Availity

Utilization Management Nurse Analyst (Remote)

Posted on:

April 15, 2025

Job Type:

Part-Time

Role Type:

Utilization Review

License:

RN

State License:

Florida

Availity delivers revenue cycle and related business solutions for health care professionals who want to build healthy, thriving organizations. Availity has the powerful tools, actionable insights and expansive network reach that medical businesses need to get an edge in an industry constantly redefined by change. At Availity, we're not just another Healthcare Technology company; we're pioneers reshaping the future of healthcare! With our headquarters in vibrant Jacksonville, FL, and an exciting office in Bangalore, India, along with an exceptional remote workforce across the United States, we're a global team united by a powerful mission. We're on a mission to bring the focus back to what truly matters – patient care. As the leading healthcare engagement platform, we're the heartbeat of an industry that impacts millions. With over 2 million providers connected to health plans, and processing over 13 billion transactions annually, our influence is continually expanding. Join our energetic, dynamic, and forward-thinking team where your ideas are celebrated, innovation is encouraged, and every contribution counts. We're transforming the healthcare landscape, solving communication challenges, and creating connections that empower the nation's premier healthcare ecosystem.

The position of UM Nurse Analyst will report to the Medical Director of Availity’s Auth AI solution. The UM Nursing Analyst is responsible for the interpretation of payer medical policy guidelines and the construction of NLP/AI–enabled decision trees that accurately reflect medical necessity criteria. The role requires in-depth knowledge of utilization management principles, the role and purpose of medical necessity guidelines and prior authorization adjudication practices. This individual will work in a team environment and will be expected to perform highly complex tasks while collaborating with team members with both clinical and engineering/programming backgrounds. The successful candidate will be detail oriented with strong analytic reasoning skills, demonstrate strong communication and organizational skills while remaining open-minded, embracing change and the spirit of innovation. Sponsorship, in any form, is not available for this position. Location: Remote, US Why you want to work on this team: Dynamic, collaborative group working on innovative technologies to disrupt the status quo and solve the problem of prior authorization in healthcare. Opportunity to work directly on cutting edge AI technology and its application to the healthcare industry.

Bachelor’s degree in nursing. At least 3+ years of experience in an outpatient Utilization Management program, either with an insurer or with a healthcare provider OR equivalent clinical experience with familiarity with prior authorization submission practices. Additional experience in fields of billing / coding, claims review or inpatient utilization management, while not necessary, would enhance the application. “Computer smart” – General power user of technology and confident with navigating new technologies and applications. Familiarity and understanding of interpreting medical records to be able to identify how physicians may document conditions and findings. You will set yourself apart: If you have exceptional critical thinking and reasoning skills. If you can synthesize complex, abstract problems, and collaborate effectively with team members with diverse skillsets to create solutions. If you are self-motivated and a quick learner with an ability to multi-task.

Reviewing payer Medical Policy Guidelines to identify pertinent medical necessity criteria related to specific Procedural codes or CPT codes. Use programming language to construct attestation questions that reflect medical necessity criteria. Assign coded medical constructs to attestation trees based on clinical relevance to facilitate automation of responses to the questions. Identify medical terms that should be added to the existing vocabulary of coded medical concepts. Serve as Subject Matter Expert and general medical resource to engineering teams and developers

Frederick National Laboratory for Cancer Research

Clinical Research Nurse III

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Maryland

The Frederick National Laboratory is operated by Leidos Biomedical Research, Inc. The lab addresses some of the most urgent and intractable problems in the biomedical sciences in cancer and AIDS, drug development and first-in-human clinical trials, applications of nanotechnology in medicine, and rapid response to emerging threats of infectious diseases. Accountability, Compassion, Collaboration, Dedication, Integrity and Versatility; it's the FNL way.

Within Leidos Biomedical Research Inc., the Clinical Monitoring Research Program Directorate (CMRPD) provides strategic, operational, and program/project management support to domestic and international clinical research initiatives sponsored by the National Cancer Institute (NCI), the National Institute of Allergy and Infectious Diseases (NIAID), and various other institutes within the National Institutes of Health (NIH). CMRPD’s services are strategically aligned with the program’s mission to provide comprehensive, dedicated support to assist NIH researchers in providing the highest quality of clinical research that complies with applicable regulations and guidelines, maintains data integrity, and protects human subjects. These clinical trials investigate the prevention, diagnosis, and therapeutic treatment of cancer, influenza, HIV, and other diseases and disorders. CMRPD is providing support to NCI’s Division of Cancer Treatment and Diagnosis (DCTD) Virtual Clinical Trials Office (VCTO) pilot. The pilot aims to determine if participant enrollment to NCI clinical trials, particularly for minority and underserved populations, can be improved by establishing a team of virtual research support staff to provide remote, centralized support to U.S. NCI research sites, including those sites participating in the NCI Community Oncology Research Program (NCORP). The remote support team will supplement and compliment the clinical site staff at NCI research sites to offset clinical-trial specific activities, including subject screening, enrollment, and data entry. A research nurse is required to implement and lead the VRS team in support of this program. The position is 100% remote. Candidates must reside in the U.S.

Possession of a Bachelor’s degree from an accredited college or university according to the Council for Higher Education Accreditation (CHEA) in a related field. Foreign degrees must be evaluated for U.S. equivalency. Possession of a current unencumbered professional license as a Registered Nurse (RN) from any U.S. state. In addition to educational requirements, a minimum of five (5) years of progressively responsible, relevant nursing experience in clinical research, including directly managing multiple concurrent projects and patient data systems, as well as an advanced understanding of clinical trial protocol operations and design. Advanced to expert clinical research nursing experience in adult oncology. Working knowledge and understanding of: Biological principles and scientific methods International Conference on Harmonization/Good Clinical Practices (ICH/GCP) guidelines, clinical research concepts, regulatory, ethics, processes, and clinical protocol implementation Cancer pathophysiology, treatment modalities and side effects Technical proficiency using: Cloud–based clinical trial data management systems (i.e., Medidata Rave) and enrollment tracking systems (e.g., OPEN) Electronic health record systems (e.g., Epic, Cerner, etc.) Microsoft Office products (e.g., Excel, Word) Online/virtual platforms (e.g., Webex, Zoom, MS Teams) Highly effective: Interpersonal and cross-cultural communication skills (written, verbal, non-verbal, and virtual) Organizational skills with the ability to prioritize and manage multiple tasks with a high degree of accuracy and attention to detail Planning, and problem-solving skills Computer skills Ability: Ability to work effectively, both independently and collaboratively, with ability to motivate team members, track progress, and contribute to the team’s performance Identify trends and appropriately escalate findings Demonstrate strong initiative, accountability, and reliability Multidirectional leadership Manage customer relationships Troubleshoot basic IT problems Ability to obtain and maintain a security clearance. PREFERRED QUALIFICATIONS: Candidates with these desired skills will be given preferential consideration: Prior experience with: Study coordination NCTN trials Performing user acceptance trainings Epic, Cerner, OPEN, Medidata Rave, OnCore, Velos eResearch, Complion Professional Certification in Oncology and Clinical Research

Collaboration and Leadership: Serves as the clinical expert for a team of clinical research professionals, providing education to team members on disease processes, treatment modalities, and best practices Coordinates with team leads to perform routine quality control checks, communicates findings, and provides staff education/training to improve team performance Provides coverage for team leads, including leading team and site meetings Works with pilot administrative leadership to coordinate, implement, and monitor pilot expansion Identifies and implements additional opportunities to further minimize the research burden on the clinical site research staff and study participants Works with clinical site staff to coordinate care and provides education on research needs/requirements and VCTO procedures Ability to adapt to evolving requirements and willingness to perform a variety of tasks that may be required to launch and implement the VCTO program Participant Identification, Screening, and Enrollment: Communicates with potential clinical trial participants and referring providers about the screening and enrollment process Facilitates the procurement of outside medical records and materials, and appropriately organize and file those materials Reviews participant materials to appropriately advise local teams on potential participant eligibility for protocols Documents screening and enrollment activities in appropriate databases (e.g., NCI Oncology Patient Enrollment Network, also known at OPEN) Participant Management: Assists with participant retention efforts Reviews medical records to identify con-meds and AEs/unanticipated problems/SAEs Provides medical coding to ensure standardization of terminology and grading Tracks AEs/SAEs through end of event Maintains accurate con-meds and problem lists Assists study sites with follow-up AE/SAE reporting requirements and close-out procedures Data Management: Completes the collection and entry of research participant data and study-related information sourced from the Electronic Health Record (e.g., Epic, Cerner, etc.) into electronic clinical data capturing systems (e.g., eCRFs, Medidata Rave, REDCap) and clinical trial management systems (e.g., OnCore, Florence e-Reg, Velos eResearch, Complion, etc.) timely and accurately to ensure data integrity Tracks and confirms source materials (i.e., images, path) and submit for protocol-defined processing Files and maintains records in accordance with protocol and site-specific guidance Evaluates clinical data for accuracy and completeness while ensuring the safety and confidentiality of clinical trial participant data Collaborates with local site staff and remote VCTO team members to resolve queries to meet protocol requirements in an efficient and effective manner Alerts site study teams to adverse events, abnormal outcomes, or problematic trends, specifically regarding protocol requirements Protocol Coordination: Assists in the preparation of regulatory and protocol-specific documents Edits protocol template documents to add site-specific language and confirms consistency across all protocol documents Helps to ensure proper and timely filing of protocol amendments, annual reports, and other regulatory documents to the IRB and NCI Tracks and manages IRB submissions Enters study coordinators progress notes Assists with study start-up and closure

Wellbox Health

Remote Chronic Care Coordinator - LPN (PST/MST)

Posted on:

April 15, 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. Pay Structure Orientation + Training (First two months): $20 hourly. Post-Orientation: $22 hourly, plus bonus incentive. Monthly Bonuses up to $525. Referral Bonuses up to $1000.

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) are preferred; candidates in Pacific or Central time zones will also be considered.

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.

