Nurse Practitioner (FNP-C) - American Academy of Nurse Practitioners (AANP) State of Work Location: Wisconsin Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS) Or Physician Assistant - Wisconsin Department of Safety and Professional Services Or Physician - Regional MSO Credentialing Or Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services Or Advanced Practice Nurse Prescriber (APNP) - Wisconsin Department of Safety and Professional Services

Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate diagnosis review group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI). Maintains appropriate productivity level. Conducts follow-up reviews of patients every to support and assign a working or final DRG assignment upon patient discharge, as necessary. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Identifies issues with reporting of diagnostic testing proactively. Enhances expertise in query development, presentation, and standards including understanding of published query guidelines and practice expectations for compliance. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. Attends department meetings to review documentation related issues. Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics. Collaborates with coding to reconcile the DRG and resolves mismatches utilizing the escalation policy. Troubleshoots documentation or communication problems proactively and appropriately escalates. Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurateDRGassignment, SOI, and/or ROM.Assists in the mortality review and risk adjustment process utilizing third-party models. Demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record. Impartsknowledge to providers and other members of the healthcare team. Maintains a level of expertise by attending continuing education programs. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service. Works in a constant state of alertness and safe manner. Performs other duties as assigned.

IntellaTriage

Remote Hospice Triage RN- PT 2 shifts 3:30p-9:30p + rotating Sat & Sun 7:30-4p

Posted on:

May 4, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-9:30p CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

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

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

CVS Health

Case Manager Registered Nurse (Remote)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Florida

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

CVS Health Aetna has an opportunity for a full-time Case Manager, Registered Nurse (RN). Case Managers serve as dedicated advocates for members who are unable to advocate for themselves. In this role, you will assess, plan, implement, and coordinate comprehensive case management activities. Your focus will be to evaluate members’ medical needs and facilitate services that support their overall health and well-being. Schedule: Monday–Friday, 8:00 AM–5:00 PM EST No nights, weekends, or holidays required.

Required Qualifications: Must be a Registered Nurse with an active state license in good standing, valid in the region where duties are performed. Compact RN License or license in multiple states or willing to obtain within 3-6 months. 3–5 years of clinical practice experience. 2–3 years of experience in case management, discharge planning, or home health care coordination. Comfortable working remotely and independently using collaboration tools and virtual communication platforms. Willingness and ability to travel within a designated geographic area for in-person case management activities as needed. Preferred Qualifications: Bilingual proficiency in Arabic, Korean, or Spanish preferred. Compact RN license or licensure in multiple states. Strong analytical and problem-solving skills. Excellent communication, organizational, and interpersonal skills. Self-motivated and able to work independently. Proficient in navigating multiple systems and applications; skilled in typing and keyboard use. Familiarity with corporate software tools such as Microsoft Word, Excel, Outlook, PowerPoint, and proprietary applications. New Education: Associate’s Degree in Nursing. BSN preferred.

Conduct comprehensive assessments of members’ physical, emotional, and social needs. Develop and implement individualized care plans based on clinical findings and member goals. Coordinate services across healthcare providers, specialists, and community resources. Monitor and evaluate care plans regularly, adjusting as needed to improve outcomes. Advocate for timely and appropriate healthcare services to support member well-being. Document case activities, interventions, and communications accurately and in compliance with regulatory requirements. Collaborate with interdisciplinary teams to ensure continuity of care. Participate in team meetings, training sessions, and quality improvement initiatives. Travel locally for in-person case management activities, as directed by leadership or business needs.

CareHarmony

Remote - Licensed Practical Nurse (LPN) - Intake Coordinator

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

License:

LPN/LVN

State License:

Virginia

CareHarmony’s Care Coordinators (LPN) (NLC) (LVN) work comprehensively with providers to deliver value-based care management initiatives for their patients CareHarmony is seeking an experienced Licensed Practical Nurse – LPN Nurse (LPN) (NLC) (LVN) with at least 3 years of direct patient-facing work experience; that thrives in a fast-paced environment, is self-motivated, has impeccable attention to detail, and values the impact they can have on a patient’s healthcare journey. You will have experience identifying resources and coordinating needs for chronic care management patients. What's in it for you? Fully remote position - Work from the comfort of your own home in cozy clothes without a commute. Score! Consistent schedule - Full-Time Monday – Friday, no weekends, rotational on-call-once per year on average. Flexible hours - Have an appointment you need to attend? We will work with you to make up the hours at another time. Career growth - Many of our team members move up in the company at a faster-than-average rate. We love to see our people succeed!

Additional Requirements: Active Washington D.C. License & active Compact/Multistate License (LPN) Technical aptitude – Microsoft Office Suite Excellent written and verbal communication skills Plusses: Epic Experience Bilingual Additional state licensures (LPN) 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.

CVS Health

Utilization Management Nurse Consultant (Weekends - CST)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Florida

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

Hours of operation/Work schedule Friday/Saturday/Sunday/Monday 10 hour shifts. First 6 months of training will be M-F 8-5 CST.

Required Qualifications: Registered Nurse in state of residence. 3+ years of Nursing experience. Preferred Qualifications: Prior authorization utilization management/review experience preferred Outpatient Clinical experience. Knowledge of Medicare/Medicaid Managed care experience Education: Associates Degree in Nursing BSN preferred

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Molina Healthcare

Sr. Specialist, Provider Engagement (RN Preferred / Remote)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Mississippi

Remote and must live in Mississippi Job Summary: The Sr Specialist, Provider Engagement role implements Health Plan provider engagement strategy to achieve positive quality and risk adjustment outcomes through effective provider engagement activities. Ensures the core set of Tier 2 providers in the Health Plan have engagement plans to meet annual quality and risk adjustment goals. Drives coaching and collaboration with providers to improve performance through regular meetings and action plans. Addresses practice environment challenges to achieve program goals and improve health outcomes. Tracks engagement activities using standard tools, facilitates data exchanges, and supports training and problem resolution for the Provider Engagement team. Communicates effectively with healthcare professionals and maintains compliance with policies.

Bachelor's degree in Business, Healthcare, Nursing or related field or equivalent combination of education and relevant experience Min 3 years experience experience improving provider Quality performance through provider engagement, practice transformation, managed care quality improvement, or equivalent experience. Experience with various managed healthcare provider compensation methodologies including but not limited to: fee-for service, value-based care, and capitation Strong working knowledge of Quality metrics and risk adjustment practices across all business lines Demonstrates data analytic skills Operational knowledge and experience with PowerPoint, Excel, Visio Effective communication skills Strong leadership skills Preferred Qualifications: Min 3 years experience improving Quality performance for Medicaid, Medicare, and/or ACA Marketplace programs To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Ensures assigned Tier 2 & Tier 3 providers have a Provider Engagement plan to meet annual quality & risk adjustment performance goals. Drives provider partner coaching and collaboration to improve quality performance and risk adjustment accuracy through consistent provider meetings, action item development and execution. Addresses challenges/barriers in the practice environment impeding successful attainment of program goals and understands solutions required to improve health outcomes. Drives provider participation in Molina risk adjustment and quality efforts (e.g. Supplemental data, EMR connection, Clinical Profiles programs) and use of the Molina Provider Collaboration Portal. Tracks all engagement and training activities using standard Molina Provider Engagement tools to measure effectiveness both within and across Molina Health Plans. Serves as a Provider Engagement subject matter expert; works collaboratively within the Health Plan and with shared service partners to ensure alignment to business goals. Assist Provider Engagement Specialists with training and problem escalation. Accountable for use of standard Molina Provider Engagement reports and training materials. Facilitates connectivity to internal partners to support appropriate data exchanges, documentation education and patient engagement activities. Develops, organizes, analyzes, documents and implements processes and procedures as prescribed by Plan and Corporate policies. Communicates comfortably and effectively with Physician Leaders, Providers, Practice Managers, Medical Assistants within assigned provider practices. Maintains the highest level of compliance. This position may require same day out of office travel approximately 0 - 80% of the time, depending upon location.

Aarorn Technologies Inc

REMOTE F/T OVERNIGHT RN TELEPHONE TRIAGE (NYS LICENSED)

Posted on:

May 4, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

New York

MUST LIVE WITHIN A 2 HOUR DRIVE TO THE WNY AREA**** We are looking for qualified Registered Nurse's to join our team. We are a fully remote 24-hour triage center where we receive incoming calls for our clients/individuals in need of immediate medical attention. We provide assessment, guidance, and disposition to the appropriate level of care. We work closely with our team of RN's and providers to determine Right Care, Right Place and Right Time disposition, which may be care instructions, tele medicine visit with a provider or advise, Urgent Care, ER or 911 level of care required MUST BE WITHIN A 2 HOUR DRIVE TO THE WNY AREA**** Rotating (4) 10 hour shifts with 3-12's including rotating weekends, premium shift differential. Salary range: $68,000-$71,500 (excellent medical benefits package and more)

New York State Registered Nurse Licensure Only Unrestricted New York State Licensed RN with a minimum of two years of experience as a clinical hospital nurse in an emergency room, critical care or med/surg, OR a minimum of two years’ experience in RN telephone triage in a primary care setting required AAS in Nursing, Bachelor’s Degree in Nursing or related fields preferred, not required Knowledge of OPWDD regulations recommended, not required Previous Chronic Care Management / Case Management required Previous Chronic Disease Management and Education required Current CPR/BLS required Current Infection Control Certificate required Must be proficient with advanced computer technology and in using multiple computer applications and internet at one time

Receives incoming calls from contracted clients Assess patient's current health status and recommends appropriate level of care based on clinical judgment, evidenced based guidelines and clinical protocols Develops plan(s) of nursing service appropriate to the patients’ health care needs Demonstrates knowledge of medications. Telephone communication skills with appropriate phone etiquette necessary Must have the ability to make critical independent decisions and prioritize appropriately. Document all calls and actions taken into the patient’s medical record Utilizes technology as appropriate to meet the requirements of the job functions. Communicates to the health care team members the outcome of the assessment/reassessment to ensure appropriate follow up occurs based on the needs of the patient care. Displays an exemplary level of patience, courtesy, and flexibility. Interacts with patients, physicians, and staff in a manner conducive to maintain positive relationships and to meet the goals and objectives of the agency. Adheres to ethical, legal/regulatory and accreditation standards Assumes responsibility for his/her own education, using formal and informal resources that contribute to professional self‐growth. Consult with administrator for issues or requested services outside scope of practice or requiring assistance in performing Must be detail oriented and able to multitask Performs other duties as assigned

Inizio Engage

Remote RN- Call Center Experience Only

Posted on:

May 3, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Pennsylvania

Inizio Engage is a strategic, commercial, and creative engagement partner specializing in healthcare. Our passionate, global workforce combines local expertise with a diverse mix of skills, data, science, and technology to deliver bespoke engagement solutions. Our mission is to help healthcare professionals and patients get the medicines, knowledge, and support they need to improve treatment outcomes. We believe in our values: We empower everyone We rise to the challenge We work as one We ask what if We do the right thing To learn more about Inizio Engage, visit us at: https://inizio.health/

In this position, you’ll be able to leverage your healthcare knowledge and skills in a supportive, non-clinical setting. This role is remote, meaning you'll need to be self-motivated and comfortable working independently without the typical face-to-face interactions of clinical settings. The primary focus of this role is to deliver inbound or outbound telephonic educational support to identified patients, caregivers, Healthcare Professionals, and their staff within primary care or specialist facilities. The goal is to support education and engagement related to a designated disease state, meeting all relevant standards as set by the company and Clinical Manager.

Current US healthcare professional license (RN) Associate’s Degree/Bachelor’s/BSN or equivalent work-related experience 3+ years’ experience working in a specific disease state or related field (preferred) Effective communication skills with a strong focus on outbound calling and follow-up Ability to manage multiple calls and priorities simultaneously with minimal disruption Proficiency with call center telephone technology Organizational skills to track and document interactions and follow-up activities A self-starter attitude with high personal motivation to achieve goals and meet objectives Evidence of ongoing professional development and commitment to lifelong learning

Conducting outbound calls to provide non-promotional disease-state-related educational support to identified customers as directed by the client company Providing outbound/inbound support for therapy and/or medical device product education, including but not limited to supplemental injection/infusion/inhalation training support or technique Proactively reaching out to Healthcare Professionals/Patients/Caregivers to present virtual educational programs in accordance with client procedures Conducting outbound medication adherence support to patients and caregivers, ensuring consistent follow-ups to support positive health outcomes Scheduling and enrolling patients and caregivers into educational seminars or providing resources to assist them with finding local community resources or centers of care for their specialty or primary care disease Collecting and managing demographic data and disposition for product, sample, reimbursement services, and literature fulfillment Maintaining high standards of customer service by adhering to program talking points or scripts and leveraging live video conferencing software as applicable Ensuring compliance by using only approved materials provided by Inizio or by the client, without changes, copying, or distribution Participating in training by attending and completing all required courses and competency assessments, maintaining a high standard of performance Building and nurturing relationships with key customers, acting as a trusted resource for disease-related education Collaborating across healthcare sectors to develop and provision services that benefit customers and support the client’s goals Driving innovation by considering new approaches that could create new partnership opportunities Completing administrative responsibilities such as daily computer updates, weekly activity summaries, emails, and time reporting in a timely and accurate manner Maintaining equipment and materials according to company standards and instructions Adhering to all policies and procedures set by Inizio and the client, ensuring compliance at all times

IntellaTriage

Remote Hospice Triage RN- PT 2 shifts 3:30p-8:30p rotating Sat & Sun 7:30-4p

Posted on:

May 3, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-8:30p CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

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

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

Synergy Healthcare USA, LLC

Nurse Advocate - Greater Charlotte Area

Posted on:

May 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

North Carolina

We are seeking an experienced Case Manager to join our growing team and serve as a Nurse Advocate for our new clients and their employees. The ideal candidate will be located in the greater Charlotte area, with the ability to travel on occasion to visit clients in NC/SC. He/she will have a thorough understanding of the healthcare system, and will be responsible for providing guidance and support to members in navigating the complex healthcare landscape. As a dedicated Nurse Advocate, you will be responsible for resolving a myriad of issues for their members and allow you the flexibility to “think outside the box”. With your clinical experience and background, you will help members better understand their health status and available treatment options. You will have a unique opportunity to develop valued relationships with members and executive teams with your specific employer clients. This opportunity allows for remote work so can be flexible on location. Minimal travel within the States of NC/SC for periodic client visits (open enrollment meeting, annual activity reviews etc) may be required. Most if not all work will be done virtually out of the convenience of your own home office. The key to your success will rely on your ability to cultivate trusted relationships with stakeholders, members, and their families. Our growing Synergy team is passionate about delivering an exceptional healthcare experience that is personal, data driven, and value based to help every person live their healthiest life.

Active nursing license with a Bachelor of Science in Nursing (BSN) degree preferred. Minimum of 3 years of experience as a nurse case manager or in a related healthcare field. CCM certification or CCM eligible. Commit to CCM exam within the first year. In-depth knowledge of the healthcare and insurance systems. Strong analytical and problem-solving skills with the ability to identify and resolve complex healthcare issues. Excellent communication and interpersonal skills with the ability to interact effectively with employees and healthcare professionals. Ability to work remotely, independently, and as part of a team in a fast-paced, dynamic environment. Strong organizational skills with the ability to manage multiple tasks and priorities simultaneously. Proficient in the use of electronic health records (EHRs), Outlook, Excel, and other healthcare-related software.

Serve as the primary point of contact for members seeking assistance with navigating the healthcare system. Work with members to identify their healthcare needs and provide clinical support. Liaison with TPAs and insurance companies to resolve claim and billing issues. Educate members on their healthcare benefits and how to effectively utilize them. Advocate for members so they can receive improved healthcare outcomes, including referrals to specialists and timely access to care. Collaborate with other healthcare professionals, including physicians and nurses to ensure seamless coordination of care. Monitor member health status and progress towards achieving their healthcare goals. Maintain accurate and up-to-date records of member interactions and healthcare interventions. Client facing reporting with the potential for limited travel to client worksites. Health Risk Assessment review to encourage lifestyle modification and improve overall wellness.