Red River Pharmacy Services

Part Time LPN

Posted on:

April 15, 2025

Job Type:

Part-Time

Role Type:

License:

LPN/LVN

State License:

Akansas

Red River Pharmacy is seeking a dedicated, skilled, and compassionate Licensed Practical Nurse (LPN) with IV therapy experience to meet our growing patient census. The LPN is responsible for providing care to assigned patients under the supervison of a Registered Nurse (RN) and in accordance with the patient’s plan of care in the home and clinical setting. The ideal candidate is confident with basic IV therapy, patient education, and is willing to travel.

Graduate of an accredited school of nursing and current LPN state license. At least one year of recent nursing experience. Effective interpersonal, time management and organizational skills. Strong communication skills in speaking and writing. Ability to recognize and direct information to the appropriate health care provider. Computer skills that include word processing, and efficient use of the internet and e-mail. Current CPR card, valid driver’s license, reliable transportation, automobile

Demonstrates competency in providing patient care and provides care in accordance with professional standards and state’s nurse practice act. Educates patients and caregivers about IV therapy, medication administration, potential side effects, and signs of complications in the home and clinical setting. Collaborates with other healthcare professionals, including physicians, RNs, and other members of the healthcare team, to ensure continuity of care. Maintains strict infection control practices to prevent complications associated with IV therapy. Thoroughly documents all aspects of patient care, including assessments, medication administration, monitoring, and patient education. Supports patients with professionalism and kindness Represents agency in a positive and professional manner.

UW Medicine

RN Clinical Documentation Second Level Reviewer

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Washington

UW Medical Center is an acute care academic medical center located in Seattle with two campuses: Montlake and Northwest. As the No. 1 hospital in Seattle and Washington State since 2012 (U.S. News & World Report) and nationally ranked in seven specialties, UW Medical Center prides itself on compassionate patient care as well as its pioneering medical advances. The UW Medical Center-Montlake campus is located on the edge of the beautiful UW campus which includes many amenities available to our staff as well as very convenient public transit options including the Sound Transit’s light rail station across the street. Excellence. Exploration. Education. Become part of our team. Join our mission to make life healthier for everyone in our community.

UW MEDICAL CENTER – MONTLAKE has an outstanding opportunity for a Second Level Review Clinical Documentation Integrity Specialist (RN). WORK SCHEDULE Full-time day shift. The work is fully remote. POSITION HIGHLIGHTS Following established policies, procedures, and professional guidelines, the Second Level Review Clinical Documentation Integrity Specialist (SLR CDIS) provides industry expertise on focused accounts that are set by the direction of CDP leadership to ensure high quality standards are met for risk adjustment, DRG accuracy, SOI and ROM. DEPARTMENT DESCRIPTION The Clinical Documentation Integrity Program (CDIP) performs concurrent review of inpatient medical records to ensure provider documentation accurately reflects patient severity of illness (SOI), acuity of care needs, risk of mortality (ROM) and the quality of treatment provided. Team members also serve on various multidisciplinary committees promoting quality improvement and patient safety initiatives.

Please apply only if you meet the listed requirements below. Current WA RN License or compact RN license Minimum of 6 years of nursing experience to an acute inpatient hospital setting with in-depth knowledge of medical and surgical care. ER or ICU experience preferred. Minimum of 5 years of experience in Clinical Documentation Improvement role. Risk adjustment experience required (Vizient and Elixhauser preferred) Current Certification in CDI (CCDS, CDIP or CCS)

Reviews target DRGs specified by CDP Manager, which is an evolving workflow. This review may focus various elements including, but not limited to, CC/MCC capture rate and/or risk adjustment review and will be clarified by DRG. Ensures that pertinent patient conditions and treatments are documented such that appropriate reimbursement is received for the level of acuity and service rendered to all patients using a DRG based payer (Medicare) methodology. Verifies the accuracy and completeness of clinical information used for measuring and reporting outcomes related to patient care, physician practice and the medical center performance. Participates in various projects and initiatives within the Clinical Documentation Program. Based on findings, department goals and initiatives and industry expectation, the SLR CDIS will participate in the education and evaluation of the CDI team. Collaborate with medical records coding staff, patient financial services (PFS) and compliance for Clinical Validation Denial appeals.

Momentum Life Sciences

Bilingual (Spanish) Virtual Clinical Educator (Remote)

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Indiana

**This posting is for future opportunities with Momentum Life Sciences** The Bilingual (Spanish) Virtual Clinical Educator is responsible for utilizing professional clinical skills, including the ability to foster patient relationships through empathy and clinical experience, to provide personalized, high-touch support to patients recently prescribed a complex therapy. The role will engage with patients and providers to provide expert, clinically relevant, individualized counsel in conjunction with product support the new therapy regimen. The VCE will manage a series of touch points as the trusted clinical advocate to a specified patient caseload. The touch points will uncover patient barriers and internal motivators, taking patients from product onboarding to therapy initiation to milestone celebrations, motivation, maintenance, and eventual “graduation” from the program. This role will work collaboratively to enhance the patient start experience and support patient compliance and persistence initiatives by building individual relationships with patients. The educator will provide ongoing education and therapy support to the patient, their caregiver, clinical staff, and/or support network.

Registered Nurse with current, unrestricted license Previous telephonic patient support environment experience, including use of an inbound/outbound call system, with seamless warm transfers HCP and/or Patient education experience, including infusion or injection experience required Compassion, high emotional intelligence, and a passion to be a patient educator Strong communication and written skills to a variety of audiences, and experience working with a treatment team Proven adaptability to changing business demands and problem solving in a fast-paced environment Competent and comfortable utilizing technology Experience working for or contracting with pharmaceutical preferred Experience in motivational interviewing and coaching behavior change Ability to work within established guardrails while maintaining personal rapport with the patient Self-starter with proven adaptability to changing business demands and product relevance in a fast-paced environment Ability to actively listen while multi-tasking High level of comfort with technology, including Microsoft Office products, working on dual monitors, CRM, and strong typing skills are required #LI-Remote

Serves as the single point of contact in the treatment process from start to finish Demonstrates empathy and effectively engages patients, creating a personalized relationship-based connection built on trust and rapport Provide disease education, product overview, device training, and side effect management Proactively reaches out to the patient to provide high-touch support to connect the dots for the patient throughout their program journey Create patient empowerment through a series of “wow” engagements along the patient journey Utilize motivational interviewing tools to quickly and accurately anticipate and address patient barriers; personalize patient messaging concisely, within established time parameters, and in a way that resonates Communicate effectively; understand and influence patient initiation and support processes, encourage patient confidence and accountability to help patients start and stay on therapy Ensure success of program through collaborative partnerships with patients, brand, and operations partners Use intuition and clinical expertise to offer patients appropriate responses to their questions; discern the most beneficial information for the patients; accurately assess patients using provided guidelines outlined in approved messaging Ensure the patient is aware of all the patient services available to them and assisting to connect them to the right resource Connect the patient to local support groups, advocacy groups, and other external resources Provide health coaching throughout the journey to support adherence and compliance to medication Provide assistance and guidance through access and affordability journey Provide HCP feedback to keep them aware of the patient’s participation in the support program Provide education to the care team and proactively reaching out after the clinical decision has been made to start a new patient on regimen Triage and follow-up with Specialty Pharmacy to support patient getting product and knowing where product is in process Provide continuous updates, guidance, and triaging when needed and most importantly ensuring that the patient is driving towards the right health outcomes. Ensure all activities are conducted in a manner that is compliant with all Momentum, client, and industry mandated rules and regulations

Momentum Life Sciences

Full Time Virtual Clinical Educator (11-8p EST) (Remote)

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Indiana

**This role will be covering the the hours of 11-8p EST, Monday through Friday** The Virtual Clinical Educator is responsible for utilizing professional clinical skills, including the ability to foster patient relationships through empathy and clinical experience, to provide personalized, high-touch support to patients recently prescribed a complex therapy. The role will engage with patients and providers to provide expert, clinically relevant, individualized counsel in conjunction with product support the new therapy regimen. The VCE will manage a series of touch points as the trusted clinical advocate to a specified patient caseload. The touch points will uncover patient barriers and internal motivators, taking patients from product onboarding to therapy initiation to milestone celebrations, motivation, maintenance, and eventual “graduation” from the program. This role will work collaboratively to enhance the patient start experience and support patient compliance and persistence initiatives by building individual relationships with patients. The educator will provide ongoing education and therapy support to the patient, their caregiver, clinical staff, and/or support network.

Registered Nurse with current, unrestricted license Previous telephonic patient support environment experience, including use of an inbound/outbound call system, with seamless warm transfers HCP and/or Patient education experience, including infusion or injection experience required Compassion, high emotional intelligence, and a passion to be a patient educator Strong communication and written skills to a variety of audiences, and experience working with a treatment team Proven adaptability to changing business demands and problem solving in a fast-paced environment Competent and comfortable utilizing technology Experience working for or contracting with pharmaceutical preferred Experience in motivational interviewing and coaching behavior change Ability to work within established guardrails while maintaining personal rapport with the patient Self-starter with proven adaptability to changing business demands and product relevance in a fast-paced environment Ability to actively listen while multi-tasking High level of comfort with technology, including Microsoft Office products, working on dual monitors, CRM, and strong typing skills are required #LI-Remote

Serves as the single point of contact in the treatment process from start to finish Demonstrates empathy and effectively engages patients, creating a personalized relationship-based connection built on trust and rapport Provide disease education, product overview, device training, and side effect management Proactively reaches out to the patient to provide high-touch support to connect the dots for the patient throughout their program journey Create patient empowerment through a series of “wow” engagements along the patient journey Utilize motivational interviewing tools to quickly and accurately anticipate and address patient barriers; personalize patient messaging concisely, within established time parameters, and in a way that resonates Communicate effectively; understand and influence patient initiation and support processes, encourage patient confidence and accountability to help patients start and stay on therapy Ensure success of program through collaborative partnerships with patients, brand, and operations partners Use intuition and clinical expertise to offer patients appropriate responses to their questions; discern the most beneficial information for the patients; accurately assess patients using provided guidelines outlined in approved messaging Ensure the patient is aware of all the patient services available to them and assisting to connect them to the right resource Connect the patient to local support groups, advocacy groups, and other external resources Provide health coaching throughout the journey to support adherence and compliance to medication Provide assistance and guidance through access and affordability journey Provide HCP feedback to keep them aware of the patient’s participation in the support program Provide education to the care team and proactively reaching out after the clinical decision has been made to start a new patient on regimen Triage and follow-up with Specialty Pharmacy to support patient getting product and knowing where product is in process Provide continuous updates, guidance, and triaging when needed and most importantly ensuring that the patient is driving towards the right health outcomes. Ensure all activities are conducted in a manner that is compliant with all Momentum Life Sciences, client, and industry mandated rules and regulations