Humana

SNF Utilization Management RN

Posted on:

May 3, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

The Utilization Management Nurse utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Compact licensure Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action. 2-3 years Skilled nursing facility experience and /or skilled nursing facility utilization management review experience. Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting Comprehensive knowledge of Microsoft Word, Outlook and Excel Ability to work independently under general instructions and with a team Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 25 x10 (25mbs download x 10mbs upload) is required Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications: Education: BSN or Bachelor's degree in a related field Health Plan experience Previous Medicare/Medicaid Experience a plus Bilingual is a plus Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

The SNF Utilization Management Nurse uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Conifer Health Solutions

Healthcare Appeals Clinician RN - Remote $10K sign on bonus

Posted on:

May 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost, and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

The Revenue Cycle Clinician for the Appellate Solution is responsible for: Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review Preparing and documenting appeal based on industry accepted criteria.

KNOWLEDGE, SKILLS, ABILITIES: 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. Demonstrates proficiency in the application of medical necessity criteria, currently InterQual® Possesses excellent written, verbal and professional letter writing skills Critical thinker, able to make decisions regarding medical necessity independently Ability to interact intelligently and professionally with other clinical and non-clinical partners Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms Ability to multi-task Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process. Ability to conduct research regarding off-label use of medications. Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings. EDUCATION / EXPERIENCE: Include minimum education, technical training, and/or experience required to perform the job. Must possess a valid RN nursing license (Registered Nurse) Minimum of 3 years acute care experience in a facility environment Medical-surgical/critical care experience preferred Minimum of 2 years UR/Case Management preferred Managed care payor experience a plus either in Utilization Review, Case Management or Appeals Patient Accounting experience a plus Previous classroom led instruction on InterQual® or MCG products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred CERTIFICATES, LICENSES, REGISTRATIONS: Current, valid RN licensure Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to lift 15-20lbs Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sites Ability to sit and work at a computer for a prolonged period of time conducting medical necessity reviews WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc. OTHER: May require travel – approximately 10% Interaction with facility Case Management, Physician Advisor is a requirement.

Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review. Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual® or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization. Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process. Adheres to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines. Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office. Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc. Additional responsibilities: Serves as a resource to non-clinical personnel. Provides CRC leadership with sound solutions related to process improvement Assist in development of policy and procedures as business needs dictate. Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.

CorVel Corporation

CA UR Case Manager II

Posted on:

May 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

CorVel, a certified Great Place to Work® Company, is a national provider of industry-leading risk management solutions for the workers’ compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 4,000 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

The Utilization Review Case Manager gathers demographic and clinical information on prospective, concurrent and retrospective in-patient admissions and out-patient treatment, certifies the medical necessity and assigns an appropriate length of stay; supporting the goals of the Case Management department, and of CorVel. This is a remote position.

KNOWLEDGE & SKILLS: Must have a thorough knowledge of both CPT and ICD coding. Effective multi-tasking skills in a high-volume, fast-paced, team-oriented environment. Ability to interface with claims staff, attorneys, physicians and their representatives, and advisors/clients and coworkers. Ability to promote and market utilization review products with attorneys and claims staff. Strong ability to negotiate provider fees effectively. Excellent written and verbal communication skills. Ability to meet designated deadlines Computer proficiency and technical aptitude with the ability to utilize MS Office including Excel spreadsheets Strong interpersonal, time management and organizational skills. Ability to work both independently and within a team environment. EDUCATION/EXPERIENCE: Graduate of accredited school of nursing with a diploma/Associates degree (Bachelor of Science degree or Bachelor of Science in Nursing preferred) Current Nursing licensure in the state of operation required. RN is required unless local state regulations permit LVN/LPN. 4 or more years of recent clinical experience. Previous experience in the following areas, preferred: Prospective, concurrent and retrospective utilization review Experience in the clinical areas of O.R., I.C.U., C.C.U., E.R., orthopedics Knowledge of the workers’ compensation claims process Outpatient utilization review

Identifies the necessity of the review process and communicates any specific issues of concern to the appropriate claims staff/customer. Collects data and analyzes information to make decisions regarding certification or denial of treatment. Documenting all work in the appropriate manner. Requires regular and consistent attendance. Complies with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP). Additional duties as required.

CorVel Corporation

Itemization Review Nurse II

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Texas

CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

The Itemization Review Manager is responsible for the overall aspects of the medical review team including personnel hiring, quality assurance of product, workflow, maintaining the tracking of and accountability of staff regarding production standards and turn-around expectations. This is a remote position.

KNOWLEDGE & SKILLS: Understanding of audit guidelines including CMS and payor policies Extreme attention to detail Must possess problem solving, critical thinking skills Must be team oriented Effective and professional communication skills, both verbal and written Ability to act in a professional manner with both internal and external customers Ability to think and work independently Ability to work in a fast-paced production environment Proficient in Microsoft Office Suite EDUCATION & EXPERIENCE: Associate degree and current RN license required. Bachelor’s or master’s degree in nursing or other healthcare related field preferred Previous supervisory experience required Previous nurse audit or payment integrity experience preferred

Responsible for managing the daily file flow coming into Medical Review while maintaining awareness of potential file flow from other departments to track rush or special files, test files, pilot studies for prospective clients Writing performance evaluations for direct report staff on annual basis as per CorVel/CERIS guidelines Responsible for meeting client specific turnaround times and metrics Responsible for quality of review results and an error rate of less than 2% on all completed files per month Responsible for human resources matters directly related to department staff under direct supervision including documentation of events or occurrences and verbal counseling direct report staff when attendance or performance deficiencies are discovered Requires regular and consistent attendance and the tracking of attendance of staff under direct supervision, in addition to ensuring adequate staffing levels to meet business needs and productivity standards Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP) Responsible for implementing new procedures/protocols as necessary Responsible for identifying process improvement opportunities and reporting these to the director of audit Responsible for maintaining and updating department protocol library Responsible for monitoring various reports daily to ensure productivity metrics and client goals are met Assist with additional projects as requested Participate in provider and client calls as needed Participate in leadership calls as needed May be required to travel overnight to attend meetings and/or training Additional duties as assigned by director of audit and/or SVP of operations

Green Key Resources

Nurse Case Manager

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Serve as a team member on a multidisciplinary team, coordinating care, resources and/or services for members to achieve optimal clinical and resource outcomes.

RN with 3 years of clinical and/or case management experience required. Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties. For some roles, additional specialty certification (i.e. CCM, CDCES) may be required. If so, incumbents must obtain relevant certification within 2 years of employment.

Utilize applicable clinical skillset and perform comprehensive assessments to determine how to best collaborate with members, family, internal partners and external services/providers on plans for treatment, appropriate intervention and/or discharge planning. Develop a member-centric plan tailored to members’ needs, health status, educational status and level of support needs; identify barriers to meeting goals or plan of care Utilize community resources and funding sources as needed in the development of the plan of care. Perform ongoing monitoring and management of member which may include scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation, assessment of progress towards goals, modification of plan/goals as needed, with contact frequency appropriate to member acuity. Evaluate and facilitate care provided to members through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care, etc). Educate members and encourage pro-active intervention to limit expense and encourage positive outcomes Effectively document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome. May outreach directly to members identified as high risk, high cost, or high utilization cases. May review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options, where eligible. May evaluate medical necessity and appropriateness of services as defined by department. As needed, develop relevant policies/procedures, education or training for use both internally and externally.

Optimize Health

Care Navigator- LPN/LVN - Remote - EST Time Zone - CT, MA, or NY AND Compact License Required

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

At Optimize Health, we believe that it's time to rethink brick-and-mortar-only healthcare visits. With our powerful combination of the leading platform technology, patient-friendly devices, and trusted support, we are pioneering how medical groups use technology and real-time data to treat patients' health outside the practice walls. As the most trusted and experienced remote care vendor in the industry, we simplify the complexities of delivering effective, high-quality remote patient monitoring and optimize our clients’ clinical and financial performance.

As a care team member, you love building relationships with patients based on trust, utilizing motivational communication techniques , to help drive positive health behavior change and improved patient outcomes. This program is based around triaging vital signs and using this data to promote positive lifestyle and health behavior changes. This is accomplished through collaboration with the patients care team to provide wellness calls with patients to outline patient-centric goals and the development of associated action plans to improve their health and well-being. Our ideal candidate has clinical background working with the adult and geriatric patient population ideally with experience in phone triage. Has a strong working knowledge of remote-patient monitoring (RPM) preferred and/or Chronic Care Management (CCM), Behavioral Health, Care Coordination or Utilization Management principles. Experienced in remote working technologies, being a strong team player and a desire to clinically and emotionally support our patients while keeping a keen eye on reimbursement requirements are valued in this role. Being a Care Team Member at Optimize Health provides the chance to serve patients by proactively monitoring vital signs, educating, and coaching patients on a plan for better health. Early intervention through RPM, reduces risk for emergent care and/or hospital admission/re-admissions. Encounters with patients will be performed via phone through a Remote Care Platform that receives electronically transmitted physiological markers like blood pressure/weight/blood glucose . The care team member will perform monitoring as well as synchronous and asynchronous communication with the patient within Optimize Health’s industry-leading platform.

Unrestricted LPN/LVN license in a compact state and CT, MA, or NY Ability to work EST zone between 8:00a - 5:00pm Spanish speaking a plus 1-3 years of clinical experience, patient management, or disease management desired Experience working with different provider practices and workflows Fast learners Ability to work independently with minimal direction Experience with Medicare patients Experience performing virtual visits with patients and telephonic care management Interest in professional leadership growth and development opportunities with a growing organization Interest in operating in a new, exciting clinical program and become an integral player in the development of processes and best practices in caring for RPM patients Motivational Interviewing/Health Behavior Change experience a plus Health Coach certification a plus.

Manage physiological markers like blood pressure/weight/blood glucose with clinical appropriateness Meet team goals and standards outlined metrics Significantly impact longitudinal patient engagement in RPM program(s) Provide preventive health and disease management education and coaching Perform monthly wellness calls with assigned patients Lead collaborative wellness calls with the patients to define health goals outlined by their Care Team Manage patient messaging and alerts Direct patients to treating physician for routine questions Meet patient engagement program goals Follow appropriate escalation pathways for any urgent care needs

Optimize Health

Care Navigator - LPN/LVN - Remote - CST Time Zone

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

At Optimize Health, we believe that it's time to rethink brick-and-mortar-only healthcare visits. With our powerful combination of the leading platform technology, patient-friendly devices, and trusted support, we are pioneering how medical groups use technology and real-time data to treat patients' health outside the practice walls. As the most trusted and experienced remote care vendor in the industry, we simplify the complexities of delivering effective, high-quality remote patient monitoring and optimize our clients’ clinical and financial performance.

As a care team member, you love building relationships with patients based on trust, utilizing motivational communication techniques , to help drive positive health behavior change and improved patient outcomes. This program is based around triaging vital signs and using this data to promote positive lifestyle and health behavior changes. This is accomplished through collaboration with the patients care team to provide wellness calls with patients to outline patient-centric goals and the development of associated action plans to improve their health and well-being. Our ideal candidate has clinical background working with the adult and geriatric patient population ideally with experience in phone triage. Has a strong working knowledge of remote-patient monitoring (RPM) preferred and/or Chronic Care Management (CCM), Behavioral Health, Care Coordination or Utilization Management principles. Experienced in remote working technologies, being a strong team player and a desire to clinically and emotionally support our patients while keeping a keen eye on reimbursement requirements are valued in this role. Being a Care Team Member at Optimize Health provides the chance to serve patients by proactively monitoring vital signs, educating, and coaching patients on a plan for better health. Early intervention through RPM, reduces risk for emergent care and/or hospital admission/re-admissions. Encounters with patients will be performed via phone through a Remote Care Platform that receives electronically transmitted physiological markers like blood pressure/weight/blood glucose . The care team member will perform monitoring as well as synchronous and asynchronous communication with the patient within Optimize Health’s industry-leading platform.

Unrestricted LPN/LVN license in a compact state and IL Ability to work CST zone between 8:00a - 5:00pm Spanish speaking a plus 1-3 years of clinical experience, patient management, or disease management desired Experience working with different provider practices and workflows Fast learners Ability to work independently with minimal direction Experience with Medicare patients Experience performing virtual visits with patients and telephonic care management Interest in professional leadership growth and development opportunities with a growing organization Interest in operating in a new, exciting clinical program and become an integral player in the development of processes and best practices in caring for RPM patients Motivational Interviewing/Health Behavior Change experience a plus Health Coach certification a plus.

Manage physiological markers like blood pressure/weight/blood glucose with clinical appropriateness Meet team goals and standards outlined metrics Significantly impact longitudinal patient engagement in RPM program(s) Provide preventive health and disease management education and coaching Perform monthly wellness calls with assigned patients Lead collaborative wellness calls with the patients to define health goals outlined by their Care Team Manage patient messaging and alerts Direct patients to treating physician for routine questions Meet patient engagement program goals Follow appropriate escalation pathways for any urgent care needs

Optimize Health

Care Team Member - LPN/LVN - Remote - PST Time Zone (Compact licensed + CA, OR, or NV required)

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Compact / Multi-State

At Optimize Health, we believe that it's time to rethink brick-and-mortar-only healthcare visits. With our powerful combination of the leading platform technology, patient-friendly devices, and trusted support, we are pioneering how medical groups use technology and real-time data to treat patients' health outside the practice walls. As the most trusted and experienced remote care vendor in the industry, we simplify the complexities of delivering effective, high-quality remote patient monitoring and optimize our clients’ clinical and financial performance.

As a care team member, you love building relationships with patients based on trust, utilizing motivational communication techniques , to help drive positive health behavior change and improved patient outcomes. This program is based around triaging vital signs and using this data to promote positive lifestyle and health behavior changes. This is accomplished through collaboration with the patients care team to provide wellness calls with patients to outline patient-centric goals and the development of associated action plans to improve their health and well-being. Our ideal candidate has clinical background working with the adult and geriatric patient population ideally with experience in phone triage. Has a strong working knowledge of remote-patient monitoring (RPM) preferred and/or Chronic Care Management (CCM), Behavioral Health, Care Coordination or Utilization Management principles. Experienced in remote working technologies, being a strong team player and a desire to clinically and emotionally support our patients while keeping a keen eye on reimbursement requirements are valued in this role. Being a Care Team Member at Optimize Health provides the chance to serve patients by proactively monitoring vital signs, educating, and coaching patients on a plan for better health. Early intervention through RPM, reduces risk for emergent care and/or hospital admission/re-admissions. Encounters with patients will be performed via phone through a Remote Care Platform that receives electronically transmitted physiological markers like blood pressure/weight/blood glucose . The care team member will perform monitoring as well as synchronous and asynchronous communication with the patient within Optimize Health’s industry-leading platform.

Unrestricted LPN/LVN license in a compact state Unrestricted LPN/LVN license in CA, NV, or OR Ability to work PST zone between 8:00a - 5:00pm Spanish speaking preferred 1-3 years of clinical experience, patient management, or disease management desired Experience working with different provider practices and workflows Fast learners Ability to work independently with minimal direction Experience with Medicare patients Experience performing virtual visits with patients and telephonic care management Interest in professional leadership growth and development opportunities with a growing organization Interest in operating in a new, exciting clinical program and become an integral player in the development of processes and best practices in caring for RPM patients Motivational Interviewing/Health Behavior Change experience a plus Health Coach certification a plus.