Momentum Life Sciences

Call Center Nurse Case Manager (Remote)

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Indiana

**Assigned shift: 12-9p EST** The Nurse Case Manager will provide ongoing contact center and virtual support as an integral part of the patient support services provided for patients prescribed an oral therapy for narcolepsy and idiopathic hypersomnia. The Nurse Case Manager will be responsible for utilizing professional nursing skills, ability to foster patient relationships, strong empathy, and clinical experience to provide ongoing personalized high-touch telephonic support to patients . The role will engage with patients and their caregivers to provide clinically relevant individualized education in conjunction with product support. The Nurse Case Manager will leverage their knowledge while combining technical expertise to deliver best-in-class support, customer service, and ongoing education to these unique patients and their caregivers. The Nurse Case Manager will also partner closely with cross-functional stakeholders, including Field Nurse Educators, to ensure continuity of care and escalation as appropriate across teams

Required Education and/or Experience: Associate’s degree in nursing with patient education experience Experience working for (or contracting with) a pharmaceutical company within a contact center environment, a minimum of 2 years Preferred Education and/ or Experience: Bachelor’s Degree Required License and/or credential(s): Current, unrestricted RN or NP license Required Skills: Background in neurological conditions and/or rare disease Demonstrated ability to collaborate with numerous cross-functional partners/key stakeholders to deliver an optimized patient experience High emotional intelligence and ability to exhibit empathy to meet each patient where they are Strong clinical skills and experience with medication compliance, specialty pharmacy knowledge, and motivational interviewing Desire and ability to create individualized relationships with patients as they progress through their journey Ability to communicate clearly about complex information in a way that resonates with patients Optimistic, upbeat, and enthusiastic in times of challenge and constant change. Ability to deliver outstanding patient experience. Demonstrate experienced competency and ability to independently navigate technology using multiple platforms, computer screens, and other technical components. (Ex: virtual engagement platforms, Telephony Systems, CRM tools, Microsoft Suite) Advanced knowledge of written and verbal communication skills and problem-solving technique Detail-oriented, highly organized, and able to work through ambiguity Able to work independently with minimal supervision, self-motivated Ability to maintain cases and complete calls on time Ability to maintain compliant conversations and documentation in a high-volume role Ability to maintain patient confidentiality by using the headset during all conversations, maintaining a private environment for home office without distraction

Provide telephonic support via inbound and outbound calls, virtual calls, and omnichannel support through email, chat, and text Demonstrate strong empathy and high emotional intelligence to engage patients with complex health conditions effectively, creating an individual relationship-based connection built on trust and rapport Provide instruction and education about treatment/therapy, and connect patients with additional resources when needed while partnering with the Field Nurse Educators, HUB (Certified Pharmacy) and other key stakeholders to ensure the patient feels supported and confident from initiation through any transitions in their therapy journey Collaborate and work cohesively within a POD structure (with VMS Field Nurse Educator team) to identify gaps, barriers, and opportunities to improve process and overall patient experience Communicate complex information effectively and empathetically to patients and their caregivers Accurately complete patient engagements based on provided criteria Identify the root cause for any potential barriers the patients experience in adhering to the therapy through a motivational interviewing model Understand and coach patient initiation and support processes while encouraging patient confidence to help start and stay on therapy Ensure the success of the program through collaborative partnerships with patients, brand, and operational partners Provide your manager constructive patient feedback on the product, patient, and industry insights to enable enhancements. Reporting Adverse Event Product Quality Complaint (AEPQC) reporting per VMS and client policy Ensure all activities are conducted in a manner that complies with all VMS, client, and industry-mandated rules and regulations.

Athletico

Occ Health RN Telephone Triage - Full-Time - Day Shift (Remote)

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Athletico’s Greater Purpose is to empower people, inspire hope and transform lives. We accomplish this by providing exceptional, progressive, and cost-effective fitness, performance and rehabilitative services through personalized care that emphasizes education and prevention of future injury. This is accomplished through building on our Core Values of one team, understanding our business, recognition, people-focused, accountability, continuous innovation and trust and integrity, which are the foundation for our unique culture.

Pivot Onsite Innovations is now hiring an experienced and passionate Remote Triage Registered Nurse (RN) for our healthcare clinic located at our client's manufacturing plants. This is your opportunity to step out of a traditional nurse setting and make your impact on employee health, wellness and safety! Great schedule: Monday - Friday 6AM to 2PM. Position Summary: The Remote Occupational Health Nurse is responsible for utilizing evidence-based guidelines to employ best practices that require early intervention and setting of realistic expectations for recovery and return to work.

Education: Associate’s Degree in Nursing required, BSN preferred Work Experience: Min 2 years in occupational health preferred Telephonic case management experience preferred Certification/Licensure: Current Compact RN License required Maintain Enhanced Nurse Licensure Compact (eNLC) and reside in a compact state Adhere to the requirements and time frames of licensure in all other states Knowledge and Technical Skills: Strong clinical knowledge in Occupational Health Nursing Positive telephone interaction skills including ability to ask open-ended questions to identify problems and focus conversation for goal directed and time limited conversation Ability to effectively interact with HR, safety staff, local medical providers and other designated personnel for proper initiation and follow-up of possible work-related injuries and illnesses Excellent written and oral communication skills and computer skills Competence with Windows operating system environment, Adobe Professional, Microsoft Office Suite (Outlook, Word, Excel and PowerPoint) and learn other software as needed Language Skills: Ability to read, write and speak English proficiently Bi-lingual (Spanish speaking) beneficial Physical Demands: Ability to fulfill office activities including but not limited to remain stationary for extended periods of time (i.e., while working at a desk), stand/stoop/kneel/crough/stretch, bending and stretching, communicate with others (verbal and written), and use fine motor skills including fine hand manipulation and keyboarding. Working under stress and use of computer/phone required Ability to see at close range, distance vision, peripheral vision, depth perception, and the ability to adjust focus. Work Environment: Fully remote position Mainly indoor, office environment conditions Environment must be free from background noise and distraction, noise level is acceptable, temperature is controlled. A home set-up; must meet all Company IT, privacy and safety requirements

Provide initial injury intake, follow up and case closures in accordance with Policy Procedures Provide initial contact with injured worker, employer, provider and other appropriate stakeholders Obtain history of injury (mechanism and setting) and current job functions Assesses functional status and provide recommendations for first aid, self-care, or medical treatment according to treatment protocols Assess and collect data regarding risk factors for delayed recovery, and generate creative solutions to minimize or eliminate obstacles which prevent, or delay return to work Provide appropriate stakeholders with updates regarding the nature and mechanism of injury as well as suggested level of care Serve as an advocate for the injured/ill worker Counsel’s employees on reduction of risks associated with occupational and environmental hazards, and provides appropriate care plans as needed Request medical records as needed Direct care to preferred providers and negotiates as necessary Ensure appropriate use of medical facilities, early and appropriate referrals, and quality of care at controlled or reduced cost Identify excessive, ineffective or inefficient delivery of health care services and redirect care as needed Perform additional duties and assumes additional responsibilities as identified by supervisor

Athletico

Occ Health RN Telephone Triage - Full-Time - Afternoon Shift (Remote)

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Athletico’s Greater Purpose is to empower people, inspire hope and transform lives. We accomplish this by providing exceptional, progressive, and cost-effective fitness, performance and rehabilitative services through personalized care that emphasizes education and prevention of future injury. This is accomplished through building on our Core Values of one team, understanding our business, recognition, people-focused, accountability, continuous innovation and trust and integrity, which are the foundation for our unique culture.

Pivot Onsite Innovations is now hiring an experienced and passionate Remote Triage Registered Nurse (RN) for our on-site healthcare clinic located at our client's manufacturing plants. This is your opportunity to step out of a traditional nurse setting and make your impact on employee health, wellness and safety! Must be able to afternoons: Monday - Friday 2PM to 10PM! Position Summary: The Remote Occupational Health Nurse is responsible for utilizing evidence-based guidelines to employ best practices that require early intervention and setting of realistic expectations for recovery and return to work.

Education: Associate’s Degree in Nursing required, BSN preferred Work Experience: Min 2 years in occupational health preferred Telephonic case management experience preferred Certification/Licensure: Current Compact RN License required Maintain Enhanced Nurse Licensure Compact (eNLC) and reside in a compact state Adhere to the requirements and time frames of licensure in all other states Knowledge and Technical Skills: Strong clinical knowledge in Occupational Health Nursing Positive telephone interaction skills including ability to ask open-ended questions to identify problems and focus conversation for goal directed and time limited conversation Ability to effectively interact with HR, safety staff, local medical providers and other designated personnel for proper initiation and follow-up of possible work-related injuries and illnesses Excellent written and oral communication skills and computer skills Competence with Windows operating system environment, Adobe Professional, Microsoft Office Suite (Outlook, Word, Excel and PowerPoint) and learn other software as needed Language Skills: Ability to read, write and speak English proficiently Bi-lingual (Spanish speaking) beneficial Physical Demands: Ability to fulfill office activities including but not limited to remain stationary for extended periods of time (i.e., while working at a desk), stand/stoop/kneel/crough/stretch, bending and stretching, communicate with others (verbal and written), and use fine motor skills including fine hand manipulation and keyboarding. Working under stress and use of computer/phone required Ability to see at close range, distance vision, peripheral vision, depth perception, and the ability to adjust focus. Work Environment: Fully remote position Mainly indoor, office environment conditions Environment must be free from background noise and distraction, noise level is acceptable, temperature is controlled. A home set-up; must meet all Company IT, privacy and safety requirements

Provide initial injury intake, follow up and case closures in accordance with Policy Procedures Provide initial contact with injured worker, employer, provider and other appropriate stakeholders Obtain history of injury (mechanism and setting) and current job functions Assesses functional status and provide recommendations for first aid, self-care, or medical treatment according to treatment protocols Assess and collect data regarding risk factors for delayed recovery, and generate creative solutions to minimize or eliminate obstacles which prevent, or delay return to work Provide appropriate stakeholders with updates regarding the nature and mechanism of injury as well as suggested level of care Serve as an advocate for the injured/ill worker Counsel’s employees on reduction of risks associated with occupational and environmental hazards, and provides appropriate care plans as needed Request medical records as needed Direct care to preferred providers and negotiates as necessary Ensure appropriate use of medical facilities, early and appropriate referrals, and quality of care at controlled or reduced cost Identify excessive, ineffective or inefficient delivery of health care services and redirect care as needed Perform additional duties and assumes additional responsibilities as identified by supervisor

Athletico

Occ Health RN Telephone Triage - Full-Time - Overnights (Remote)

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Athletico’s Greater Purpose is to empower people, inspire hope and transform lives. We accomplish this by providing exceptional, progressive, and cost-effective fitness, performance and rehabilitative services through personalized care that emphasizes education and prevention of future injury. This is accomplished through building on our Core Values of one team, understanding our business, recognition, people-focused, accountability, continuous innovation and trust and integrity, which are the foundation for our unique culture.