Manage physiological markers like blood pressure/weight/blood glucose with clinical appropriateness Meet team goals and standards outlined metrics Significantly impact longitudinal patient engagement in RPM program(s) Provide preventive health and disease management education and coaching Perform monthly wellness calls with assigned patients Lead collaborative wellness calls with the patients to define health goals outlined by their Care Team Manage patient messaging and alerts Direct patients to treating physician for routine questions Meet patient engagement program goals Follow appropriate escalation pathways for any urgent care needs

Actalent

Chronic Care Management LPN

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Alabama

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

Chronic Care Manager - Remote Opportunity We are actively seeking multiple Chronic Care Managers to join our team and support our clients from the comfort of your home. This role offers a competitive pay rate and a flexible schedule, making it an excellent opportunity for those who value work-life balance. Job Description: Our Chronic Care Management (CCM) program is dedicated to delivering the highest quality of care to our patients.

Essential Skills: Licensed Practical Nurse (LPN) certification. Proficiency in Microsoft Outlook and Excel. Familiarity with documentation in Electronic Medical Records (EMRs). Ability to work independently and self-motivated in a remote environment. Work Environment: This position is 100% remote. Employees must have a high-speed internet connection and be comfortable taking a typing test.

Conduct initial risk assessments by gathering clinical elements necessary for patient-specific Care Plans. Collaborate with patients to plan and monitor their care as determined by the PCP. Promote compliance with PCP/Specialist office visits and medication regimens. Serve as a patient advocate, liaison, and information resource. Provide chronic care education for chronic/complex conditions as needed.

CareHarmony

Remote - Bilingual - Spanish + English - Licensed Practical Nurse - LPN - LVN

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

License:

LPN/LVN

State License:

Compact / Multi-State

CareHarmony’s Care Coordinators (LPN) (LVN) work comprehensively with providers to deliver value-based care management initiatives for their patients. CareHarmony is seeking an experienced Licensed Practical Nurse to work 100% Remote – LPN Nurse (LPN) (LVN) with at least 3 years of direct patient-facing work experience; that thrives in a fast-paced environment, is self-motivated, has impeccable attention to detail, and values the impact they can have on a patient’s healthcare journey. You will have experience identifying resources and coordinating needs for chronic care management patients. What's in it for you? Fully remote position - Work from the comfort of your own home in cozy clothes without a commute. Score! Consistent schedule - Full-Time Monday – Friday, no weekends, rotational on-call-once per year on average. Career growth - Many of our team members move up in the company at a faster-than-average rate. We love to see our people succeed!

Additional Requirements: Active Multi-State/Compact License (LPN) (NCL) (LVN) Technical aptitude – Microsoft Office Suite Excellent written and verbal communication skills Plusses: Epic Experience Bilingual Additional single state licensures (LPN) 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.

Atrium Health Wake Forest Baptist

Telephone Nurse Triage

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

North Carolina

Wake Forest University School of Medicine (WFUSM) is a U.S. News and World Report top 50 ranked medical school, integrated with a world-class health system, Atrium Health. WFUSM, the academic core of Atrium Health Enterprise, is a recognized leader in experiential medical education and groundbreaking research that includes Wake Forest Innovations, a commercialization enterprise focused on advancing health care through new medical technologies and biomedical discovery. WFUSM, has over $300M in annual, extramural funding that drives a cutting-edge Academic Learning Health System by integrating innovative research with excellent patient care across our enterprise. Atrium Health Wake Forest Baptist is based in Winston-Salem, North Carolina and is part of Advocate Health, which is headquartered in Charlotte, North Carolina, and is the fifth-largest nonprofit health system in the United States, created from the combination of Atrium Health and Advocate Aurora Health. AHWFB is an 885-bed tertiary-care hospital in Winston-Salem – that includes Brenner Children’s Hospital, five community hospitals, more than 300 primary and specialty care locations and more than 2,700 physicians. Our highly integrated academic and clinical environment is deeply committed to improving health, elevating hope, and advancing healing – for all. It should be noted that while you are applying on the Wake Forest University School of Medicine Career Site, you will receive communications from the Atrium Health Recruitment Team. Please know that this is an expected process. Thanks in advance for your flexibility.

Job Title: Telephone Nurse Triage Shift: 10am-10pm, 3 days per week JOB SUMMARY: Independently plans and provides professional nursing care for patients within a specific population and in accordance with the medical and nursing plans of care and established policies and procedures. Delivers, manages, and coordinates care and services via telecommunications technology within the domain of Ambulatory Care Nursing. Provides nursing services to patients and families in accordance with the scope of the RN as defined by the North Carolina Board of Nursing. Directs and leads other assigned team members and collaborates with multidisciplinary team members to provide age/developmentally appropriate care in accordance with nursing standards of care and practice.

EDUCATION/EXPERIENCE: Graduation from an accredited School of Nursing with two years of acute care experience required. BSN preferred. Prefer acute care experience within the last 10 years. Previous experience in Telephone Triage and with Health Insurance and Managed Care concepts preferred. LICENSURE, CERTIFICATION, and/or REGISTRATION: Current license as a Registered Nurse (RN) in the State of North Carolina and Basic Cardiac Life Support (BCLS) certification required. Licensure in other states as required by law or client contract. Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) or Pediatric Emergency Assessment, Recognition and Stabilization (PEARS) may be required within one year in select areas. SKILLS/QUALIFICATIONS: Ability to assess nursing needs of acute and chronically ill patients through technology methods Ability to seek out resources independently and work collaboratively Ability to establish and maintain effective working relationships Ability to communicate clearly with patients, families, visitors, healthcare team, physicians, administrators, leadership and others Ability to teach patients and families in accordance with the nursing plan of care Ability to use the computer and learn new software programs Ability to document and communicate pertinent information using computer and/or paper documentation tools WORK ENVIRONMENT: Typical clinic setting PHYSICAL REQUIREMENTS: 0% 35% 65% to to to 35% 65% 100% N/A Activity X Standing X Walking X Sitting X Bending X Reaching with arms X Finger and hand dexterity X Talking X Hearing X Seeing Lifting, carrying, pushing and or pulling: X 20 lbs. maximum X 50 lbs. maximum X 100 lbs. maximum

Provides patient/family centered care, acting as partner and adviser assists and supports patients and families to manage optimally their health care, respecting their culture and values, individual needs, health goals and treatment preferences. Applies critical reasoning and astute clinical judgment in order to expedite appropriate care and treatment, especially given that the patient may present with complex problems or potentially life threatening conditions that the nurse will assess through use of telecommunication technologies i.e. telephone, fax, email, internet, or patient portal technology. Ensures proper scheduling and follow up on test results for providers. Uses active listening skills, approved protocols, and evidence based practice in explaining test results and medications to patients. Applies the provisions of the American Nurses Association Code of Ethics for Nurses to professional obligations and for the patients entrusted to their care. Participates in own professional development by maintaining required competencies, identifying learning needs and seeking appropriate assistance or educational offerings. Demonstrates the ability to function in a professional setting through active participation in a professional practice model. Includes participating in shared governance, adherence to standards of care, participation in peer review and professional development promoting leadership and clinical excellence, effective team skills, autonomous practice and acknowledgment of accountability for actions and critical thinking. Pursues lifelong learning that updates and expands clinical, organizational, professional roles and responsibilities. Focuses on patient safety and the quality of nursing care by applying appropriate nursing interventions, such as identifying and clarifying patient needs, conducting health education, promoting patient advocacy, coordinating nursing and other health services, assisting the patient to navigate the health care system, and evaluating patient outcomes. Maintains knowledge of care teams for coordination of patient care, self-management, population management and communication skill. Adapts personal communication style to meet the needs of the patient in diverse personal, professional, cultural, and socio-economic backgrounds. Demonstrates exceptional assessment, critical thinking, and customer service skills. Performs other related duties incidental to the work described herein.

Evolent

Manager, Appeals and Grievances

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Virginia

Your Future Evolves Here Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing: The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and procedures while complying with timeliness guidelines. Our team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes for the Clients and Members we serve. Collaboration Opportunities: The manager collaborates both internally and externally on the Team. They interact with the Director for guidance, policy updates, new Client Implementations, and much more. The also guide the Lead Coordinators for team daily oversight assistance and support on all tasks including triage/assignments/case review questions; and Coordinators for overall management, monitoring for trends and review of metrics. The Appeals teamwork strategies and opportunities for collaboration include all-team and individual team meetings, Teams chats, and monthly communication on team metrics and accomplishments.

Management experience in a Health Care Setting, preferably Utilization Management is required. Minimum of 5 years in Utilization Management, health care Appeals, compliance and/or grievances/complaints in a quality improvement environment is required. Strong verbal and written communication skills. Working knowledge of Microsoft Office Product Suit. Technical Requirements: We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Monitors and manages intake for Specialty appeals, cases needing second level medical necessity review and escalated questions. Oversight of non-clinical staff including training, performance management, and case guidance. Manages staff by monitoring staff production and adherence to departmental standards and expectations. Monthly Team Meetings, individual monthly 1:1’s, monitoring productivity. Facilitates the timeliness and accuracy standards adhering to client, state and federal requirements. Organizes volume of work and manages work assignments of staff. Assists with providing employee training on different specialized task processes. Assists in the development of department workflows and implementations. Consults with clinical and/or claims staff on problem cases and interfaces with all departmental staff in resolving denial, appeal, provider dispute issues and/or grievances/complaints. Assists in the data gathering and analysis of reports regarding appeal and provider dispute activity, as well as preparation for audits. Oversees staff intake of calls related to appeal filing and case questions. Provides direction to Senior Coordinators assigned to your team.

Evolent

Appeals Nurse

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Virginia

Your Future Evolves Here Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing: The Evolent Appeals Nurse team offers candidates the opportunity to make a meaningful impact as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and client policies and procedures while complying with timeliness guidelines. Our clinical nurse reviewer team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes for the clients and members we serve. Collaboration Opportunities: The Appeals Nurses provide appeal reviews for dedicated clients. They interact with coordinators who set up the appeal, physicians and other clinicians who review the appeal, the claims department to review provider post-service claims for medical necessity, and managers for direction and leadership. The Appeals teamwork strategies and opportunities for collaboration include all-team and individual team meetings, Teams chats and monthly communication on team metrics and accomplishments.

1-3 years' experience in clinical Appeals Review or Utilization Management Review as an LPN or RN is required. Must maintain a courteous and respectful disposition, and a positive, helpful attitude in all business settings. Must be able to exercise independent and sound judgment in clinical decision making. Must be computer literate and able to navigate through internal and external computer systems. Strong organizational and effective time management skills; demonstrated ability to manage multiple priorities are a must. Outstanding interpersonal and negotiation skills to effectively establish positive relationships both internally and externally. Strong written and verbal communication skills. Technical Requirements: We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Communicates with medical office personnel to obtain pertinent clinical history and information. Documents and summarizes clinical or administrative rationale for all approvals and denials to all parties involved in the case. Interfaces with other departments to satisfactorily resolve issues related to appeals and retrospective reviews. Participates in on-going training programs to ensure quality performance follows applicable standards and regulations. Practices and maintains the principles of utilization management and appeals management by adhering to company policies and procedures. Provides optimum customer service through professional and accurate communication while maintaining accreditation and health plan's required timeframes. Documents communications with medical office staff and/or MD provider as required. Refers cases to appropriate internal reviewers according to the business needs of the particular health plan. Research requests for post-determination review and categorizes each for processing based on the applicable health plan policies and procedures. Reviews and coordinates documentation; interprets data obtained from clinical records and ensures appropriate clinical criteria and policies are aligned with regulatory and accreditation requirements for members and providers. Tracks all post-determination cases to completion to ensure compliance. Trains new employees on the appeals and de-certification process as needed. Works closely with the appeals-dedicated Clinical Reviewers to ensure timely adjudication of processed appeals.

Dynamic Hospice

Hospice and Palliative Nurse

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Georgia

Palliative Care and Hospice and Palliative Nursing expertise Strong Nursing and Patient Care skills Knowledge of Medicine and effective pain management approaches Compassionate, patient, and empathetic demeanor Excellent communication and teamwork skills Ability to work independently and remotely Experience in hospice care is a plus Current nursing license and certification in palliative care

This is a full-time remote role for a Hospice and Palliative Nurse. The nurse will be responsible for providing comprehensive palliative care, managing pain and symptoms, coordinating care with families, and ensuring quality of life for patients. Day-to-day tasks include administering medication, monitoring patient health, creating care plans, offering emotional support, and educating patients and families about managing conditions. Regular communication with the healthcare team to optimize patient outcomes is also required.

Diverse Lynx

Remote RN/Telehealth

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

New York

Registered Nurse Remote (NY) Fulltime/Permanent Rate is $38/hr + full benefits – we need RNs who have an active NY License. – this is full time role and the rate to the candidate will be $38 so you can offer this rate. The rate is low because it is a full remote role. This is a non-touching patient job, candidates who can assist patients over the call/telehealth ---- this is a fully remote position --- candidates can live anywhere in US if they have active NY License. Need - APC – 6- RN, Peds- 2 RN, OB/GYN 3- RN for a total of 11. Must have skills: Active NY License, Triage, EPIC (EMR) - TRIAGE IS A MUST, do not submit candidates without all 3 of these requirements We are seeking RNs who combine excellent nursing and call center skills with the ability to function effectively both as part of a team or on an individual basis to bring their talent to our team.

Current unrestricted RN licensure in applicable Licensure in NY 2+ years’ experience of Nursing Minimum of one year experience using EPIC Adult, Pediatric/GYN experience for those specific roles; Peds for PCP offices Triage experience Proficient level of experience with Microsoft Office applications, and solid technical aptitude Highly organized, self-directed worker with an ability to function in high volume, fast-paced environment. Demonstrated solid verbal and written communication skills.

Assesses and triages immediate health concerns telephonically. Provides concise, appropriate, and safe nursing guidance. Identifies problems or gaps in care, offering opportunity for intervention, and ER diversion as appropriate. Communicates with patients, and respective members of the healthcare team regularly. Engages with fellow teammates, and leadership via multiple communication platforms. Provides health education and coaches consumers on available care options. Documents all patient interactions via multiple EMR - nextGen and tracking platforms. Special projects, initiatives, and other job duties as assigned.

Vesta Healthcare

Triage Registered Nurse (Remote)

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Vesta Healthcare is a specialized medical group dedicated to enhancing the lives of individuals with long-term home care needs. By collaborating closely with caregivers and leveraging innovative technology, Vesta transforms the home into a comprehensive care setting. Named after the Roman Goddess of home, hearth, and family, Vesta Healthcare offers caregivers, patients, and family members personalized support and guidance through a dedicated clinical team, ensuring that care recipients receive the highest quality care in the comfort of their own homes.

The ability to commit to a full-time opportunity working 8, 10, or 12 hour shifts during the daytime on weekdays and commit to four weekend shifts per month (required) Has a Compact AND New York nursing license (required) Is bilingual and fluent in both English AND Spanish (preferred) Graduated from an accredited nursing program (required) At least 2 years of nursing experience providing care to adult and geriatric patient populations (required) Confidence with clinical skills in performance of telephonic triage/assessment (required) The ability to work remotely and has a private area in their home/workspace (required) A genuine, compassionate desire to serve others and help those in need High speed home WiFi/data connection to support company provided IT equipment

Plan and conduct intervention opportunity evaluations, respond to urgent alerts and remote patient monitoring alerts as needed to help drive high quality care at a lower cost Have the ability and skill to recognize clinical scenarios that require escalation to the internal team nurse practitioner Work directly with the member, via various forms of communication, texting, virtual visits, and telephone, to develop and achieve patient centered chronic care management goals Develop and update care plans for members while keeping a close eye on caregiver and/or family support Apply clinical experience and judgment to the utilization management/care management activities Be responsible for day to day work with patients related to interventions needed for quality outcomes to reduce avoidable admissions, readmissions and ED utilization. Collaborate with engagement and product teams to promote quality outcomes, optimize service experience, and promote effective use of resources for complex or elevated medical issues

Elevance Health

Nurse Reviewer 1

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

California

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

Location: Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Schedule: 9:30am-6:00pm PST, ability to work weekends if necessary. New Grads are encouraged to apply! The Nurse Reviewer I will be responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines.

Minimum ​Requirements : AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required. Preferred Skills, Capabilities, and Experiences ​ : Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred. BA/BS degree preferred. Previous utilization and/or quality management and/or call center experience preferred. Knowledge in Microsoft office

Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits. Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment. Primary duties may include, but are not limited to: Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review. Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network. Notifies ordering physician or rendering service provider office of the preauthorization determination decision. Follows-up to obtain additional clinical information. Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.

Blue Cross Blue Shield of Michigan

RN Care Manager - Care Management

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Michigan

This position is fully remote (not mobile due to equipment requirements). To work remote your internet speed must be 25mbps or higher, please check with your Internet provider to confirm that you have enough speed. The Care 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 the BCBSM online messaging platform. The Care 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.

Departmental Preferences: 3 years of case management experience strongly preferred. Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred. Certification in Chronic Care Professional (CCP) preferred CCM Certification preferred Discharged Planning experience preferred QUALIFICATIONS: 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. 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 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.

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). This position is fully remote. To work remote your internet speed must be 25mbps or higher, please check with your Internet provider to confirm that you have enough speed.

Advocate Aurora Health

Registered Nurse (RN) - Triage, Full-time, Remote

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Wisconsin

Aurora Health Care is the largest health system in Wisconsin and a national leader in clinical innovation, health outcomes, consumer experience and value-based care. The state’s largest private employer, the system serves patients across 17 hospitals, more than 70 pharmacies and more than 150 sites of care. Aurora Health Care, in addition to Advocate Health Care in Illinois and Atrium Health in the Carolinas, Georgia and Alabama, is now part of Advocate Health, the third-largest nonprofit, integrated health system in the United States. Committed to providing equitable care for all, Advocate Health provides nearly $5 billion in annual community benefits.

Looking for full time RNs – Position is 100% remote **Candidate MUST have 2+ years' acute care experience (ED, Urgent Care, ICU and some Med/Surg will be considered) is required within the last 4 years to be considered.** Due to complex requirements, remote work is NOT permitted from the following states: CA, CO, CT, HI, MA, MD, MN, NJ, MY, OR, RI, VT, WA Schedule: Full time position Start times days: 8a-10a or PM 12p-2p (or later) 8 hour or 10 hour shifts are available for different shifts MUST be available to work every 3rd weekend and holiday rotation.

Licensure, Registration, and/or Certification Required: Registered Nurse license issued by the state in which the team member practices. Education Required: Associate's Degree (or equivalent knowledge) in Nursing. Experience Required: Typically requires 2+ years' of acute care experience, preferably within the last 4 years (ED, Urgent Care, ICU and some Med Surg will be considered). Knowledge, Skills & Abilities Required: Critical thinking skills necessary to independently determine and prioritize the needs of patients using sound judgment and strong problem-solving skills. Knowledge of a variety of healthcare specialties, including levels of care, symptom identification and proven treatment recommendations. Ability to incorporate past experience with established protocols. Excellent verbal communication skills demonstrating empathy, respect, restatement, open-ended questions, active listening and diplomacy with a diverse customer population. Ability to develop rapport and maintain positive, professional relationships with a variety of patients, staff and physicians. Proven ability to independently organize and prioritize work, managing multiple priorities and maintaining a flexible schedule in a fast paced, dynamic customer service environment. Excellent customer service and follow-up skills including the ability to stay calm during stressful situations. Demonstrated proficiency as a technology user with computers, internet, desktop software packages and multiple-line telephone systems. Ability to converse with customers/patients while researching and documenting calls on multiple systems. Knowledge of documentation techniques for communication Physical Requirements and Working Conditions: Required stable and secure internet connection Must have functional vision, touch, speech, and hearing. Required sitting a majority of the workday. Operates all equipment necessary to perform the job. Must have quiet space to make and receive phone calls Ability to lift 15 lbs.

Uses the nursing process and guidance of established protocols to assess the needs of the patient telephonically including the patient, guardian, or family in the conversation when necessary. Determines most appropriate level of care needed, provides detailed education, establishes a plan of care including interventions, and communicates follow up instructions to the patient. Escalates and collaborates with the appropriate on call provider when additional guidance is needed. Prioritizes patient interactions by acuity and need considering all available information and resources. Applies evidence-based practice to deliver patient care. Implements strategies to reduce patient risk and increase patient safety. Assesses patient and family readiness to learn and individualizes the approach as necessary. Works collaboratively to develop strategies to meet the learning needs of the patient and family. Supports shared governance activities and initiatives to improve processes and patient outcomes. Participates in department quality/process improvement initiatives aimed at enhancing the patient care experience. Participates in professional activities which contribute to personal professional development and the development of others. Seeks opportunities to be taught, coached, and mentored. Attends required meetings/educational programs and completes annual competencies in a timely manner. Demonstrates effective communication, feedback, and conflict resolution skills. Promotes collaboration with clinicians and other healthcare team members to coordinate patient-centered care. Promotes a culture of safety through identifying threats to patient safety and intervening to prevent patient harm. Reports patient safety events and near misses in a timely manner. Seeks to identify potential safety issues and assists in the implementation of corrective action. Applies ethical decision making, demonstrates respect and understanding for peers, and other clinical disciplines. Participates as an effective member of the patient care team to formulate an integrated, unbiased, individualized approach to care. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret appropriate information needed to identify each patient’s requirements relative to his/her age specific needs and provide the care advice/disposition outlined in the departments policies, procedures, and protocols. Schedules appointments with emphasis on making the appointment in correlation to the recommended end point of the protocol used. Collaborates with other health care team members to coordinate medical and nursing management of patient care, including procedures and medication refills. Accurately maintains and updates the patient’s clinical records according to agency, State and Federal guidelines. Documents all call encounters utilizing the patient’s Electronic Medical Record at the time of the call. Communicates information relating to the patient’s physical and psychological status to the physician, Advanced Practice Clinician and/or additional members of the interdisciplinary team as appropriate. Provides pertinent and concise reports describing patient’s response to medical and nursing plans of care. Participates in team meetings and works on special projects/tasks as assigned by leadership. Participates in the ongoing development of comprehensive health information resources, system and operational efficiencies and resources. Assists in interpreting department policies and procedures and advises staff on procedural changes.

CVS Health

Appeals Nurse Consultant (Remote)

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Conneticut

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

This is a full-time telework position. Hours for this role are Monday-Friday 8a-5p in time zone of residence with the possibility of occasional on-call weekend requirements.

Required Qualifications: Must have active and unrestricted RN licensure in state of residence 3+ years clinical experience Preferred Qualifications: Appeals Experience Managed Care Experience Utilization review experience Proficiency with computer skills including navigating multiple systems Exceptional communication skills. Time efficient, highly organized, and ability to multitask Education: Associate's Degree minimum

Responsible for the review and resolution of clinical appeals. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. This position may support UM, MPO, Coding, or Behavioral Health appeals.

Optum

Assess and Triage Care Advocate - Remote Nationwide

Posted on:

May 2, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Minnesota

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

Are you an independently licensed mental health professional with background in insurance/managed care industry? Are you a clinician who has worked in a mental health, chemical dependency and/or crisis role in direct service? Bring your clinical experience to a rewarding position on a fast-paced, supportive team. We’re looking for a clinically curious, passionate, dedicated professional to fill a queue-based, telephonic care advocacy role. The schedule is Monday through Friday 10:45am – 7:15pm Central and requires working a minimum of 2 holidays per year. You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Master’s degree in Psychology, Social Work, Counseling, or Marriage and Family Counseling; Licensed Ph.D.; or RN with 2+ years of experience in behavioral health Active, unrestricted, independent clinical license in State of Residency (i.e., counselor, therapist, social worker, registered nurse) 3+ years of experience in a related mental health environment Intermediate proficiency in Microsoft Office Suite (Word, Excel, Outlook, Teams) Proven ability to talk and type at the same time while simultaneously navigating multiple programs and screens Ability to work 10:45am to 7:15pm Central Preferred Qualifications: Crisis intervention experience Dual diagnosis experience with mental health and substance abuse Call center experience Experience determining levels of care for behavioral health services Experience using Interqual, ASAM, and/or Locus criteria Experience working with various age groups Experience working in an environment that required coordination of benefits and utilization of multiple groups and resources for members

Field inbound calls in a queue from members for the purpose of assessment and triage Focus on psychiatric and chemical dependency treatment for members Provide psychoeducation Complete clinical assessments Assist members in determining appropriate levels of care Obtain information from members for outpatient and higher level of care requests for treatment Coordinate benefits and transitions between various levels of care Provide crisis intervention and support to members

SCRI Oncology Partners

Telephone Triage Nurse

Posted on:

May 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Tennessee

SCRI Oncology Partners, located in Nashville, Tenn., is a dedicated cancer treatment center led by globally recognized oncologists with disease expertise in cancer care and clinical research. This center offers patients state-of-the art personalized cancer care and opportunities to participate in clinical trials with innovative treatments. The practice conducts clinical trials through their affiliation with Sarah Cannon Research Institute (SCRI), a global leader in oncology research that has been offering and managing clinical trials in the community for over 30 years. Since its inception, SCRI has contributed to pivotal research that has helped advance the majority of new cancer therapies approved by the FDA today.

This role requires the candidate to be within a commutable distance to the practice location. While primarily remote, initial training will be on-site for around 2 weeks, potentially longer, with the occasional need to be on-site for meetings or training. The telephone triage nurse assesses patient needs over the telephone, collaborates with a physician or qualified staff members to meet those needs, then documents all elements of care in the patient’s medical record. The telephone triage nurse will accurately identify patients with high-risk conditions and will direct care to the appropriate resources if they cannot be managed by the nurse and/or within the clinic. Under general supervision, provides professional nursing care for patients, adhering to national and organizational standards and guidelines for specialty care and scope of practice per state licensing board. Must recognize physical, psychological, and spiritual aspects of care and participates in company-wide quality initiatives. Supports and adheres to the US Oncology Compliance Program, to include the Code of Ethics and Business Standards.

MINIMUM QUALIFICATIONS: Graduate from an accredited program for professional nursing education, BSN preferred. RN state license and current registration with the State Board of Nursing in practicing state. Current Basic Life Support (BLS) certification. Must maintain continuing education requirements. 3-5 years nursing experience including at least one year in oncology preferred. Oncology certification preferred. PHYSICAL REQUIREMENTS: A large percent of time performing computer-based work is required. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; and reach with hands and arms. The employee frequently is required to walk and talk or hear. The employee is occasionally required to sit; climb or balance; and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. WORKING CONDITIONS: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly exposed to the risk of blood borne pathogens, carcinogenic drugs and other conditions common to a clinic environment.

Addresses patient calls, portal messages and emails in a timely manner. Asks appropriate open-ended questions as well as utilizing computerized algorithms/pathways to assist in the assessment of patient's symptoms and side effect management and documents interventions. Manages a wide range of patient symptoms/side effects, assessing urgency and addressing them appropriately to prevent unnecessary emergency department and hospital utilization. If emergency care is needed, collaborates with physicians via electronic communication, face to face, or the telephone to discuss patient care needs that cannot be independently and appropriately addressed using standard orders or practice protocols. Collaborates with providers if the patient can be seen in an outpatient clinic setting for their symptoms. Documents all conversations with patients to maintain a comprehensive medical record. Provides clear instructions and education to the patients via the telephone and other duties as assigned.

Gallagher Bassett

Concierge Nurse Consultant- Bilingual

Posted on:

May 1, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Join our growing team of dedicated professionals at Gallagher Bassett, who guide those in need to the best possible outcomes for their health and wellbeing. You'll be part of a resilient team that works together to redefine the boundaries of excellence. At our organization, we value collaboration and making a positive impact in the lives of our clients and claimants, offering you the opportunity to join a team where your skills and dedication can truly make a difference. GUIDE. GUARD. GO BEYOND.

This role requires Active Compact Registered Nursing license within resident state or California RN license with additional non-compact state licenses. Concierge Nurse Consultant Role: Gallagher Bassett’s GBCARE division is looking for a bilingual nurse to join its new Clinical Concierge group. Clinical Concierge is an innovative and exciting early intervention offering to improve claim outcomes through proactive management of the medical treatment process from day one. Our purpose is to help people in need who are dealing with an injury or health-related setback. We understand them, support them, guide them, and get them the right type of specialist help, when needed. How you'll make an impact This is an opportunity to join a growing team where you can expect to learn and contribute in a number of different ways. The role would be based in a high velocity process-based setup where the nurse would be expected to handle up to 5-7 new cases a day. The position entails getting trained in and be effective in using a modern technology platform for case management, workflow, and communication. There will also be career growth opportunities as the team expands.

Required: Degree from applicable program of training and a minimum of 3 years clinical experience in an acute care setting required. Active Registered Nursing license or equivalent within the state of practice or states in which CM is performed. Candidate must be Bilingual ( Fluent in Spanish / English) Preferred: Bachelor's degree preferred. Workers’ Compensation experience is preferred. CCM, CRRN or equivalent preferred Experience triaging injuries or other medical issues is desirable Behaviors: Empathetic, patient-centric disposition Motivated to make a difference in lives of individuals dealing with injury related setback Very particular about getting things done on time Comfortable delegating tasks and ensuring they get done Comfortable working with offshore team Strong written and oral communication skills Strong organizational and time management skills Ability to work in a fast-paced environment Ability to work independently without much oversight Ability to work in a process-based environment where multiple people will be working on the same case, supporting the nurse

Perform risk assessment via an empathetic interview of the injured worker over the phone. Provides outstanding claimant service and builds trust with the injured worker. Sets the direction in terms of what level of clinical oversight is needed on the claim. Keep all parties - injured worker, claims adjuster, physician, referral source-- informed on case progress. Help facilitate direction of care, including referrals to different providers, by delegating to support nurse and other support staff. Reviews medical records post appointment and checks for compliance with Evidence Based Medicine Determines if the claim needs ongoing nurse oversight Works collaboratively with support nurse and other support staff and ensures all delegated tasks on the case are getting done.

SSM Health

LPN-Phone Triage

Posted on:

May 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Missouri

It's more than a career, it's a calling MO-REMOTE Worker Type: Regular Job Highlights: Department: Primary Care and OBGYN Clinic Schedule: M-F Day Shift | No Weekends or Holidays Starting Pay: 20.78+/hr. (Offers are based on years of experience and equity for this role.) Sign On Bonus: Available for external qualified candidates Location: MO-REMOTE (Must Reside in Missouri) We are seeking a dedicated and motivated individual to join our team at our Saint Charles, MO office. This position requires a comprehensive 90-day in-office training period to ensure you are fully equipped with the knowledge and skills needed to excel in your role. After the training period, you will be required to work in the office one day every other month to maintain a strong connection with the team and stay updated on any new developments. Job Summary: Provides care to patients under the direction of a registered nurse or physician, functioning within the scope of license.

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

Contributes to the assessment of patients and ensures the well-being of patients. Administers medications and observes patients for adverse reactions to medications or treatments. Performs laboratory tests and therapeutic services. Educates patients/families about disease treatment plan including self care post discharge, holistic health needs, available resources and follow up care. May documents the provider's encounter with patients. Lists all proper diagnoses and symptoms, as well as discharge/follow-up instructions and prescriptions, as indicated by the provider. May transcribes patient orders including laboratory tests, radiology tests and medications. Completes patient's charts by transcribing results of any labs, x-rays, or other evaluations. Continuously checks the progress of data availability for orders, to ensure the patient's workup is complete so that the provider is able to make treatment decisions regarding that patient. May transcribes consultations or discussions with family and/or the patient's private physician or the on-call physician. Works in a constant state of alertness and safe manner. Performs other duties as assigned.

TeamHealth

Full-time Split Shift RN Telephone Triage (Work from Home)

Posted on:

May 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

The AccessNurse-TeamHealth Medical Call Center is a 24/7 Call Center offering remote telephone triage and Health Information services to Hospitals, Physician Offices, and Insurance Plans across the country. If you want to be a part of a growing industry and work from home from day one, contact us today!