Pivot Onsite Innovations is now hiring an experienced and passionate Remote Triage Registered Nurse (RN) for our on-site healthcare clinic located at our client's manufacturing plants, supporting telephonically. This is your opportunity to step out of a traditional nurse setting and make your impact on employee health, wellness and safety! Must be able to work overnights: Monday - Friday 10PM to 6AM! Position Summary: The Remote Occupational Health Nurse is responsible for utilizing evidence-based guidelines to employ best practices that require early intervention and setting of realistic expectations for recovery and return to work.

Education: Associate’s Degree in Nursing required, BSN preferred Work Experience: Min 2 years in occupational health preferred Telephonic case management experience preferred Certification/Licensure: Current Compact RN License required Maintain Enhanced Nurse Licensure Compact (eNLC) and reside in a compact state Adhere to the requirements and time frames of licensure in all other states Knowledge and Technical Skills: Strong clinical knowledge in Occupational Health Nursing Positive telephone interaction skills including ability to ask open-ended questions to identify problems and focus conversation for goal directed and time limited conversation Ability to effectively interact with HR, safety staff, local medical providers and other designated personnel for proper initiation and follow-up of possible work-related injuries and illnesses Excellent written and oral communication skills and computer skills Competence with Windows operating system environment, Adobe Professional, Microsoft Office Suite (Outlook, Word, Excel and PowerPoint) and learn other software as needed Language Skills: Ability to read, write and speak English proficiently Bi-lingual (Spanish speaking) beneficial Physical Demands: Ability to fulfill office activities including but not limited to remain stationary for extended periods of time (i.e., while working at a desk), stand/stoop/kneel/crough/stretch, bending and stretching, communicate with others (verbal and written), and use fine motor skills including fine hand manipulation and keyboarding. Working under stress and use of computer/phone required Ability to see at close range, distance vision, peripheral vision, depth perception, and the ability to adjust focus. Work Environment: Fully remote position Mainly indoor, office environment conditions Environment must be free from background noise and distraction, noise level is acceptable, temperature is controlled. A home set-up; must meet all Company IT, privacy and safety requirements

Provide initial injury intake, follow up and case closures in accordance with Policy Procedures Provide initial contact with injured worker, employer, provider and other appropriate stakeholders Obtain history of injury (mechanism and setting) and current job functions Assesses functional status and provide recommendations for first aid, self-care, or medical treatment according to treatment protocols Assess and collect data regarding risk factors for delayed recovery, and generate creative solutions to minimize or eliminate obstacles which prevent, or delay return to work Provide appropriate stakeholders with updates regarding the nature and mechanism of injury as well as suggested level of care Serve as an advocate for the injured/ill worker Counsel’s employees on reduction of risks associated with occupational and environmental hazards, and provides appropriate care plans as needed Request medical records as needed Direct care to preferred providers and negotiates as necessary Ensure appropriate use of medical facilities, early and appropriate referrals, and quality of care at controlled or reduced cost Identify excessive, ineffective or inefficient delivery of health care services and redirect care as needed Perform additional duties and assumes additional responsibilities as identified by supervisor

Athletico

Occ Health RN Telephone Triage - Part Time (Weekends) - Day Shift (Remote)

Posted on:

April 15, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Athletico’s Greater Purpose is to empower people, inspire hope and transform lives. We accomplish this by providing exceptional, progressive, and cost-effective fitness, performance and rehabilitative services through personalized care that emphasizes education and prevention of future injury. This is accomplished through building on our Core Values of one team, understanding our business, recognition, people-focused, accountability, continuous innovation and trust and integrity, which are the foundation for our unique culture.

Pivot Onsite Innovations is now hiring an experienced and passionate part-time Remote Triage Registered Nurse (RN) for our on-site healthcare clinic located at our client's manufacturing plants, supporting telephonically. This is your opportunity to step out of a traditional nurse setting and make your impact on employee health, wellness and safety! Must be able to work every weekend remotely: Saturday and Sunday 6A-6P! Position Summary: The Remote Occupational Health Nurse is responsible for utilizing evidence-based guidelines to employ best practices that require early intervention and setting of realistic expectations for recovery and return to work.

Education: Associate’s Degree in Nursing required, BSN preferred Work Experience: Min 2 years in occupational health preferred Telephonic case management experience preferred Certification/Licensure: Current Compact RN License required Maintain Enhanced Nurse Licensure Compact (eNLC) and reside in a compact state Adhere to the requirements and time frames of licensure in all other states Knowledge and Technical Skills: Strong clinical knowledge in Occupational Health Nursing Positive telephone interaction skills including ability to ask open-ended questions to identify problems and focus conversation for goal directed and time limited conversation Ability to effectively interact with HR, safety staff, local medical providers and other designated personnel for proper initiation and follow-up of possible work-related injuries and illnesses Excellent written and oral communication skills and computer skills Competence with Windows operating system environment, Adobe Professional, Microsoft Office Suite (Outlook, Word, Excel and PowerPoint) and learn other software as needed Language Skills: Ability to read, write and speak English proficiently Bi-lingual (Spanish speaking) beneficial Physical Demands: Ability to fulfill office activities including but not limited to remain stationary for extended periods of time (i.e., while working at a desk), stand/stoop/kneel/crough/stretch, bending and stretching, communicate with others (verbal and written), and use fine motor skills including fine hand manipulation and keyboarding. Working under stress and use of computer/phone required Ability to see at close range, distance vision, peripheral vision, depth perception, and the ability to adjust focus. Work Environment: Fully remote position Mainly indoor, office environment conditions Environment must be free from background noise and distraction, noise level is acceptable, temperature is controlled. A home set-up; must meet all Company IT, privacy and safety requirements

Provide initial injury intake, follow up and case closures in accordance with Policy Procedures Provide initial contact with injured worker, employer, provider and other appropriate stakeholders Obtain history of injury (mechanism and setting) and current job functions Assesses functional status and provide recommendations for first aid, self-care, or medical treatment according to treatment protocols Assess and collect data regarding risk factors for delayed recovery, and generate creative solutions to minimize or eliminate obstacles which prevent, or delay return to work Provide appropriate stakeholders with updates regarding the nature and mechanism of injury as well as suggested level of care Serve as an advocate for the injured/ill worker Counsel’s employees on reduction of risks associated with occupational and environmental hazards, and provides appropriate care plans as needed Request medical records as needed Direct care to preferred providers and negotiates as necessary Ensure appropriate use of medical facilities, early and appropriate referrals, and quality of care at controlled or reduced cost Identify excessive, ineffective or inefficient delivery of health care services and redirect care as needed Perform additional duties and assumes additional responsibilities as identified by supervisor

Athletico

Occ Health RN Telephone Triage - Part Time (Weekends) - Overnights (Remote)

Posted on:

April 15, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Athletico’s Greater Purpose is to empower people, inspire hope and transform lives. We accomplish this by providing exceptional, progressive, and cost-effective fitness, performance and rehabilitative services through personalized care that emphasizes education and prevention of future injury. This is accomplished through building on our Core Values of one team, understanding our business, recognition, people-focused, accountability, continuous innovation and trust and integrity, which are the foundation for our unique culture.

Pivot Onsite Innovations is now hiring an experienced and passionate part-time Remote Triage Registered Nurse (RN) for our on-site healthcare clinic located at our client's manufacturing plants, supporting telephonically. This is your opportunity to step out of a traditional nurse setting and make your impact on employee health, wellness and safety! Must be able to work weekend overnights consistently: Saturday and Sunday 6P-6A! Position Summary: The Remote Occupational Health Nurse is responsible for utilizing evidence-based guidelines to employ best practices that require early intervention and setting of realistic expectations for recovery and return to work.