We are searching for registered nurses of all backgrounds with at least 2 years of experience who are seeking an exciting and rewarding alternative to direct patient care. If you are looking for a way to continue to positively impact patients and use your nursing skills without the wear and tear of working in a hospital you should send your resume today! We promote success through a supportive work environment, provide excellent benefits, and offer pay beginning at $28/hr and paid time off. Part-time and full-time split-shift, weekend and evening shifts are currently available. Now also recruiting for bilingual nurses who can fluently speak both Spanish and English.

Current multi-state RN license with no restrictions; nurses currently holding a single-state RN license must obtain a multi-state license prior to being made a job offer Computer Skills a MUST 2+ years of Nursing Experience Successful Completion of Background Check, Drug Screen, and References 4-week remote training over Zoom video (100% attendance required) Week 1: June 23 - June 27 M-F 9a-5p Eastern Week 2: June 30 - July 4 M-F 9a-5p Eastern Week 3: July 7 - July 11 M-F 2p-10p Eastern Week 4: Shift days/times with a preceptor will be discussed with your recruiter Ability to type a minimum of 25 wpm Excellent organizational and computer skills and ability to multi-task while speaking with patients Excellent listening and comprehension skills to determine key information by patient Professional, courteous telephone voice Dependable, reliable and trustworthy Ability to defuse conversations Ability to handle confidential information; HIPAA compliance is mandatory Flexibility with scheduling Ability to receive feedback on job performance Bilingual Telephone Triage Nurses must be able to converse in Spanish and document in English simultaneously (a Spanish/English proficiency test is required) Must be able to provide a HIPAA-compliant workspace during training and your regular shifts Must be able to pass a pre-employment test plus have a successful background check and reference check*(references are verified) Remote Workstation Requirements Internet: A reliable high speed internet connection is required for this position. Please select a cable internet provider. Examples include Xfinity/Comcast, AT&T, Spectrum. Satellite internet and cellular hotspots are not sufficient to adequately connect to our servers. You must hardwire your internet from your modem or Ethernet jack to your work computer. WiFi is not acceptable and disrupts the connection to our servers. The minimum bandwidth speeds must be fast enough for 23 megabits download and 10 megabits upload Test your home internet speeds here Please verify this information with your internet provider Please note these requirements do not include other demands on your internet (e.g. another household member working from home, streaming videos, streaming music, online gaming). It is your responsibility to either limit activities like the ones mentioned above or work with your internet provider to increase your bandwidth so you can work without issues. Workstation: Allow enough space to provide room for 2 (two) 27” computer monitors, a computer, a keyboard, a mouse, and a dial pad/phone, which is company provided. Arrange your workstation where you can hardwire to your internet and phone line. Your workstation must be located in a room where there is a door with a lock. HIPAA compliant and protects PHI Prevents disruptions during work hours Physical and Environmental Demands: Job performed in a well-lit, modern office setting Occasional lifting (20 pounds or less) Visual and Auditory acuity Manual and finger dexterity Occasional stress Occasional pushing, pulling, carrying, lifting, bending, and reaching Frequent work on a PC/Computer Prolonged telephone work and prolonged sitting

The telephone triage nurse is a registered nurse who helps patients across the lifespan determine the best way to address their medical issues and concerns over the phone: Assess symptoms: Utilizing a physician-written algorithm Provide guidance: Recommend a variety of levels of care (e.g. home care, an office visit, emergency room) Answer questions: Provide and document health education to help patients manage their symptoms when indicated Consult with physicians as needed

IntellaTriage

Remote Hospice Triage RN PT Weekend (Sat & Sun) only 7:30a-6p CST

Posted on:

May 1, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is strongly preferred **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence ** Weekday only requirement is both Saturday & Sunday every weekend 7:30a-6p CST

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

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

Guideway Care

Triage Nurse RN (Telehealth)

Posted on:

May 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Since 2004, Sequence Health has offered a wide breadth of innovative patient engagement and patient management solutions to help optimize operational efficiency, elevate brand awareness, and grow physician practices and healthcare businesses.

We are seeking a Registered Nurse who will provide nursing and administrative support to a range of practices across the country. Candidates should have strong computer skills and excellent phone skills to work with providers, patients, and administrators. The pay range is a $25-30 hourly rate. This position is full time being offered remotely.

Registered Nurse Current demonstration of clinical proficiency Excellent written and oral communication skills Excellent critical thinking and problem-solving skills Ability to work within approved procedure and clinical guidelines Electronic Medical Record Experience, i.e EPIC, Cerner, Greenway Ability to use windows-based computer software including ADOBE, MS Word, MS Excel, Fax and others Minimum Requirements: Registered Nurse with Unencumbered e-NCL Licensure. Wisconsin Multistate license OR licensure in California and Minnesota preferred. Minimum of 3 years’ experience in Adult Nursing Oncology nursing experience preferred Able to work remotely at home in a private HIPAA compliant workspace Able to house company equipment needed to perform job Broadband Internet Access Immigration or work visa sponsorship will not be provided Physical Demands: Ability to hear in normal range and wear a headset / earpiece Good visual acuity to read computer screens, scripts, forms etc. May sit 100% of the time when taking calls Internet download speed must be at least 24 mbps and upload speed at least 4 mbps Immigration or work visa sponsorship will not be provided

Receive inbound calls from patients and place outbound calls to patients. Provide clinical assessment based on established protocols and triage patients by phone or through patient portal. Respond to patients’ messages in patient portal, create orders and route to appropriate parties. Provide administrative support for patients’ and providers’ needs in terms of FMLA, ADA, and LTD/STD Communicate with Health Care Provider through approved methods as needed. Any other duties necessary to drive our values, fulfill our mission, and abide by our company values

Peachtree Care Health Services

Nurse - RN, LPN | Lead Generator

Posted on:

May 1, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

Georgia

Are you an RN or LPN with direct experience and relationships with Medicaid-eligible or SSI-disabled clients? Peachtree Care Services is expanding our network and looking for motivated professionals to join us as Lead Generators for home care services. This is a commission-based role designed to integrate naturally with your current position or caseload, creating a passive income stream while helping clients get the home care services they need.

Active or former nurses RN/LPN Direct contact with Medicaid recipients or SSI-disabled individuals Familiarity with community resources and home care services Reliable, discreet, and ethically driven professionals

Identify individuals who may qualify for Medicaid-funded home care Refer them to Peachtree Care Services Earn a competitive commission for every qualified lead Earn up to $250 per lead conversion

Headlands ATS

Remote Triage Nurse – Temp-to-Hire

Posted on:

May 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Are you seeking integrity, purpose, and meaning in your work? Do you want to make a difference by improving access to quality addiction medicine services? Join the Headlands Addiction Treatment Services (ATS) provider team. At Headlands ATS, we are an industry leader in addiction and psychiatric services, dedicated to improving patient care in residential and outpatient addiction and mental health programs. Our team consists of compassionate healthcare professionals who are committed to delivering evidence-based care, education, and organizational improvements to historically underserved populations.

THIS POSITION IS OPEN TO BOTH RN AND LVN/LPN LICENSED NURSES. Remote Triage Nurse (RN or LVN/LPN) – Temp-to-Hire | 30 Hours/Week 6–8 Month Assignment | Potential for Long-Term Role After 1 Year This position is 100% remote and accepting applications from applicants with COMPACT LICENSES living in the following states: CA, AZ, NV, WA, CO, NE, KS, OK, TX, MO IL, IN, TN, FL, MD, NJ, WI, and NC. About the role As a Remote Triage Nurse at Headlands ATS, you will play a critical role in providing high-quality care to patients dealing with addiction and mental health conditions. Working closely with our dedicated team of healthcare professionals, you will manage nursing requests, triage patient needs, and ensure seamless communication between patients, providers, and programs—all from the comfort of your home. In this role, you will utilize your clinical expertise to: Address and resolve patient care issues using established protocols within your scope of practice. Coordinate and delegate tasks such as admissions and follow-ups to providers, ensuring timely and effective care. Support providers by managing medication orders and refill requests. Serve as a compassionate and responsive point of contact for patients and programs, fostering trust and positive relationships. Schedule and Availability Shift: Fri-Sun, 6:00 AM - 4:00 PM PST Shift: Fri-Sun, 4:00PM - 2:00AM Shift: Fri-Sun, 10:00 PM - 8:00 AM PST

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

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

UnitedHealth Group

RN Field Clinical Care Coordinator/HCBS - Burnet County, TX

Posted on:

May 1, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

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 equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

This is a Field Based role with a Home-Based office. If you are located within 30-50 miles of Burnet County, TX, you will enjoy the flexibility to telecommute* as you take on some tough challenges.

Required Qualifications: Current unrestricted RN license in the State of Texas 2+ years of experience working within the community health setting or in a health care role Intermediate level of computer proficiency including the use of Microsoft Outlook, Teams, Excel, Word, and the ability to navigate through multiple web applications Reliable transportation and the ability to travel in this assigned region to visit Medicaid members in their homes and/or other settings, including community centers, hospitals, nursing facilities or providers’ offices High-speed internet at residence Access to reliable transportation & valid US driver’s license Preferred Qualifications: 1+ years of experience with long term care services and support, Medicaid or Medicare Ability to create, edit, save and send documents, spreadsheets and emails Knowledge of the principles of most integrated settings, including federal and State requirements like the federal home and community-based settings regulations Reside within commutable distance of assigned duties *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the health care team

UnitedHealth Group

Field HSS Clinical Coordinator RN - Fairbanks-NW Crossing or Spring Branch, TX

Posted on:

May 1, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

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 equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

In this RN HSS Clinical Coordinator role, you will be an essential element of an Integrated Care Model by relaying the pertinent information about the member needs and advocating for the best possible care available, and ensuring they have the right services to meet their needs. Our team is made up of RNs, LVN’s, and CACs dedicated to helping members achieve their health care goals. We work closely with the nursing facilities in which our members reside. If you are within Fairbanks – NW Crossing or Spring Branch, TX, or ideal areas within these zip codes 77092, 77018, 77080, 77091 and can travel locally, you will enjoy the flexibility to telecommute* as you take on some tough challenges. Travel required in local areas about 75% of the time based on business needs. This is a field-based position with a home-based office.

Required Qualifications: Current and unrestricted RN license in the state of Texas 2+ years of experience working within the community health setting or in a health care role Intermediate level of proficiency with Microsoft Office, including Word, Excel, and Outlook Access to a designated quiet workspace in your home (separated from non-workspace areas) with the ability to secure Protected Health Information (PHI) Reside in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service Access to reliable transportation and the ability to travel in this ‘assigned region’ to visit Medicaid members in their homes and/or other settings, including community centers, hospitals, nursing facilities or providers’ offices Valid US driver’s license Preferred Qualifications: 1+ years of experience with long term care services and support, Medicaid, or Medicare Ability to create, edit, save and send documents, spreadsheets and emails Knowledge of the principles of most integrated settings, including federal and state requirements like the federal home and community-based settings regulations Reside within commutable distance of assigned duties Bilingual English/Spanish *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, lease restrictive level of care Utilize both company and community-based resources to establish a safe and effective case management plan for members Collaborate with patient, family, and healthcare providers to develop an individualized plan of care Identify and initiate referrals for social service programs, including financial, psychosocial, community, and state supportive services Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the healthcare team Utilize approved clinical criteria to assess and determine appropriate level of care for members Document all member assessments, care plan and referrals provided Participate in Interdisciplinary team meetings and Utilization Management rounds and provide information to assist with safe transitions of care Understand insurance products, benefits, coverage limitations, insurance, and governmental regulations as it applies to the health plan Accountable to understand role and how it affects utilization management benchmarks and quality outcomes You’ll need to be flexible, adaptable and, above all, patient in all types of situations

Medasource

Triage Nurse

Posted on:

May 1, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Triage Nurse – Remote Start Date: ASAP Contract Period: 3 months with possible extension Shift: Wed./Thurs./Fri. 12:00a - 10:00a MST (off Mon./Tues./Sat./Sun.) Equipment Provided

At least 1 year of Remote Acute Triage Experience 3+ years of acute floor nursing experience Experience with telephonic assessments for acute care needs; remote experience required RN License in the state of Colorado, OR Compact RN License

Collect and analyze critical patient information Educates and counsels patients regarding transmitted diseases and risk reduction Performs a variety of duties relating to the preparation of reports, entering personal data on patient registers and preparing correspondence to send to patients who are in need of medical examination and treatment. Utilizes appropriate methods of communication for interacting professionally with patients Decision making skills are crucial

ChenMed

Advanced Practice Provider 1, CareLine (Remote) Telehealth (Part Time)

Posted on:

May 1, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

We’re unique. You should be, too. We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Advanced Practice Provider (APP) I, CareLine is responsible for diagnostic patient care primarily through virtual, remote consultation via video conference or telephone. The incumbent in this role serves as the dispositional authority for after-hours and weekend clinical calls. They are accountable for assessing, diagnosing, treating and precisely documenting patients' physical and psychosocial health status through the collection of health data.

KNOWLEDGE, SKILLS AND ABILITIES: If supporting patients in Georgia, required to adhere to Georgia state law which requires travel to the State of Georgia on a quarterly basis (or as mandated by law) for onsite observation and medical record review by the respective delegating physician. If supporting patients in Tennessee, required to adhere to Tennessee state law which requires travel to the State of Tennessee on a bi-annual (or as mandated by law) basis for onsite observation and medical record review by the respective delegating physician. Required to adhere to any other state laws which may require travel for onsite observation by the respective delegating physician. Expert-level business acuity Expert knowledge and understanding of general/core job-related functions, practices, processes, procedures, techniques and methods Knowledge and understanding of medical practices to function independently as a certified practitioner and in collaboration and consultation with licensed physicians, specialists and other medical providers Demonstrated record of consistently achieving clinical performance metrics Technical capability to conduct telemedicine visits in accordance with state and federal regulations Ability to demonstrate excellent clinical judgement Ability to problem solve Ability to prioritize and work under pressure Ability to provide constructive feedback Ability to communicate and collaborate with physicians, patients and other team members in a professional manner Ability to operate effectively with a multidisciplinary team Proficient skill in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook; competent in keyboarding and other systems required for the position Ability and willingness to travel to attend meetings and trainings up to 10% of the time. Depending on the assigned schedule required availability to work evenings/overnights and/or weekends. Ability and willingness to travel to Georgia or any other state that requires a quarterly onsite observation and medical records review with the respective physician. Minimum requirement to work four holidays in the calendar year. Spoken and written fluency in English; bilingual (Spanish/Creole) a plus This job requires use and exercise of independent judgment Ability and willingness to obtain independent/autonomous practice as an NP in applicable states Acquires knowledge and skills to maintain expertise in area of practice. EDUCATION AND EXPERIENCE CRITERIA: Bachelor’s degree in Nursing (BSN) and graduate of a school of nursing for Advanced Practice Nursing with certification in area of specialty required; Master's degree in Nursing required. For NPs: Board certification by AANP or ANCC required Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required upon hire. Current DEA number from the DEA for schedule II-V controlled substances may be required based on State of practice Multi state licensure to include FL, VA, and at least 2 licenses in the following states: GA, MI, MO, OH, PA, TN, TX, IL, KY, LA. A minimum of 3 years' acute/primary care clinical work experience required A minimum of 2 years' telehealth work experience preferred

Through virtual video conference or telephone, assesses acute and non-acute clinical problems. Performs and documents physical evaluations and patient histories, analyzes trends in patient conditions and develops, documents and implements a patient management plan based on interpretation of findings. Aids in the development of a plan of care that may include health education, physician referrals, case management referrals and patient/family counseling. Plans patient care based on knowledge of the patient population and/or protocol. Considers the patient's cultural background, level of understanding, personality and support systems to anticipate and identify physiological and/or psychological problems. Serves as patient advocate. Collects comprehensive and focused data relating to the health needs of patients and families. Analyzes data to determine appropriate health maintenance and/or improvement methods. Confers with the patient's PCP and other medical providers to report health data and ensure compliance with guidelines. Ensures achievement of optimal patient outcomes through use of Telemedicine. Collaborates with on-call PCP, as needed, to support expected clinical outcomes. Implements the appropriate protocol to attain expected outcomes. Evaluate progress toward expected outcomes. Works with key contributors to enhance the quality of telehealth practices and systems through the utilization of data demonstrating program effectiveness and success. Communicates using a variety of formats, tools and technologies to build professional relationships and deliver care across the continuum. Utilizes appropriate resources to plan and provide services that are safe, effective and financially responsible. Provides extraordinary customer service and professionalism to all internal and external customers. May also participate in clinical rounds and conferences, risk and quality management programs, clinical and other relevant meetings. Adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, policies, and procedures. Practices in accordance with a written or electronic practice agreement. Participates with the clinical team in the formulation of telehealth/telemedicine policies, procedures and protocols. Initiates/participates in quality improvement activities that result in approved outcomes Participates with committee(s) to support growth Provides feedback regarding the practice of others to improve patient care Coordination of services with other programs Performs other duties as assigned and modified at manager’s discretion.