Education: Associate’s Degree in Nursing required, BSN preferred Work Experience: Min 2 years in occupational health preferred Telephonic case management experience preferred Certification/Licensure: Current Compact RN License required Maintain Enhanced Nurse Licensure Compact (eNLC) and reside in a compact state Adhere to the requirements and time frames of licensure in all other states Knowledge and Technical Skills: Strong clinical knowledge in Occupational Health Nursing Positive telephone interaction skills including ability to ask open-ended questions to identify problems and focus conversation for goal directed and time limited conversation Ability to effectively interact with HR, safety staff, local medical providers and other designated personnel for proper initiation and follow-up of possible work-related injuries and illnesses Excellent written and oral communication skills and computer skills Competence with Windows operating system environment, Adobe Professional, Microsoft Office Suite (Outlook, Word, Excel and PowerPoint) and learn other software as needed Language Skills: Ability to read, write and speak English proficiently Bi-lingual (Spanish speaking) beneficial Physical Demands: Ability to fulfill office activities including but not limited to remain stationary for extended periods of time (i.e., while working at a desk), stand/stoop/kneel/crough/stretch, bending and stretching, communicate with others (verbal and written), and use fine motor skills including fine hand manipulation and keyboarding. Working under stress and use of computer/phone required Ability to see at close range, distance vision, peripheral vision, depth perception, and the ability to adjust focus. Work Environment: Fully remote position Mainly indoor, office environment conditions Environment must be free from background noise and distraction, noise level is acceptable, temperature is controlled. A home set-up; must meet all Company IT, privacy and safety requirements

Provide initial injury intake, follow up and case closures in accordance with Policy Procedures Provide initial contact with injured worker, employer, provider and other appropriate stakeholders Obtain history of injury (mechanism and setting) and current job functions Assesses functional status and provide recommendations for first aid, self-care, or medical treatment according to treatment protocols Assess and collect data regarding risk factors for delayed recovery, and generate creative solutions to minimize or eliminate obstacles which prevent, or delay return to work Provide appropriate stakeholders with updates regarding the nature and mechanism of injury as well as suggested level of care Serve as an advocate for the injured/ill worker Counsel’s employees on reduction of risks associated with occupational and environmental hazards, and provides appropriate care plans as needed Request medical records as needed Direct care to preferred providers and negotiates as necessary Ensure appropriate use of medical facilities, early and appropriate referrals, and quality of care at controlled or reduced cost Identify excessive, ineffective or inefficient delivery of health care services and redirect care as needed Perform additional duties and assumes additional responsibilities as identified by supervisor

Amcord Care Inc.

Nursing Facility Service Coordinator - Kutztown area - Remote

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

License:

None Required

State License:

Pennsylvania

The Nursing Facility Service Coordinator will be responsible for identifying, coordinating, and facilitating all necessary support and services for residents of nursing facilities. This role requires an individual with excellent communication and interpersonal skills, the ability to manage multiple tasks and priorities, and a strong understanding of nursing facility operations.

Must have a Bachelor’s degree in social work, psychology, or other related fields with practicum experience, or in lieu of a Bachelor’s degree have at least three (3) or more years’ experience in a social service or healthcare related setting. Excellent communication and interpersonal skills. Ability to work collaboratively with staff, program participants, and community organizations. Strong organizational and problem-solving skills. *Must be willing and able to travel regularly through these areas and surrounding counties* Pottsville, PA 17901 Bethlehem, PA 18017 Allentown, PA 18103-18104 Shenandoah, PA 17976 Easton, PA 18042 Reading, PA 19611

Manage an active caseload which involves monitoring and evaluating options and services to meet an individual's health needs. Develop and modify care plans at least annually or on an as needed basis in collaboration with the resident, their family, and facility staff. Ensure that nursing facility residents receive appropriate healthcare services and that their medical needs are being met. Notify the member of their right to choose any willing and qualified provider to provide a service on the members service plan. Serve as a liaison between nursing facility residents, their families, and healthcare providers. Coordinate and participate in interdisciplinary care conferences with nursing facility staff and healthcare providers as needed. Ensure compliance with all legal and regulatory requirements related to nursing facility services. Required to complete forty (40) hours orientation training and ongoing twenty (20) hour annual training. Responsible for following Amcord Care Inc. policies and procedures for document maintenance, confidentiality or records and employees' rights. Willingness and ability to work in the field while also having the ability to work independently with integrity in a virtual setting.

The Cigna Group

RN Utilization Management Clinical Reviewer Senior Analyst - Work from Home, Anywhere, USA

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Conneticut

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.

Provides advanced professional input to complex Nurse Case Management assignments/projects. Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan. Handles more complex, high acuity cases, and/or account sensitive cases involving largest reserves. Utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate options and services in order to facilitate appropriate healthcare outcomes for members. Ensures that case management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained. Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select outpatient services. May review initial liability disability claims to determine extent and impact of insured's medical condition, medical restrictions and limitations and expected duration. Performs leadership role on team when implementing new tools or case management programs/initiatives. Manages own caseload and coordinates all assigned cases. Supports and provides direction to more junior professionals. Works autonomously, only requiring “expert” level technical support from others. Exercises judgment in the evaluation, selection, and adaptation of both standard and complex techniques and procedures. Utilizes in-depth professional knowledge and acumen to develop models and procedures, and monitor trends, within Nurse Case Management. RN and current unrestricted nursing license required.

Minimum requirements: Active unrestricted Registered Nurse (RN) license in state or territory of the United States. Preferred requirements: Bachelors degree a plus 3 years clinical experience in inpatient or managed care setting Demonstrated ability to anticipate, plan, coordinate and organize. Knowledge of community, state and federal resources. Possession of a valid driver’s license, proof of insurance, good driving record and reliable transportation. Strong skills in teamwork, negotiation, conflict management, problem solving, and effective decision making. Experience in medical management and case management in a managed care setting or hospital is highly desirable. Ability to assess complex issues, recommend changes and resolve problems. Strong computer knowledge and abilities. Knowledge of managed care products and strategies. Ability to work within changing business environment and balance business needs with patient advocacy. Experience managing multiple projects in a fast paced matrix driven environment. Effective at negotiation, teamwork and cooperative relations with diverse internal and external stakeholders. 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.

Position Scope: Manages/Coordinates an active caseload of inpatient case management cases for Cigna. Uses clinical knowledge to assess inpatient admission level of care, treatment plan and goals, identified gasps or risk for readmission or complications and any barriers to discharge. Establishes patient centric goals and interventions to meet the member’s needs while inpatient and post inpatient stay. Interfaces with facility, member, family, and other healthcare team members as well as internal matrix partners. Balances business needs with patient advocacy. Builds solid working relationships with internal staff, matrix partners, key functional areas, customers, and providers. Summary description of position: Plans, implements and evaluates appropriate health care services in conjunction with the physician treatment plan. Handles more complex, high acuity cases and /or account sensitive cases. Performs prospective, concurrent and retrospective reviews for inpatient acute care, rehabilitation, referrals and select outpatient services including DME (durable medical equipment). Ensures that inpatient case management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained. Excellent time management, organization and negotiation skills. Strong research and analytical skills. Ability to assess complex issues, recommend changes and resolve problems. Knowledge of managed care preferred. Works independently, receiving direction from manager or team leader for new or unprecedented situations. Manages own caseload and coordinates all assigned cases. Acts as a resource to others. Utilizes Cigna's approved guidelines and tools to rigorously assess the clinical status of the member, the level of care and the services the member is receiving as clinically appropriate covered services. Anticipates care needs along the continuum of inpatient and outpatient services and facilitates coordination across the network of providers, participants and caregivers to assure timely discharge/transfer to an alternate level of care. Consults with manager and medical director to resolve any issues related to delay of services or barriers to discharge in a timely manner. Major responsibilities and desired results: Develops and defines a structured working relationship with key partners in inpatient facilities to support regular, effective communication and exchange of information in order to manage the member’s needs in compliance with all Federal/State/Facility contract and internal Cigna requirements. Retrieves active daily census each morning and prioritizes cases for impact. Access the approved Cigna guidelines for inpatient review and directs communication with the facility to elicit clinical information and facilitate discharge planning. Identified all cases appropriate for inpatient case management interventions, initiates and discusses options for discharge planning with the facility, provider, vendor, member and/or family and documents interactions and outcomes related to those actions. Identify and build effective relationships with a network of community, government, and knowledge resources. Maintain information on those resources and share with peers as appropriate. Act as liaison and patient advocate between account, participant, family, physician(s) and facilities/agencies. Take appropriate action to ensure participant and practitioner satisfaction within benefit constraints. Develop a participant centered plan for short term and long term objectives, including time frames for follow up. Utilize available internal and community resources in development of plan. Involve all appropriate parties (member, physician, providers, employers, etc) to determine case results/outcomes. Provide information and resources as appropriate to empower participants to take an active role in care, treatment and cost decisions. Implement, coordinate, monitor and evaluate the plan on a systematic, ongoing, appropriate basis. Negotiate price and quality care levels, intensity and durations of services. Document findings and continue to anticipate needs, determine benefit coverage status and communicate proactively to participant and members of treatment team. Identifies new referrals for complex and specialty CM programs and coordinates transition to appropriate CM when necessary. Identifies and elevates potential quality of care issues to Cigna's Quality representatives for follow up determination. Works to identify gaps in care and resolution of those identified and prevention of future gaps in care. May be required to participate in customer and auditor visits. Participates in special projects as deemed necessary. Other duties as required and related to this role.

Solace

Case Manager - Healthcare Advocate (Remote 1099)

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

None Required

State License:

California

By harnessing the power of human connection through technology, Solace is transforming healthcare in the U.S. Healthcare in the U.S. is fundamentally broken. The system is so complex that 88% of U.S. adults do not have the health literacy necessary to navigate the system without help. By helping people work with professional health advocates, Solace serves as an integral, personal support layer for health issues in a way that the health system can’t. Using proprietary technology to match patients with experienced advocates, Solace cuts through the red tape of healthcare and helps individuals and families make informed decisions that result in better outcomes. Solace is a Series B startup founded in 2022 and backed by Inspired Capital, Craft Ventures, Torch Capital, Menlo Ventures and Signalfire. We have a lean, fully-remote U.S. team distributed coast-to-coast.

As a Healthcare Advocate for Solace, you will work with Medicare patients throughout their healthcare journey. In this role, you will navigate patients through difficult and complex health concerns to help them achieve their health and wellness goals while addressing Social Determinants of Health (SDOH). You’ll be an empathetic listening ear and an action-oriented guide who knows what to do to solve patient problems—and actually does it. Please note that this is a 1099 role. You can choose to work part time or full time. The role is remote.

Demonstrated experience in care management, patient advocacy, or healthcare navigation. Deep understanding of Social Determinants of Health and experience working with diverse patient populations. Endless empathy for people, and a strong ability to fight for those who cannot. Strong clinical skills paired with exceptional organizational abilities. You can balance multiple tasks and work under pressure without sacrificing clarity in your communications and documentation. Pride in your technical savvy; you can quickly and fluently learn new systems and software. An extreme bias toward action and execution. A willingness to provide fearless feedback. You care about forging a system that empowers better patients outcomes, and are not shy about sharing your thoughts.

Learn the Solace systems, tools, technology, partners, and expectations, while also providing your unique expertise in every interaction. Build strong, trusting relationships with Medicare patients, where listening and empathy are the foundation for every interaction. Be able to identify and prioritize Medicare patients’ needs and assist them to maintain a streamlined care continuum. Develop comprehensive patient care plans that holistically address social determinants of health, i.e. food resources, transportation access, and support at home. Build the systems of the future in working with Medicare patients.

Solace

RN Healthcare Advocate (Remote 1099)

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

California

By harnessing the power of human connection through technology, Solace is transforming healthcare in the U.S. Healthcare in the U.S. is fundamentally broken. The system is so complex that 88% of U.S. adults do not have the health literacy necessary to navigate the system without help. By helping people work with professional health advocates, Solace serves as an integral, personal support layer for health issues in a way that the health system can’t. Using proprietary technology to match patients with experienced advocates, Solace cuts through the red tape of healthcare and helps individuals and families make informed decisions that result in better outcomes. Solace is a Series B startup founded in 2022 and backed by Inspired Capital, Craft Ventures, Torch Capital, Menlo Ventures and Signalfire. We have a lean, fully-remote U.S. team distributed coast-to-coast.

As an RN Healthcare Advocate for Solace, you will work with Medicare patients throughout their healthcare journey. In this role, you will navigate patients through difficult and complex health concerns to help them achieve their health and wellness goals while addressing Social Determinants of Health (SDOH). You’ll be an empathetic listening ear and an action-oriented guide who knows what to do to solve patient problems—and actually does it. Please note that this is a 1099 role. You can choose to work part time or full time. The role is remote.

RN license in good standing. Deep understanding of Social Determinants of Health and experience working with diverse patient populations. Endless empathy for people, and a strong ability to fight for those who cannot. Strong clinical skills paired with exceptional organizational abilities. You can balance multiple tasks and work under pressure without sacrificing clarity in your communications and documentation. Pride in your technical savvy; you can quickly and fluently learn new systems and software. An extreme bias toward action and execution. A willingness to provide fearless feedback. You care about forging a system that empowers better patients outcomes, and are not shy about sharing your thoughts.

Learn the Solace systems, tools, technology, partners, and expectations, while also providing your unique expertise in every interaction. Build strong, trusting relationships with Medicare patients, where listening and empathy are the foundation for every interaction. Be able to identify and prioritize Medicare patients’ needs and assist them to maintain a streamlined care continuum. Develop comprehensive patient care plans that holistically address social determinants of health, i.e. food resources, transportation access, and support at home. Build the systems of the future in working with Medicare patients.

Wellbox Health

Virtual Nurse Coordinator: LPN

Posted on:

April 15, 2025

Job Type:

Full-Time

Role Type:

Telehealth

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.

Position Type And Expected Hours Of Work We are seeking full-time LPN team members who can work 40 hours per week, between the hours of 8 am – 6 pm in the patient’s time zone, Monday – Friday. Pay Structure Orientation + Training (First two months): $20 hourly. Post-Orientation: $22 hourly, plus bonus incentive. Monthly Bonuses up to $525 monthly. Referral Bonuses up to $1000.

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.

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.

NaphCare, Inc.

PRN Utilization Managment Registered Nurse

Posted on:

April 14, 2025

Job Type:

Role Type:

Utilization Review

License:

RN

State License:

Alabama

NaphCare is a family owned, medical technology company that has been delivering high quality healthcare to correctional facilities across the nation for over 30 years. Come join our team of over 4000 employees and growing! NaphCare pays well, offers outstanding benefits, and has an incredibly engaged corporate support team to make sure you have what you need to be truly excellent at what you do. NaphCare partners with correctional facilities to provide proactive, patient-focused healthcare. We recognize that we serve a unique and diverse patient population, and our onsite teams take pride in bringing excellence in care to a population in great need. Be part of a world-class team of professionals who are revolutionizing correctional healthcare as you use our cutting-edge resources, including our award-winning electronic operating system NaphCare has a partnership with NetCE that provides CEU/CME for our staff. NetCE uses a rigorous peer review process to ensure that all activities and content are up-to-date. This service streamlines continuing education for all NaphCare Employees to meet state specific requirements for maintaining licensing. With NaphCare, you'll play a critical role in our continuing mission to be the leading provider of quality healthcare in the correctional industry. If you want a career that will make a difference, choose the company that is different. We support your growth and internal promotion. Once hired, we encourage our employees to continue to seek opportunities for advancement and leadership.

NaphCare is hiring experienced PRN-Utilization Management Registered Nurse just like you at the Corporate Headquarters located in Birmingham, Alabama.

A current and unrestricted RN license in Alabama A minimum of 3 years’ experience in an acute care setting and 2 years’ experience in utilization review and/or case management Valid cpr card Excellent communication and interpersonal skills attention to detail and decision-making skills are essential BSN or ADN required. Some travel required.

Develop, implement, and administer the quality assurance and utilization review processes Monitor and report on the quality of all facets of the medical care provided to patients Perform utilization and concurrent review of patient cases Conduct detailed clinical chart assessments Gather clinical information to assess and expedite care needs Determine need, if any, for intervention, and discussing with physicians Reviews requests from providers regarding medical necessity of requested services for patients Reviews and audits patients' medical records as indicated to determine medical necessity Utilizes nationally recognized criteria to determine medical necessity of requested services Refers provider requests to Medical Director or designee when medical necessity of requested services does not meet recognized criteria

Tuesday Health

Complex Care Navigator (RN)

Posted on:

April 14, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Ohio

Tuesday Health launched in 2023 to deliver compassionate, supportive care for patients and caregivers navigating serious illness. We believe that each patient's journey is unique. As such, we deliver member-directed, whole-person care to seriously ill patients in our program, using leading edge supportive care models, including appropriate transitions to hospice when the time is right. This results in drastically improved quality of life for members and their caregivers, and a meaningful reduction in unproductive medical spend. Our overall mission is to transform serious illness and end of life care; our team believes deeply in this mission and puts our members first in all that we do.

Location: Canton, OH This is a full-time position, traveling within the community. Monday-Friday with hours of 8:00am-5:00pm Tuesday Health is looking for a creative and experienced Registered Nurse to join our team as a Complex Care Navigator. You will work alongside other members of the Tuesday Health clinical teams, providing a multi-disciplinary approach to care for our members with serious illness and ensuring the delivery of high-quality supportive care services to our patients and their families. The RN will conduct home visits and work remotely on occasion.

Active and unrestricted Registered Nurse license in the State of Ohio without any board action Experience in clinical/medical setting preferred Experience in a multi- disciplinary care model working across network providers, health plan care management support, and employed clinicians Strong communication and organization skills Ability to multitask and work under pressure without sacrificing a positive member experience Ability to know when to escalate and potentially act professionally in an emergent situation Strong technical skills to navigate different documentation systems and tools; as well as ability to learn new systems as the company grows and evolves Strong written skills Ability to drive during daytime, nighttime, or inclement weather Valid driver's license with safe driving record State minimum automobile insurance coverage Comfort with change and ambiguity; you understand that rapid changes to the business, strategy, organization, and priorities will come with rapid evolution of our business

Administer multiple assessments and screening tools within the clinical model at different times throughout the care timeline Interpret responses to assessments and screening tools and support prioritization of need based on responses Be accountable for care plan development within the multidisciplinary care team Lead in internal and joint rounds to ensure the member experience is optimal and coordinated Learn the Tuesday Health electronic systems, tools, technology, to deliver a coordinated approach to ensure the members have a unique experience Build a strong, trusting relationship with every member, where listening and empathy are the foundation of every interaction Serve as the quarterback of the multidisciplinary team transforming care for members with serious illness

HV Health and Safety

Occupational Health Nurse Case Manager (LVN)

Posted on:

April 14, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

LPN/LVN

State License:

Compact / Multi-State

At HV Occupational Health and Safety, we are passionate about fostering growth, embracing change to create thriving, and encouraging safe work environments. As a double minority-owned company, we bring a unique perspective to workplace safety, offering exceptional services that help businesses achieve the best outcomes. Our commitment to honesty, integrity, and respect defines everything we do. We take pride in our ability to be problem solvers, finding practical solutions to complex challenges, and maintaining a positive outlook in every situation. Our team members are not only professionals—they are family-oriented individuals who understand the importance of safety and well-being for both the workforce and their loved ones. Our mission is to empower employees with confidence, providing tailored solutions and expert knowledge to cultivate a culture of safety and success. Together, we aim to build a safer future, one job site at a time.

**We are looking for compassionate and caring LVNs with a compact state license to join our remote team.** You’re a dedicated medical professional who cares deeply about helping people stay healthy, safe, and informed—especially in the workplace. You recognize that supporting employees’ health goes beyond just responding to incidents; it’s about early intervention, clear communication, and being a trusted clinical presence from wherever you are. Whether you’re triaging an injury, guiding someone through a return-to-work process, or educating a patient on preventative care, you approach each interaction with empathy, professionalism, and a strong sense of purpose. You work well with teams, think on your feet, and bring calm to high-pressure situations. If you have a background in nursing and a heart for service—even if you don’t check every box—we’d love to hear from you. At HV Health and Safety, integrity, teamwork, and excellence are core to everything we do. Join us and help make a meaningful difference in the lives of working people every day.

EDUCATION AND EXPERIENCE QUALIFICATIONS: Licensed Vocational Nurse (LVN) license in good standing (multi-state/compact license preferred). Minimum of 2 years of clinical experience, ideally with exposure to occupational health, urgent care, or telehealth. Familiarity with workplace health standards, OSHA reporting, and/or workers’ compensation procedures. Strong clinical judgment and ability to make confident decisions remotely. Comfortable using telehealth platforms, electronic health records (EHR), and communication tools. PREFERRED: COHN/COHN-S, CAOHC, or occupational health experience a plus. Bilingual (English/Spanish or other languages) a plus. Experience in case management or injury triage.