ChenMed

Advanced Practice Provider, CareLine - PRN (Remote)

Posted on:

May 1, 2025

Job Type:

Part-Time

Role Type:

Primary Care

License:

NP/APP

State License:

Compact / Multi-State

We’re unique. You should be, too. We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Advanced Practice Provider (APP), CareLine, PRN is responsible for diagnostic patient care primarily through virtual, remote consultation via video conference or telephone. Providing on-call coverage, the incumbent in this role serves as the dispositional authority for after-hours and weekend clinical calls. He/She is accountable for assessing, diagnosing, treating and precisely documenting geriatric patients’ physical and psychosocial health status through the collection of health data.

KNOWLEDGE, SKILLS AND ABILITIES: Expert-level business acuity Expert knowledge and understanding of general/core job-related functions, practices, processes, procedures, techniques and methods Knowledge and understanding of medical practices to function independently as a certified practitioner and in collaboration and consultation with licensed physicians, specialists and other medical providers Demonstrated record of consistently achieving clinical performance metrics Technical capability to conduct telemedicine visits in accordance with state and federal regulations Ability to demonstrate excellent clinical judgement Ability to problem solve Ability to prioritize and work under pressure Ability to provide constructive feedback Ability to communicate and collaborate with physicians, patients and other team members in a professional manner Ability to operate effectively with a multidisciplinary team Ability and willingness to travel locally, within south Florida to attend meetings and trainings up to 10% of the time. Depending on the assigned schedule required availability to work evenings/overnights and/or weekends. Minimum requirement to work three holidays in the calendar year. Proficient skill in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook; competent in keyboarding and other systems required for the position Spoken and written fluency in English; bilingual (Spanish/Creole) a plus This job requires use and exercise of independent judgment Acquires knowledge and skills to maintain expertise in area of practice. EDUCATION AND EXPERIENCE CRITERIA: Bachelor's degree in Nursing (BSN) and graduate of a school of nursing for Advanced Practice Nursing with certification in area of specialty required; Master's degree in Nursing required. Valid, active Registered Nurse license required For NPs: Board certification by AANP or ANCC required Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required w/in first 90 days of employment Current DEA number from the DEA for schedule II-V controlled substances may be required based on State of practice Multi state licensure to include FL, VA, and at least 2 licenses in the following states: GA, KS, MI, MO, NC, OH, PA, SC, TN, TX, IL, KY, LA. A minimum of 3 years' acute/primary care clinical work experience required A minimum of 2 years' telehealth work experience preferred

This is a PRN/Per Diem position, requiring a minimum of 160 hours per year, with scheduling flexibility based on the needs of the department. Works on an as-needed basis, including nights, weekends and holidays. Expected to pick up shifts to cover PTO, LOA and other unexpected absences, with some shifts being planned in advance and others requiring minimal notice. Through virtual video conference or telephone, assesses acute and non-acute clinical problems. Performs and documents physical evaluations and patient histories, analyzes trends in patient conditions and develops, documents and implements a patient management plan based on interpretation of findings. Aids in the development of a plan of care that may include health education, physician referrals, case management referrals and patient/family counseling. Evaluates need for immediate nursing intervention, consultation and/or referral and facilitates the necessary patient care. Plans patient care based on knowledge of the patient population and/or protocol. Considers the patient’s cultural background, level of understanding, personality and support systems to anticipate and identify physiological and/or psychological problems. Serves as patient advocate. Collects comprehensive and focused data relating to the health needs of patients and families. Analyzes data to determine appropriate health maintenance and/or improvement methods. Confers with the patient’s PCP and other medical providers to report health data and ensure compliance with guidelines. Consults with patients and/or family members on health outcomes and works with them to maintain positive health habits and/or improve opportunities. Leads efforts to ensure achievement of optimal patient outcomes through use of Telemedicine. Collaborates with on-call PCP, as needed, to support expected clinical outcomes. Implements the appropriate protocol to attain expected outcomes. Evaluate progress toward expected outcomes. Documents assessments, interventions and progress toward outcomes in an easy-to-understand and translate format. Works with key contributors to enhance the quality of telehealth practices and systems through the utilization of data demonstrating program effectiveness and success. Communicates using a variety of formats, tools and technologies to build professional relationships and deliver care across the continuum. Utilizes appropriate resources to plan and provide services that are safe, effective and financially responsible. Provides extraordinary customer service and professionalism to all internal and external customers. May also participate in clinical rounds and conferences, risk and quality management programs, clinical and other relevant meetings. Adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, policies, and procedures. Practices in accordance with a written or electronic practice agreement. Participates with the physician in the formulation of telehealth/telemedicine policies, procedures and protocols. Performs other duties as assigned and modified at manager’s discretion.

ChenMed

Advanced Practice Provider 1, CareLine (Remote) Telehealth

Posted on:

May 1, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

Compact / Multi-State

We’re unique. You should be, too. We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Advanced Practice Provider (APP) I, CareLine is responsible for diagnostic patient care primarily through virtual, remote consultation via video conference or telephone. The incumbent in this role serves as the dispositional authority for after-hours and weekend clinical calls. They are accountable for assessing, diagnosing, treating and precisely documenting patients' physical and psychosocial health status through the collection of health data.

KNOWLEDGE, SKILLS AND ABILITIES: If supporting patients in Georgia, required to adhere to Georgia state law which requires travel to the State of Georgia on a quarterly basis (or as mandated by law) for onsite observation and medical record review by the respective delegating physician. If supporting patients in Tennessee, required to adhere to Tennessee state law which requires travel to the State of Tennessee on a bi-annual (or as mandated by law) basis for onsite observation and medical record review by the respective delegating physician. Required to adhere to any other state laws which may require travel for onsite observation by the respective delegating physician. Expert-level business acuity Expert knowledge and understanding of general/core job-related functions, practices, processes, procedures, techniques and methods Knowledge and understanding of medical practices to function independently as a certified practitioner and in collaboration and consultation with licensed physicians, specialists and other medical providers Demonstrated record of consistently achieving clinical performance metrics Technical capability to conduct telemedicine visits in accordance with state and federal regulations Ability to demonstrate excellent clinical judgement Ability to problem solve Ability to prioritize and work under pressure Ability to provide constructive feedback Ability to communicate and collaborate with physicians, patients and other team members in a professional manner Ability to operate effectively with a multidisciplinary team Proficient skill in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook; competent in keyboarding and other systems required for the position Ability and willingness to travel to attend meetings and trainings up to 10% of the time. Depending on the assigned schedule required availability to work evenings/overnights and/or weekends. Ability and willingness to travel to Georgia or any other state that requires a quarterly onsite observation and medical records review with the respective physician. Minimum requirement to work four holidays in the calendar year. Spoken and written fluency in English; bilingual (Spanish/Creole) a plus This job requires use and exercise of independent judgment Ability and willingness to obtain independent/autonomous practice as an NP in applicable states Acquires knowledge and skills to maintain expertise in area of practice. EDUCATION AND EXPERIENCE CRITERIA: Bachelor’s degree in Nursing (BSN) and graduate of a school of nursing for Advanced Practice Nursing with certification in area of specialty required; Master's degree in Nursing required. For NPs: Board certification by AANP or ANCC required Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required upon hire. Current DEA number from the DEA for schedule II-V controlled substances may be required based on State of practice Multi state licensure to include FL, VA, and at least 2 licenses in the following states: GA, MI, MO, OH, PA, TN, TX, IL, KY, LA. A minimum of 3 years' acute/primary care clinical work experience required A minimum of 2 years' telehealth work experience preferred

Through virtual video conference or telephone, assesses acute and non-acute clinical problems. Performs and documents physical evaluations and patient histories, analyzes trends in patient conditions and develops, documents and implements a patient management plan based on interpretation of findings. Aids in the development of a plan of care that may include health education, physician referrals, case management referrals and patient/family counseling. Plans patient care based on knowledge of the patient population and/or protocol. Considers the patient's cultural background, level of understanding, personality and support systems to anticipate and identify physiological and/or psychological problems. Serves as patient advocate. Collects comprehensive and focused data relating to the health needs of patients and families. Analyzes data to determine appropriate health maintenance and/or improvement methods. Confers with the patient's PCP and other medical providers to report health data and ensure compliance with guidelines. Ensures achievement of optimal patient outcomes through use of Telemedicine. Collaborates with on-call PCP, as needed, to support expected clinical outcomes. Implements the appropriate protocol to attain expected outcomes. Evaluate progress toward expected outcomes. Works with key contributors to enhance the quality of telehealth practices and systems through the utilization of data demonstrating program effectiveness and success. Communicates using a variety of formats, tools and technologies to build professional relationships and deliver care across the continuum. Utilizes appropriate resources to plan and provide services that are safe, effective and financially responsible. Provides extraordinary customer service and professionalism to all internal and external customers. May also participate in clinical rounds and conferences, risk and quality management programs, clinical and other relevant meetings. Adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, policies, and procedures. Practices in accordance with a written or electronic practice agreement. Participates with the clinical team in the formulation of telehealth/telemedicine policies, procedures and protocols. Initiates/participates in quality improvement activities that result in approved outcomes Participates with committee(s) to support growth Provides feedback regarding the practice of others to improve patient care Coordination of services with other programs Performs other duties as assigned and modified at manager’s discretion.

ChenMed

Registered Nurse, Telehealth, Part Time, Remote (Spanish Bilingual)

Posted on:

May 1, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

We’re unique. You should be, too. We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Registered Nurse, Virtual Care, CareLine, is responsible for providing telephonic emergency triage and directional patient care advice for general and specific illnesses, health related issues, client counseling, patient advocacy, health education and referral and resource management to ChenMed patients and their families. Providing on-call coverage, the incumbent in this role provides remote clinical advice and assessments within license and as possible given the technology and medium. He/She collaborates with primary caregivers and others on the interdisciplinary care plan team to provide a team approach of care. The shift for this opening is as follows: Tuesdays 1700-2100 Wednesdays 1700-2100 Thursdays 1700-2100 Saturdays 0800-1600

KNOWLEDGE, SKILLS AND ABILITIES: Knowledge and understanding of general/core Nursing-related functions, practices, processes, procedures, techniques and methods Broad nursing knowledge and understanding Ability and willingness to provide extraordinary customer service and professionalism to all customers Maintains current nursing knowledge and competency to stay abreast of budding nursing trends and best practices Excellent written and verbal communication skills through a variety of formats, tools and technologies Capable of building trust and professional relationships to deliver VIP care across the continuum Ability to demonstrate excellent clinical judgment Ability to problem solve Ability to prioritize work under pressure Ability to provide constructive feedback Ability to effectively collaborate with a multidisciplinary team Proficient skill in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook; competent in other systems required for the position Ability and willingness to travel locally, within South Florida to attend meetings and trainings up to 10% of the time; required availability to work evening, weekends and/or holidays Minimum requirement to work 4 holidays in the calendar year Spoken and written fluency in English; bilingual (Spanish/Creole) preferred This job requires use and exercise of clinical judgement EDUCATION AND EXPERIENCE CRITERIA: Associate Degree in Nursing required, Bachelor’s Degree in Nursing preferred Nurse Licensure Compact license required, ability to obtain additional licenses as requested by the organization within 90 days of hire Basic Life Support (BLS) certification from the American Heart Association or American Red Cross required Minimum of 3 years acute clinical nursing work experience within an Emergency Setting or Urgent care setting highly preferred Experience working with older adult populations highly preferred Minimum of 1 year virtual care experience preferred

Connects with patients via phone or video call. Interviews and questions patients to collect health history and uses a computer system to record and store comprehensive and focused data relating to the health needs of patients and families. Provides health assessment and treatment solutions, monitors patient health and at-home care, aids in emergency scenarios and promotes patient wellness. Based on technology available, monitors a patient’s blood oxygen levels, heart rate, respirations, blood pressure and blood glucose as well as other assessment measures. With the help of video chatting, identifies patient’s symptoms and conditions. Analyzes data to determine the appropriate health maintenance and identify appropriate outcomes for patient and family. Collaborate with on-call providers as needed to support expected clinical outcomes for the patient and family. Evaluates and documents progress toward the anticipated outcome. Assist in ensuring achievement of optimal patient outcomes using Telemedicine. Documents interventions in a readable, understandable language. Aids in enhancing the quality and efficacy of the organization’s telehealth practices and professional nursing practice through successful utilization and improvement of outcomes that demonstrate program efficacy. Utilizes appropriate resources to plan and provide services that are safe, effective and fiscally responsible. Performs other duties as assigned and modified at manager’s discretion.

IMCS Group

Behavioral Health Nurse

Posted on:

April 30, 2025

Job Type:

Contract

Role Type:

Behavioral Health

License:

RN

State License:

North Carolina

Job Title: LTSS Service Care Manager Duration: 6 months Contract Desired Start / End Date : 5/12/2025 - 11/14/2025 Location Remote { Fayetteville NC- 3, Wilmington and Jacksonville NC-3, Goldsboro NC-1 residency preferred, plus refer to note below.} Shift Type: 8am-5pm EST , Mon-Fri

Preferred Skills/ Experience: 2+ years of Care Management experience Experience with electronic medical health records Microsoft office Long term care Discharge planning Education Requirement: Bachelor’s Certification: RN/ LCSW License

Day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD): Managing a case load for healthcare members with long term care needs. Monthly and quarterly member contact and will include 80% travel. Remote role. Will require a driver’s license. Member assessments and notes. Complete assessments with members, caregivers, or providers to obtain information regarding client status, support system, and need for services for care plan development. Monitor delivery of services and follow-up with members, caregivers, or provider s through in person visits and telephonic contact Authorize and coordinate referral for services. Ensure provider services are delivered without gaps and identify functional deficiencies in plans of care. Assist in coordinating the development of informal or voluntary services to integrate into the member care plan Collaborate with discharge planners, physicians, and other parties to ensure appropriate discharge plan, care plan, and coordination of acute care and long-term care services! Assist member with filing and resolving complaints and appeals.

Ternium Revenue Cycle Management

Clinical Review Nurse

Posted on:

April 30, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

At Ternium, we specialize in resolving complex healthcare insurance claim denials and delays. Our mission is to empower hospitals and health systems by optimizing their revenue cycle, allowing them to focus on what matters most—patient care. With a dedicated team of professionals, we consistently deliver outstanding results, increasing net patient revenue, improving cash flow, and reducing operational costs while enhancing the patient experience.

As a Clinical Review Nurse, you won’t just review charts—you’ll write compelling clinical arguments that help hospitals recover millions in lost revenue due to denied insurance claims. You’ll use your nursing knowledge, attention to detail, and love of documentation to make a real difference—without ever setting foot in a courtroom or hospital shift. This is a perfect role for nurses who: Want to step away from the bedside but still use their clinical skills. Love research, documentation, and writing. Want a fully remote, flexible role with meaningful impact. Are excited to grow with a fast-paced, mission-driven team.

RN License (required) 5+ years of acute hospital experience (required) Certification in Case Management, Legal Nurse Consulting, or Coding is a plus. Possess knowledge and experience with national clinical criteria applied in case management including InterQual and Milliman standards Experience and knowledge of managed care contracts, account receivables and revenue cycle functions (preferred) Experience and success in medical record chart review and appealing managed care denials (preferred)

Analyze denied insurance claims and complete medical records. Apply clinical reasoning, national criteria (InterQual/Milliman), and best practices to determine if appeals are justified. Draft persuasive, medically sound appeal letters that clearly support the need for treatment or services. Collaborate with our legal team to ensure appeals are compelling and complete. Stay informed on healthcare regulations, payer trends, and clinical updates.

Integrated Resources, Inc ( IRI )

Transition of Care Registered Nurse

Posted on:

April 30, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Virginia

Job Title: Transition of Care Registered Nurse Shift: Monday – Friday, 8:00 AM – 5:00 PM EST Location: 100% Remote – Preference for candidates in Northern VA or Central VA Role Overview: We are seeking a Registered Nurse (RN) with acute care experience to support inpatient case management teams in facilitating safe and timely discharge planning. This position is remote but requires familiarity with local Virginia healthcare facilities. The role may extend beyond the initial contract end date (6/30) to manage members until hospital discharge is completed.

Qualifications & Skills: Active RN license.Minimum of 2 years of acute care nursing experience Knowledge of discharge planning and case management principles Familiarity with healthcare facilities in Northern or Central Virginia preferred Ability to work standard business hours (8 AM – 5 PM EST) Monday through FridayStrong communication, coordination, and critical thinking skills. Additional Information: This is a 100% remote position. Preference for candidates residing in Northern VA or Central VA for local facility familiarity. Potential contract extension beyond 6/30 based on member needs.

Collaborate with inpatient Case Managers to coordinate safe and efficient hospital discharges. Communicate with Managed Care Organizations (MCOs) to identify and remove discharge barriers. Monitor member status and ensure continuity of care through discharge processes Document and report discharge planning activities in accordance with regulatory and organizational standards.

Integrated Resources, Inc ( IRI )

Registered Nurse

Posted on:

April 30, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

New Mexico

Title: Medical Management Specialist I Location: REMOTE in NM (with some local field visit) Duration: 6+ months (contract to hire)

Registered Nurse (RN), with 3 years direct clinical care to the consumer in a clinical setting or Licensed Professional Counselor (LPC), or Licensed Master Social Worker (LMSW), which includes 2 years of clinical practice to obtain their LPC or LMSW license. Current, valid, unrestricted license in the state of operations (or reciprocity). 3 years wellness or managed care experience presenting clinical issues with members/physicians. Knowledge of the health and wellness marketplace and employer trends. Verbal and written communication skills including discussing medical needs with members and interfacing with internal staff/management and external vendors and community resources. Analytical experience including medical data analysis. Current driver's license, transportation and applicable insurance. Ability and willingness to travel within assigned territory. PC proficiency includes Word, Excel, and PowerPoint, database experience and Web based applications. Preferred Job Qualifications: 2 years clinical experience. Patient education experience. Condition Management experience. Bilingual in English and Spanish. Transition of Care experience. Experience in managing complex or catastrophic cases. Certification in Case Management, Training, Project Management or nationally recognized health care certification.

This position is responsible for conducting medical management and health education programs for customers on government health care programs. This role will include gathering, analyzing and providing data for regulatory reports. This position will represent the company to members.

Collabera

Discharge Planning Registered Nurse

Posted on:

April 30, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Virginia

PAY RANGE: $40-$41/hr FULLY REMOTE but Candidates must be located in: Central/Northern Virginia

Must be a licensed RN Must have acute care experience Must have experience with discharge plannings Desired Skills and Experience: Registered Nurse,Discharge Plannings,Transition of Care,Acute Care

Work involves helping hospital case managers with safe and timely discharge planning May also coordinate with other insurance plans to avoid delays

Renalogic

Nurse Advocate (Bilingual)

Posted on:

April 30, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

RN

State License:

Compact / Multi-State

Renalogic is dedicated to helping our clients manage the human and financial costs of chronic kidney disease. To help us in our mission, we hire people who are humble, hungry, and smart. And it sure helps if you have a sense of humor. We're not perfect, but we're trying to build a company that we are all proud of. Our 96% client retention suggests we’re on the right path.

This role will be responsible for providing remote health coaching to members at risk for dialysis. This nurse must be bilingual in Spanish and will help members throughout the United States. Some evening hours and travel are required.

Bilingual in Spanish is required. A minimum of 3 years RN experience in a related role, including risk analysis, utilization review, population health, chronic disease management, and/or renal experience. Must have an RN license in good standing within a compact state. Ability and willingness to travel multiple times a year, which will include overnight stays for corporate gatherings, conferences, and health fairs. Ability to attend and professionally engage in video meetings. Strong technological skills, meaning you can effectively and efficiently use computers, peripheral equipment, and applications/systems, including Microsoft products. Autonomous self-starter who is comfortable with ambiguity. Creative mindset and ability to appropriately challenge the status quo. Superb written and oral communication skills. Ability to overcome obstacles with a ‘yes if...’ approach. Ability to effectively balance competing deadlines without losing focus on the bigger picture. Reliable internet and power with a designated area to conduct work with minimal interruptions.

Effectively maintain an assigned caseload of up to 100 managed members; which requires the ability to develop and maintain rapport, document effectively, and make appropriate escalations. Obtain and utilize clinical information to develop an individualized member care plan and clinician-centered care plan per NCQA guidelines. Effectively maintain an assigned caseload of up to 200 members requiring claims review, or claims monitoring; which requires the ability to make successful provider outreach as appropriate, document effectively, and make appropriate escalations. Outreach to providers to obtain information and assist with coordination of Care. Provide support and advocacy to members with barriers related to social determinants of health. Provide education and advocacy to members exploring treatment and coverage options for chronic and end-stage disease. Request/receive member PHI and ensure all information is appropriately documented/shared. Identify and share potential methods of increasing member engagement, improved reporting, or program enhancements. Support Integrated Care Nurse and Sr. Director of Member Advocacy with the collection of member level data to support cross-departmental functions. Understand the roles and responsibilities of each department within Renalogic to support company-wide business processes.

IntellaTriage

Remote Hospice Triage RN- PT 2 shift 3:30p-9:30p + rotating Sat & Sun 3:30p-12a

Posted on:

April 30, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-9:30p CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 3:30p-12a CST

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

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

IntellaTriage

Remote Hospice Triage RN- PT 3:30p-9:30p + rotating Sat & Sun 3:30-12a CST

Posted on:

April 30, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 6 days out of a 14-day pay period Part- time schedule: Work a minimum 2 evening shift weekly 3:30p-9:30p CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 3:30p-12a CST

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

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

UnitedHealth Group

Field HSS Clinical Coordinator RN – Round Rock & Georgetown, Texas

Posted on:

April 30, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

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 equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

If you are located within the Round Rock or Georgetown, TX market, you will have the flexibility to telecommute* as you take on some tough challenges. This is a Field Based role with a Home-Based office.

Required Qualifications: Current Registered Nurse unrestricted license in the state of Texas 2+ years of experience working within the community health setting or in a health care role Intermediate level of proficiency with Microsoft Office, including Word, Excel, and Outlook High-speed internet at residence Reliable transportation and the ability to travel in assigned region to visit Medicaid members in their homes and/or other settings, including community centers, hospitals, nursing facilities or providers’ office Preferred Qualifications: 1+ years of experience with long term care services and support, Medicaid or Medicare Ability to create, edit, save and send documents, spreadsheets and emails Knowledge of the principles of most integrated settings, including federal and State requirements like the federal home and community-based settings regulations. Reside within commutable distance of assigned duties

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the health care team

UnitedHealth Group

Field RN Care Coordinator - Nursing Facilities - Ellis & Johnson Counties, TX

Posted on:

April 30, 2025

Job Type:

Role Type:

License:

RN

State License:

Compact / Multi-State

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

In this RN Nurse Care Coordinator role, you will be an essential element of an Integrated Care Model by relaying the pertinent information about the member needs and advocating for the best possible care available, and ensuring they have the right services to meet their needs. Our team is made up of RNs, LVN’s, and CACs dedicated to helping members achieve their health care goals. We work closely with the nursing facilities in which our members reside. If you are within the Ellis and Johnson County, TX within one of the following zip code areas 75119, 76651, 75165, 76009 or 76031 and can travel locally, you will have the flexibility to work remotely as you take on some tough challenges. Travel required in local areas about 75% of the time based on business needs. This is a field-based position with a home-based office.

Required Qualifications: Current and unrestricted RN license in the state of Texas 2+ years of experience working within the community health setting or in a health care role Intermediate level of computer proficiency including Microsoft Outlook, Teams, and the ability to use multiple web applications Reliable transportation and the ability to travel in this ‘assigned region’ to visit Medicaid members in their homes and/or other settings, including community centers, hospitals, nursing facilities or providers’ offices Access to a designated quiet workspace in your home (separated from non-workspace areas) with the ability to secure Protected Health Information (PHI) Reside in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service Possess a valid US driver’s license Preferred Qualifications: 1+ years of experience with long term care services and support, Medicaid or Medicare Ability to create, edit, save and send documents, spreadsheets and emails Knowledge of the principles of most integrated settings, including federal and State requirements like the federal home and community-based settings regulations Reside within commutable distance of assigned duties

Assess, plan, and implement care strategies that are individualized by member and directed toward the most appropriate, lease restrictive level of care Identify and initiate referrals for member transition to community request and provide assist with social service programs, including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Communicate with all stakeholders for the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members Advocate for members and families as needed to ensure the member’s needs and choices are fully represented and supported by the health care team Visit Medicaid members in their homes and/or other settings, including community centers, hospitals, or providers’ offices

InGenesis, Inc.

LPN / Case Administrator Coordinator / Remote

Posted on:

April 30, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

InGenesis is one of the largest staffing firms in the industry and is among the largest diversity-owned healthcare staffing firms in North America. InGenesis is dedicated to placing people in positions that preserve life, improve lives, and inspire others. This does not happen without passionate people: skilled colleagues who are motivated to create innovative solutions and deliver superior service to our clients. InGenesis counts almost half of the Fortune 500 in our nearly 300 clients, including clients in the healthcare, life sciences, higher education and pharma industries.

LPN / Case Administrator Coordinator / Remote InGenesis is currently seeking a Licensed Practical Nurse / LPN to work remotely with our client located in Columbia, SC. In this role, you will perform Medical Review of clinical information using established criteria or clinical guidelines. In this role, you will provide support and review of medical claims and utilization practices. This is a REMOTE opportunity for a LPN living in the state of South Carolina. Apply today and we’ll reach out to answer any questions you may have!

Current Licensed Practical Nurse / LPN license in the State of South Carolina or active compact multistate unrestricted LPN license 3+ years managed care or physician's office experience Computer proficiency

Responsible for supporting and maintaining the coordination of daily operations of assigned area. Interfaces with the medical management on a regular basis to work more complex UR cases for the outpatient UR function Maintains the outpatient authorization process to include ensuring benefit coverage, reviewing/determining eligibility, reviewing of established UR criteria, interpreting rules and regulations. Completes authorization by following established policies Review interdepartmental requests and medical information to complete utilization process Documents process used and decision int he appropriate system in accurate and timely manner. Performed other duties as assigned.

Parexel

Clinical Research Staff - RN or Paramedic

Posted on:

April 30, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

North Carolina

Paramedic: Preferred Associate in Science degree in Life, Biomedical, or Social Science. Bachelor of Science in a health-related field desirable. Preferred qualifications include minimum of 1-2 years of work experience in clinical research trials as data collector or clinical coordinator. State of Connecticut licensure as EMT-P. Quality conscious with high degree of ethics and integrity carrying out duties in accordance to laws, regulatory standards, and with company policies and procedures. Proficiency in Microsoft (MS) Office and the ability to learn different software programs. Current certification in Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) required. Ability to work beyond normal work hours and various shift availability required. RN: Minimum of an Associate in Science degree in Life, Biomedical, or Social science. Bachelor of Science in a health-related field desirable. Minimum of 1-2 years of work experience in clinical research trials as data collector, clinical coordinator, or clinical research nurse is preferred. State of Connecticut licensure as RN. Quality conscious with high degree of ethics and integrity carrying out duties in accordance to laws, regulatory standards, and with company policies and procedures. Proficiency in Microsoft (MS) Office and the ability to learn different software programs. Current certification in Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) required. Ability to work beyond normal work hours and various shift availability required. #LI-REMOTE

Paramedic: Owns, maintains, and ensures clinical training transcripts are up to date at all times. Maintains proficiency in various clinical procedures required in study execution. Ensures clinical research studies are conducted according to protocol requirements and internal SOPs, guidelines, work instructions, and process maps. Provides basic first aid and medical/nursing care within scope of practice. Assists in sample management, collection, and generation of computer labels. Records adverse events with referral to medical or nursing personnel for evaluation & treatment. Performs electronic and diagnostic measurements including audiograms, electrocardiograms, visual exams, and other novel devices. Performs and records physical measurements including vital signs and body measurements. Creates volunteer identification (photos, badges). Provides necessary instructions to research participants. Monitors and maintains usage of daily clinic supplies. Maintains equipment log & calibration records. Creates and ensures quality in work and data output by performing data cache review. Attends various clinical meetings (i.e. study start-up, in-service, department meetings, etc.). Supports other additional clinical functions. Demonstrates holistic understanding of work processes at the Unit. Identifies with overall goals of the NHCRU and progresses clinical research studies as planned. Assists in the overall planning and delivery of clinical trials. Assists in the delivery of improved training program. Leads/supervises clinic pCROs (and colleagues, as appropriate) during various shifts of operation as required. Provides/ supervises clinic support activities such as scheduling (e.g., bed space, volunteer, staffing), supply requisitions and training, as required. Collaborates with clinical coordinators and clinical floor leads to maximize study implementation. RN: Owns, maintains, and ensures clinical training transcripts are up to date at all times. Maintains proficiency in various clinical procedures required in study execution. Ensures clinical research studies are conducted according to protocol requirements and internal SOPs, guidelines, work instructions, and process maps. Provides basic first aid and medical/nursing care within scope of practice. Assists in sample management, collection, and generation of computer labels. Records adverse events with referral to medical or nursing personnel for evaluation & treatment. Performs electronic and diagnostic measurements including audiograms, electrocardiograms, visual exams, and other novel devices. Performs and records physical measurements including vital signs and body measurements. Creates volunteer identification (photos, badges). Provides necessary instructions to research participants. Monitors and maintains usage of daily clinic supplies. Maintains equipment log & calibration records. Creates and ensures quality in work and data output by performing data cache review. Attends various clinical meetings (i.e. study start-up, in-service, department meetings, etc.). Supports other additional clinical functions as delegated by the Client. Demonstrates holistic understanding of work processes at the Unit. Identifies with overall goals of the Client’s CRU and progresses clinical research studies as planned. Assists in the overall planning and delivery of clinical trials. Assists in the delivery of improved training program. Leads/supervises clinic contractors (and colleagues, as appropriate) during various shifts of operation as required. Provides/ supervises clinic support activities such as scheduling (e.g., bed space, volunteer, staffing), supply requisitions and training, as required. Collaborates with clinical coordinators and clinical floor leads to maximize study implementation. Completes training assigned by Client and/or PXL, as necessary, including general training requirements, SOPs, system, and process related training. Adheres to PXL and Client SOPs and processes.

eClinicalWorks

Clinical Informaticist - NP/PA

Posted on:

April 30, 2025

Job Type:

Full-Time

Role Type:

Informatics

License:

NP/APP

State License:

Massachusetts

We are eClinicalWorks. We are a privately held leader in healthcare IT, providing comprehensive, cloud based EHR/PRM solutions to medical professionals worldwide to improve workflows and reduce the risk of physician burnout. We care. We are committed to positive change. And that’s where you come in. Do you value creativity and innovation? Great, so do we. At eClinicalWorks, we share a passion for improving healthcare through dedication, education, and teamwork. Everyone has that one thing they’re really good at. We value your talent and want you to join our fast-paced, fun, and culturally diverse environment. Ready to make a difference? Apply today.