Conduct virtual patient assessments, reviewing symptoms, medical history, and current concerns, including both personal and workplace-related issues. Triage injuries and illnesses to determine next steps, including appropriate care level, time off recommendations, or emergency referrals. Provide clear nursing advice, care instructions, and health education tailored to the employee population. Support return-to-work evaluations and recovery monitoring in coordination with workplace policies. Collaborate with safety, HR, and other internal teams to ensure coordinated care and support. Maintain accurate, confidential documentation in accordance with HIPAA, OSHA, and company standards. Promote preventative care, chronic condition management, and overall employee wellness. Stay up to date with best practices in occupational and virtual care.

HV Health and Safety

Telehealth Nurse (LVN)

Posted on:

April 14, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Compact / Multi-State

At HV Occupational Health and Safety, we are passionate about fostering growth, embracing change to create thriving, and encouraging safe work environments. As a double minority-owned company, we bring a unique perspective to workplace safety, offering exceptional services that help businesses achieve the best outcomes. Our commitment to honesty, integrity, and respect defines everything we do. We take pride in our ability to be problem solvers, finding practical solutions to complex challenges, and maintaining a positive outlook in every situation. Our team members are not only professionals—they are family-oriented individuals who understand the importance of safety and well-being for both the workforce and their loved ones. Our mission is to empower employees with confidence, providing tailored solutions and expert knowledge to cultivate a culture of safety and success. Together, we aim to build a safer future, one job site at a time.

**We are looking for compassionate and caring LVNs with a compact state license to join our remote team.** You’re a dedicated medical professional who cares deeply about helping people stay healthy, safe, and informed—especially in the workplace. You recognize that supporting employees’ health goes beyond just responding to incidents; it’s about early intervention, clear communication, and being a trusted clinical presence from wherever you are. Whether you’re triaging an injury, guiding someone through a return-to-work process, or educating a patient on preventative care, you approach each interaction with empathy, professionalism, and a strong sense of purpose. You work well with teams, think on your feet, and bring calm to high-pressure situations. If you have a background in nursing and a heart for service—even if you don’t check every box—we’d love to hear from you. At HV Health and Safety, integrity, teamwork, and excellence are core to everything we do. Join us and help make a meaningful difference in the lives of working people every day.

EDUCATION AND EXPERIENCE QUALIFICATIONS: Licensed Vocational Nurse (LVN) license in good standing (multi-state/compact license preferred). Minimum of 2 years of clinical experience, ideally with exposure to occupational health, urgent care, or telehealth. Familiarity with workplace health standards, OSHA reporting, and/or workers’ compensation procedures. Strong clinical judgment and ability to make confident decisions remotely. Comfortable using telehealth platforms, electronic health records (EHR), and communication tools. PREFERRED: COHN/COHN-S, CAOHC, or occupational health experience a plus. Bilingual (English/Spanish or other languages) a plus. Experience in case management or injury triage.

Conduct virtual patient assessments, reviewing symptoms, medical history, and current concerns, including both personal and workplace-related issues. Triage injuries and illnesses to determine next steps, including appropriate care level, time off recommendations, or emergency referrals. Provide clear nursing advice, care instructions, and health education tailored to the employee population. Support return-to-work evaluations and recovery monitoring in coordination with workplace policies. Collaborate with safety, HR, and other internal teams to ensure coordinated care and support. Maintain accurate, confidential documentation in accordance with HIPAA, OSHA, and company standards. Promote preventative care, chronic condition management, and overall employee wellness. Stay up to date with best practices in occupational and virtual care.

Blue Cross and Blue Shield of Louisiana

Medical Review Nurse

Posted on:

April 14, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Louisiana

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Residency in or relocation to Louisiana is preferred for all positions. POSITION PURPOSE: Responsible for coordinating, processing and managing all in-patient and out-patient claims from a medical standpoint to ensure proper administration of contractual limitations and exclusions to include medical necessity, while maintaining compliance with regulatory guidelines. NATURE AND SCOPE: This role does not manage people This job reports to: Departmental Leadership Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contcact with: Healthcare providers and subscribers to obtain medical information. Obtains request for reviews from and notifies determinations to BAD, ITS, NASCO, FEP, BMS, and legal.

Education: High School Diploma or equivalent is required Work Experience: 4 years of recent LPN experience providing direct patient care with one year of authorization, medical review experience and case management is required Skills and Abilities: Knowledge of standardized code sets and medical terminology is required Proficiency in the use of standardized code sets is required Must demonstrate excellent interpersonal, administrative, and telephone skills. Working knowledge of MS Office is required Demonstrated ability to handle multiple tasks in customer friendly manner while maintaining performance standards is required Knowledge of health insurance contracts/benefits is preferred Licenses and Certifications: Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided required CPUR or CPC certification is preferred upon hire; required within 24 months in position. A comparable professional medical review or case management certification is preferred

Reviews medical claims and requests for services and applies medical judgment and/or criteria in determining the benefits for pre-services and post-services according to contractual benefits and limitations, (i.e., contractual exclusions, cosmetic procedures, medical necessity, and administrative discrepancies) to ensure the proper administration of contractual and medical limitations/exclusions. Prepares documentation of medical information, completes research, makes recommendations, and refers potential denials to the Medical Directors and Management, when necessary, to ensure compliance with URAC standards, MNRO and DOL laws and regulations. Completes correspondence correctly when necessary to providers and subscribers to ensure that customers are aware of the determinations and appeal processes/rights meeting all regulatory standards. Meets targeted expectations for staff and unit performances as required by BCBSLA and department management. Collaborates with team members and communicates to the supervisor suggestions for improvement to ensure adherence to the corporate initiative of diversity. Additional Accountabilities and Essential Functions The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions Perform other job-related duties as assigned, within your scope of responsibilities. Job duties are performed in a normal and clean office environment with normal noise levels. Work is predominately done while standing or sitting. The ability to comprehend, document, calculate, visualize, and analyze are required. #LI_CB1 #LI-Remote

Optum

LPN Case Manager Remote

Posted on:

April 14, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

LPN/LVN

State License:

New York

Optum NY, (formerly Optum Tri-State NY) is seeking a LPN Case Manager to join our team in Middletown, NY. Optum is a clinician-led care organization that is changing the way clinicians work and live. As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone. At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

Join Our Team as an LPN Case Manager! Why Optum? At Optum, you’ll have access to the clinical resources, data, and support of a global organization, empowering you to help patients live healthier lives. Work alongside talented peers in a collaborative environment that values diversity and inclusion, driving towards the Quadruple Aim. We believe in providing an exceptional career experience, enabling you to thrive both at work and at home. Make a Difference: Are you ready to make a meaningful impact in the lives of our patients? As an LPN Discharge Coordinator, you’ll ensure smooth transitions for patients without the hassle of nights, weekends, or holidays. This full-time position offers excellent hourly compensation and benefits within 30 days, including generous PTO, paid holidays, annual bonus potential, annual reviews, tuition reimbursement, and opportunities for continued career progression. Plus, all clinical licensure costs are covered! Your Role: As a Case Manager, you’ll be an integral member of the direct delivery care team, serving as a gateway to information and support. Your daily communication with the acute care team, Embedded Care Coordination RN, PCP office care team, patients, and caregivers will ensure optimal communication and care during and after the acute care episode. Your goal is to facilitate understanding of the hospitalization, discharge care plan, and assess patient literacy.

Required Qualifications: Active and unrestricted LPN license in the state of New York Experience in caring for chronic disease patients Experience with navigation of local medical and social support systems Preferred Qualifications: Experience in clinical or community health settings Care Coordination, Case Management or Home Health experience Experience with Electronic Medical Records and Microsoft Excel

Assess patient and family’s unmet health and social needs Provide effective communications to improve health literacy Develop a care plan based on mutual goals with patient, family, and provider’s emergency plan, medical summary, and ongoing action plan Monitor patient’s adherence to plan of care and progress toward goals, facilitating changes as needed Facilitate patient access to appropriate medical and specialty providers and other care coordination team support specialists Ensure effective tracking of test results, medication management, and adherence to follow-up appointments Facilitate communication between specialists and Primary Care Physician post-discharge for cohesive care plan development Attend and actively participate in care coordinator-related training and meeting activities Perform regular visits to provide patient and family support and education

Optum

Telephonic Care Navigator – Remote in NC

Posted on:

April 14, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

None Required

State License:

North Carolina

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 Optum At Home product, together with an interdisciplinary care team we help patients navigate the health care system, and connect them to key support services. This preventive care can help patients stay well at home. We’re connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

Our Care Navigators have a serious responsibility to make every contact informative, productive, positive, and memorable for what it says about how much we care. Care Navigators will carry a case load and will work with clinical staff. Coordinate care with providers, schedule appts, arrange transportation, make sure members are aware of all their benefits, check for upcoming appts and schedule & identify gaps for members. Mostly outbound calling but blended with a few incoming callings using auto dialer and manual dialing. This position is full time Monday – Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 9am – 5:30pm EST. It may be necessary, given the business need, to work occasional overtime. We offer 3 weeks of on-the-job training. The hours during training will be 9:00 am to 5:30 pm local time. If you are located within the State of North Carolina, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: High School Diploma / GED Must be 18 years of age or older 1+ years of call center and / or telephonic customer service experience 1+ years of professional experience in an office setting using the telephone and computer as the primary instruments to perform the job duties 1+ years of Healthcare/ insurance experience and/or Social work/community outreach/advocacy experience 1+ years of experience analyzing and solving customer problems Work experience using Microsoft Word (edit, create & save documents), Microsoft Excel (sorting & filtering data), and Microsoft Outlook (email, folders, attachments and calendaring) Ability to work Monday – Friday 9:00am-5:30pm EST Preferred Qualifications: Social Work, Public Health or related field Bilingual fluency in English and Spanish OR other language Medicaid and / or Medicare experience Experience working with medical terminology Telecommuting Requirements: Reside within the state of North Carolina Ability to keep all company sensitive documents secure (if applicable) Required to have a dedicated work area established that is separated from other living areas and provides information privacy. Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service. Soft Skills: Must be able and comfortable with maintaining metrics and goals within the department Must be comfortable working on the phone and multiple systems on the computer simultaneously while assisting members Must be comfortable making outreach to members without prior engagement Excellent Organizational Skills Telephone etiquette

Completes telephonic outreach to DSNP/CSNP members utilizing multiple outreach modes: including auto-dialer, manual and inbound calls Educates member on gaps in care and assists with closure of gaps, including scheduling provider appointments Assists members with social determinants of health and links to community resources Ensures member has access to PCP Outreaches members on caseload consistent with program guidelines Consistently meets metrics, both quality & performance Provides excellent customer service to both members and providers Constantly maintains schedule adherence and good attendance Maintains confidential health information according to state and federal regulations including HIPAA.