The Clinical Informaticist serves as a clinical expert to ensure the safe delivery of healthcare technology products by eClinicalWorks. Collaborating with various departments, the Clinical Informaticist will play a key role in enhancing product quality, safety, and usability.

Experience/Education Requirements: Bachelor’s Degree required; Master’s Degree preferred Adheres to all company policies and mandatory compliance protocols as required by eCW Currently registered as a licensed Nurse Practitioner/Physician Assistant. 5+ years of direct patient care experience in an outpatient and/or inpatient setting (including utilization of an electronic medical record system) 3+ years of experience in clinical informatics, patient safety, and/or a related field and the following: Experience with Electronic Health Records (EHR) systems Familiarity with healthcare workflows and clinical decision support systems Proficiency in using and understanding EHR/EMR systems, particularly in relation to interoperability and data integration Strong analytical skills to assess clinical data and identify potential patient safety risks Other Skills/Abilities: Familiarity with HL7 Fundamentals (FHIR, V2, V3, CDA standards) Experience with clinical content development and management A degree in Clinical Informatics, or a related discipline are a plus HL7 certification is a plus Excellent communication and interpersonal skills to effectively collaborate with cross functional teams and represent customer needs Strong critical thinking and problem-solving skills with a proactive approach to identifying and mitigating risks. Ability to manage multiple tasks and projects simultaneously in a fast-paced environment A deep commitment to and representative of patient safety and quality improvement Ability to maintain detailed and accurate documentation throughout the software lifecycle

Provide functional support throughout the software development life cycle. Collaborate with cross-functional teams to enhance products safety, quality, and usability. Review and evaluate requirements for clinical products, modules, and workflows, for completeness and accuracy. Work closely with R&D teams to engineer prompts for Clinical AI (Artificial Intelligence) products and functionalities. Perform and document validations on the output generated by the Clinical AI products and functionalities. Create and maintain documentation related to clinical risk processes, including Hazard Logs and safety case reports. Review and identify patient safety concerns reported by customers and internal stakeholders. Lead customer calls where patient harm was reported to ensure all necessary documentation and appropriate actions are taken. Collaborate with internal teams to address patient safety issues by recommending corrective and preventive actions. Share clinical and patient safety information with internal and external stakeholders. Develop and maintain clinical content for various medical specialties within the EHR product suite. Work with implementation teams to engage with customers and assist with onboarding and optimizing client workflows and product utilization. Ensure compliance with regulatory standards and provide clinical safety information to external organizations. Foster a culture of safety within the organization and industry. Quarterly travel to the company headquarters is required Travel to customer sites, tradeshows, conferences, and events as needed (up to 20% of the time). Perform additional duties as assigned.

eClinicalWorks

Clinical Informaticist - RN

Posted on:

April 29, 2025

Job Type:

Full-Time

Role Type:

Informatics

License:

RN

State License:

Massachusetts

We are eClinicalWorks. We are a privately held leader in healthcare IT, providing comprehensive, cloud based EHR/PRM solutions to medical professionals worldwide to improve workflows and reduce the risk of physician burnout. We care. We are committed to positive change. And that’s where you come in. Do you value creativity and innovation? Great, so do we. At eClinicalWorks, we share a passion for improving healthcare through dedication, education, and teamwork. Everyone has that one thing they’re really good at. We value your talent and want you to join our fast-paced, fun, and culturally diverse environment. Ready to make a difference? Apply today.

The Clinical Informaticist serves as a clinical expert to ensure the safe delivery of healthcare technology products by eClinicalWorks. Collaborating with various departments, the Clinical Informaticist will play a key role in enhancing product quality, safety, and usability.

Experience/Education Requirements: Bachelor’s Degree required; Master’s Degree preferred Adheres to all company policies and mandatory compliance protocols as required by eCW Currently registered as a licensed Registered Nurse. 5+ years of direct patient care experience in an outpatient and/or inpatient setting (including utilization of an electronic medical record system) 3+ years of experience in clinical informatics, patient safety, and/or a related field and the following: Experience with Electronic Health Records (EHR) systems Familiarity with healthcare workflows and clinical decision support systems Proficiency in using and understanding EHR/EMR systems, particularly in relation to interoperability and data integration Strong analytical skills to assess clinical data and identify potential patient safety risks Other Skills/Abilities: Familiarity with HL7 Fundamentals (FHIR, V2, V3, CDA standards) Experience with clinical content development and management A degree in Clinical Informatics, or a related discipline are a plus HL7 certification is a plus Excellent communication and interpersonal skills to effectively collaborate with cross functional teams and represent customer needs Strong critical thinking and problem-solving skills with a proactive approach to identifying and mitigating risks. Ability to manage multiple tasks and projects simultaneously in a fast-paced environment A deep commitment to and representative of patient safety and quality improvement Ability to maintain detailed and accurate documentation throughout the software lifecycle

Provide functional support throughout the software development life cycle. Collaborate with cross-functional teams to enhance products safety, quality, and usability. Review and evaluate requirements for clinical products, modules, and workflows, for completeness and accuracy. Work closely with R&D teams to engineer prompts for Clinical AI (Artificial Intelligence) products and functionalities. Perform and document validations on the output generated by the Clinical AI products and functionaCreate and maintain documentation related to clinical risk processes, including Hazard Logs and safety case reports. Review and identify patient safety concerns reported by customers and internal stakeholders. Lead customer calls where patient harm was reported to ensure all necessary documentation and appropriate actions are taken. Collaborate with internal teams to address patient safety issues by recommending corrective and preventive actions. Share clinical and patient safety information with internal and external stakeholders. Develop and maintain clinical content for various medical specialties within the EHR product suite. Work with implementation teams to engage with customers and assist with onboarding and optimizing client workflows and product utilization. Ensure compliance with regulatory standards and provide clinical safety information to external organizations. Foster a culture of safety within the organization and industry. Quarterly travel to the company headquarters is required Travel to customer sites, tradeshows, conferences, and events as needed (up to 20% of the time). Perform additional duties as assigned.

The Cigna Group

RN Clinical Program Senior Advisor - Work from Anywhere, USA

Posted on:

April 29, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Conneticut

This position includes conducting research and analysis of published medical literature to respond to internal and external inquiries, as well as the development and maintenance of Cigna Medical Coverage Policies within the ICOG unit. This position requires identification of opportunities for Clinical Policy development and ability to conduct core clinical evidence reviews through the Healthcare Medical Assessment process. This position has significant interdisciplinary policy connections; the individual in this role must be comfortable, experienced and successful working in a team culture, as well as being able to take ownership of designated clinical policies.

RN, BSN, PhD degree or equivalent Active unrestricted RN in state of residency Experience with evidence-based development processes and familiarity with US governing regulatory activity related to new product approvals. Understanding of medical coverage policies; three years or more experience working for a health plan. Excellent writing, communication and presentation skills are necessary for this role. Must have prior experience with either clinical research or experience with writing (i.e., clinical papers, journal articles, training documents, SOP’s, technical writing, etc.). Ability to synthesize complex information and data into concise, understandable written responses/written responses. Ability to remain highly focused and organized in a fast-paced environment with frequent change and/or deadlines. Medicare experience a plus (i.e., understanding NCD/LCD’s and Medicare Chapter guidelines) Experience or a general understanding of genetic medical policies is a plus. If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

Develops evidence-based medical coverage policies through analytic evaluation of published medical literature. Understands levels of evidence and can discuss the quality of a study to ensure coverage policies and medical inquiry responses transparently convey the strengths, weaknesses, and implications of published evidence. Presents new and revised coverage policies to a clinical audience in monthly Healthcare Medical Assessment Committee meetings. Effectively partners with medical policy team, manager, Medical Directors, clinical subject matter experts, and external vendors. Ensures that coverage policies are implemented, deployed to internet sites, and changes communicated within and outside the organization. Participates in special projects within the team as needed. Provides support as the coverage policy subject matter expert (SME) for the creation and maintenance of automation pathways.

HealthAxis Group

Utilization Review Nurse

Posted on:

April 29, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Florida

HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. We are transforming the way healthcare is administered by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences. We live and work with purpose, care about others, act with integrity, communicate with transparency, and don’t take ourselves too seriously. We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as a team to serving our valued clients. We believe that creating a vibrant and human-centric environment can inspire engagement, empower our team members, and ignite a sense of purpose in all that we accomplish.

The Utilization Review Nurse is responsible for the medical necessity review of outpatient services that require prior authorization, and/or management of concurrent inpatient admissions. The medical necessity review process includes assessment and interpretation of plan specific benefits, medical criteria, and clinical documentation.

Licensed RN or LPN required. Minimum of two to three years varied clinical experience required. Managed care experience preferred. An equivalent combination of education, training, and experience. Ability to read and interpret documents and calculate figures and amounts. Excellent oral and written communication skills including good grammar, voice and diction. Proficient in MS Office with basic computer and keyboarding skills. Excellent customer service skills (friendly, courteous and helpful). InterQual experience helpful.

Performs prospective, concurrent, and retrospective inpatient and/or outpatient utilization reviews (UR) using evidence-based guidelines, policies and nationally recognized clinical criteria, and internal policies and procedures. Evaluates severity of illness and intensity of service of member’s needs at time of inpatient admission utilizing approved criteria. Triage and prioritize cases and other assigned duties to meet CMS turnaround time standards. Prepare and escalate cases to MDs for review when appropriate. Demonstrates effective communication methods and skills, using lines of authority appropriately. Establishes a relationship with providers to determine/provide needed services to member. Maintains accurate record of UR activities. Regular attendance is required as employee works as part of a team & requires interaction with medical staff and clients. Adheres to quality standards and confidentiality policies and procedures. Ensures compliance with all state and federal regulations and guidelines in day-to-day activities. Adapts to changes in policies, procedures, new techniques, and additional responsibilities. CUSTOMER SERVICE: Responsible for driving the HealthAxis culture through values and customer service standards. Accountable for outstanding customer service to all external and internal contacts. Develops and maintains positive relationships through effective and timely communication. Takes initiative and action to respond, resolve and follow up regarding customer service issues with all customers in a timely manner.

Molina Healthcare

Sr. Specialist, Quality Provider Engagement- RN / LPN Preferred (Remote)

Posted on:

April 29, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Mississippi

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.

The Sr Specialist, Provider Engagement role implements Health Plan provider engagement strategy to achieve positive quality and risk adjustment outcomes through effective provider engagement activities. Ensures the core set of Tier 2 providers in the Health Plan have engagement plans to meet annual quality and risk adjustment goals. Drives coaching and collaboration with providers to improve performance through regular meetings and action plans. Addresses practice environment challenges to achieve program goals and improve health outcomes. Tracks engagement activities using standard tools, facilitates data exchanges, and supports training and problem resolution for the Provider Engagement team. Communicates effectively with healthcare professionals and maintains compliance with policies.

REQUIRED QUALIFICATIONS: Bachelor’s degree in Business, Healthcare, Nursing or related field or equivalent combination of education and relevant experience Min 3 years experience experience improving provider Quality performance through provider engagement, practice transformation, managed care quality improvement, or equivalent experience. Experience with various managed healthcare provider compensation methodologies including but not limited to: fee-for service, value-based care, and capitation Strong working knowledge of Quality metrics and risk adjustment practices across all business lines Demonstrates data analytic skills Operational knowledge and experience with PowerPoint, Excel, Visio Effective communication skills Strong leadership skills PREFERRED QUALIFICATIONS: Min 3 years experience improving Quality performance for Medicaid, Medicare, and/or ACA Marketplace programs

Ensures assigned Tier 2 & Tier 3 providers have a Provider Engagement plan to meet annual quality & risk adjustment performance goals. Drives provider partner coaching and collaboration to improve quality performance and risk adjustment accuracy through consistent provider meetings, action item development and execution. Addresses challenges/barriers in the practice environment impeding successful attainment of program goals and understands solutions required to improve health outcomes. Drives provider participation in Molina risk adjustment and quality efforts (e.g. Supplemental data, EMR connection, Clinical Profiles programs) and use of the Molina Provider Collaboration Portal. Tracks all engagement and training activities using standard Molina Provider Engagement tools to measure effectiveness both within and across Molina Health Plans. Serves as a Provider Engagement subject matter expert; works collaboratively within the Health Plan and with shared service partners to ensure alignment to business goals. Assist Provider Engagement Specialists with training and problem escalation. Accountable for use of standard Molina Provider Engagement reports and training materials. Facilitates connectivity to internal partners to support appropriate data exchanges, documentation education and patient engagement activities. Develops, organizes, analyzes, documents and implements processes and procedures as prescribed by Plan and Corporate policies. Communicates comfortably and effectively with Physician Leaders, Providers, Practice Managers, Medical Assistants within assigned provider practices. Maintains the highest level of compliance. This position may require same day out of office travel approximately 0 - 80% of the time, depending upon location.

Humana

UM Nurse- Compact License required

Posted on:

April 29, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Required Qualifications: Minimum of associate degree in nursing Licensed Registered Nurse (RN) in a compact state with no disciplinary action. Must have valid compact license or reside in a compact state and be eligible to upgrade to compact licensure. Three (3) or more years of progressive clinical experience Effective telephonic and virtual communication skills Comprehensive knowledge of Microsoft Word, Outlook and Excel Ability to work independently under general instructions and within a team. Work-At-Home Requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance is 25mbs download x 10mbs upload is required. Check your internet speed at www.speedtest.net A dedicated office space lacking ongoing interruptions so you can meet productivity requirements, and to protect member PHI / HIPAA information. Preferred Qualifications: BSN 2 to 3 years of home health experience and/or utilization management experience Experience in a managed care setting Health Plan experience CGX experience Bilingual in English/Spanish Additional Job Description: A secure home-office space, full-time uninterrupted work hours and hard-wired, high-speed internet service is required for this position The Utilization Management Nurse 2 helps to ensure fully coordinated care at home for our members. Success in this role requires the following: Must be passionate about contributing to an organization focused on continuously improving consumer experiences. Excellent organizational and time management skills Solid analytical skills to understand and interpret data to make recommendations to improve patient care. Technical savvy and ability to navigate multiple systems and screens while working cases. Collaboration skills to effectively interact with multiple parties both internal and external. An understanding of department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Ability to make decisions regarding your own work methods, occasionally in ambiguous situations, and with minimal direction receiving guidance where needed. Ability to follow established guidelines/procedures. Speedtest by Ookla - The Global Broadband Speed Test Use Speedtest on all your devices with our free desktop and mobile apps. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

IMCS Group

Prior Authorization Nurse - Clinical Review

Posted on:

April 29, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Texas

Job Title: Clinical Review Nurse – Prior Authorization Duration: 12 months Contract. Desired Start Date/End Date: 6/2/2025 - 5/29/2026 Location: Remote. (MST time would be preferred) Shift Type: Mon to Thu-Sat 7am-6pm or Wed-Sat 7am-6pm (Saturday a must)

Experience Required: Prior Authorization/UM experience. Knowledge of Medicare and Medicaid regulations preferred. Microsoft Office experience. Reliable internet connection. Education/Certification Required: Graduate from an Accredited School of Nursing Preferred: Associate degree Licensure Required: LPN/LVN or RN License Preferred: RN License

Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. Performing clinical reviews for our non-par authorization requests. Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members