Optum

Virtual Health RN

Posted on:

April 14, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

Compact / Multi-State

MedExpress, part of the Optum family of businesses, is seeking a RN to join our team. Optum is a clinician-led care organization that is changing the way clinicians work and live. As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone. At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

The Virtual Registered Nurse (RN) works in conjunction with medical weight loss providers and support staff who provide healthcare solutions and clinical excellence to patients through virtual health using real-time audio-visual engagement. All duties and responsibilities are to be performed in compliance with state and federal laws and regulations governing the legal scope of nursing practice and practicing standard of evidence-based nursing to each patient. You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Graduate of an accredited School of Nursing with current and unrestricted RN licensure in a Nurse Licensure Compact State Maintain CEU/CNE’s as applicable for licensure 2+ years of dedicated nursing experience in primary care, urgent care, and or condition management program Experience using audio/visual technology or video conferencing platforms Knowledge of principles and processes for providing patient and personal services. This includes patient needs assessment, meeting quality standards for services, and evaluation of patient satisfaction. Applicable federal, state, and local laws and regulations including the requirements of the HIPAA and OSHA and applicable state rules and regulations pertinent to nursing practices Knowledge of computerized information systems used in business applications and clinical management systems (EMR) Demonstrated ability to perform duties in accordance with the customary rules of ethics and conduct of the applicable State Board of Nursing and other such regulating bodies Proven solid commitment to customer service and excellence in healthcare Proven ability to communicate effectively both orally and in writing Proven ability to work efficiently and effectively in fast paced, innovative environment Proven ability to effectively manage multiple, competing priorities Proven ability to work independently and as part of a high performing team Respectful of and sensitive to cultural/ethnic/religious healthcare needs, practices, backgrounds and competencies Preferred Qualifications: Remote experience Experience with weight loss management Experience with health and nutrition

Patient Care: Complete detailed and comprehensive data collection upon clinical intake, including appropriate evaluation of chief complaint, medication Hx, PMH, allergies, social Hx, etc. Review charts and records for completeness Facilitate telehealth services by completing virtual pre-intake with patients in preparation for appointments. Notify provider when patient is ready for visit Accommodate the patient’s needs, preferences, and potential cultural, social, physical, cognitive, and linguistic and communication barriers to technology use Process requests and referrals, providing efficient follow up with the patient, pharmacy, or other entity, as needed Prepares drug refill, lab order, and imaging order requests for review by the provider as directed by department protocols and established standing orders Oversee and coordinate the daily patient care flow, assisting and participating in all aspects of patient care for all patients within the center Apply the use of logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions and approaches to problems Provide patient education at virtual visit appointments including anticipatory guidance, information about chronic care, disease prevention and the promotion of health maintenance Clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating) Providing health education, coaching and treatment decision support for patients Engage patient with meaningful interaction that will motivate commitment and increase level of activation Identify possible challenges to patient success and provide continued support for goal attainment Collaborate with Interdisciplinary team on case management and health coaching support needs identified Participate in interdisciplinary team care conferences Complete and/or track clinical orders and results daily Assist the provider with calling patients and informing them of normal lab results reviewed by the provider. Proper, concise and complete documentation in EMR, other computer-based applications, and/or paper-based forms for all assessments and procedures Use best practices in telepresence skills to create a positive patient-clinician rapport and a meaningful encounter through technology Provide clinical oversight and guidance for unlicensed assistive personnel Comply with OSHA and HIPAA requirements, and follow policies and procedures Other duties as assigned such as new models of care, new types of procedures, use of new technology, etc. Learning and Ongoing Education: Obtain and maintain RN compact state licensure and other state licenses in virtual service areas Maintain clinical skills and competency for all procedures and participate in training and mentoring of other clinical staff patients Completes clinical competency evaluation/review as determined by leadership Maintain technical skills and apply new knowledge to position according to clinic policy Maintain knowledge of Medical Terminology and standards of nursing care Read and keep up to date on all department communications Complete all assigned training Documentation of competency is required for all role appropriate procedures, in addition to State specific licensure or certification as applicable Maintain knowledge of common safety hazards and precautions to establish a safe work environment Participate in quality improvement projects as applicable

IntellaTriage

Remote Hospice Triage RN- PT 2 shift 6p-12a rotating Sat & Sun 3:30-12 CST

Posted on:

April 13, 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 6p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 3:30p-12a CST

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

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

Morgan Stephens

Utilization Review Nurse – Outpatient (Remote)

Posted on:

April 13, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

We are seeking an experienced Utilization Review Nurse (Outpatient) to join our remote Utilization Management team. This role focuses on reviewing medical necessity for outpatient services, including DME, therapy, surgery, and imaging. The ideal candidate has experience with Virginia Medicaid (preferred) or other state Medicaid programs and is highly organized, self-motivated, and comfortable working independently to meet productivity and turnaround time (TAT) requirements. You will assess services for members to ensure appropriate care, optimal outcomes, cost effectiveness, and compliance with state and federal guidelines.

Required: Active, unrestricted RN license in Virginia or a Compact State 2+ years of clinical experience in hospital nursing, case management, or utilization review Outpatient utilization management experience including DME and therapy Strong understanding of Medicaid (Virginia preferred), Medicare, and Commercial LOBs Proficiency with InterQual, MCG, and familiarity with CMS and NCQA standards Tech-savvy with experience using Microsoft Office and EMR systems (EPIC, Allscripts, Athena, Cerner, etc.) Ability to work in EST hours (8:00 AM–4:30 PM or 8:00 AM–5:00 PM EST) Preferred: Direct experience working with Virginia Medicaid Strong knowledge of outpatient medical review practices Familiarity with TruCare, Point Click Care, or EZ-Cap a plus Bilingual in English and Spanish is a plus

Perform medical necessity reviews for outpatient services such as DME, physical/occupational therapy, surgical procedures, imaging, and other related requests Self-pull cases from queue and process efficiently while meeting turnaround time and quality expectations Apply evidence-based criteria (e.g., InterQual, MCG, CMS LCD/NCD) to determine authorization outcomes Collaborate with Medical Directors for secondary reviews when needed Identify eligibility, benefits, and expected length of stay for outpatient services Ensure timely and appropriate documentation of all clinical decisions Support discharge planning and coordinate with internal teams for transition of care when applicable Maintain compliance with Virginia Medicaid or other state Medicaid guidelines and policies Work independently in a structured remote environment using Microsoft Teams, Excel, Outlook, and clinical systems Participate in regular team meetings, audits, and staff development initiatives Demonstrate a professional, approachable, and collaborative demeanor

LanceSoft Inc.,

Family Nurse Practitioner Virtual Care Weekends and Holidays - MC#25-209219

Posted on:

April 13, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

NP/APP

State License:

Florida

LanceSoft’s mission is to establish global cross-culture human connections that further the careers of our employees and strengthen the businesses of our clients. We are driven to use the power of our global network to connect businesses with the right people, and people with the right businesses without bias. We provide Global Workforce Solutions with a human touch.

Position Type: Full time Location: Fully remote (never coming onsite) Work Type: Remote Est. Pay Range: $70.00/hr. to $75.00/hr. The Telehealth Nurse Practitioner delivers patient care services through a remote technology platform. You will work in collaboration with a dedicated team of professionals as you independently provide holistic, evidenced based care inclusive of accurate assessment, diagnosis, treatment, management of health problems, health counseling, and disposition planning for our patients ranging in age 18 months and above. Encounters are documented utilizing an electronic health record (EHR). Telehealth providers report directly to the Enterprise Initiative Lead.

Must hold a FL license and have Independent Practice (3000 hours of overall experience (100 weeks or 2.5 yrs) Must also be licensed in at least three of these states: OH, MA, MD, ME, DC, RI Must be willing/available to work two weekends per six-week cycle Must be willing/available to work one major holiday and one minor holiday per year. Minimum of two years of medical relevant experience Basic Life Support (BLS) certification A minimum of high speed/broadband internet connectivity with a download speed of at least 25 download and 3 upload speed. Speed test not required on resume, but please ensure candidate is aware of this requirement. Must hold an unrestricted license and have the ability to obtain multi state/ compact privileges and licensure in noncompact states as required by the business. Effective verbal, written, and electronic communication skills Outstanding organizational skills and ability to multi-task Initiative, problem solving ability, adaptability, and flexibility Ability to work without direct supervision and practice autonomously Is proficient with information management and technology Capacity to collaborate with professional colleagues as necessary to provide quality care. Education: Completion of a Master’s Degree level Family Nurse Practitioner program with current National Board Certification and State of Employment license to practice in the Advanced Practice Nurse role required.

Patient-Centered Quality and Safety: Evaluate primary care, acute, chronically ill, and transitional care patients, in addition to providing healthcare education and counseling, and disposition planning for our patients ranging in age 18 months and above Provide patient counseling; inclusive of pregnancy prevention, STI Prevention/safer sex practices, contraceptive care counseling and medication management Educate patients on health maintenance and respond to patient care inquiries Document all patient care within an EHR according to policies and procedures Provide care and coordination of our patients with internal and external colleagues, including the broader patient centered medical home, ensuring the highest standard of care is provided for all patients and at all times Effectively work within a patient care team, including fellow Providers, Collaborative Physicians, paraprofessionals, Pharmacists and other members of the health care team Customer Service Excellence: Deliver excellent customer service Seek to increase patient engagement and satisfaction through integration of feedback from patients, management, and professional colleagues Focuses consistently on the patient to create a warm and welcoming environment Tailor communication style to effectively influence quality outcomes and patient needs Collaborate with pharmacy and front store colleagues to provide a complete patient experience Maintain patient confidentiality in accordance with PHI and HIPAA standards Healthcare Environment Management: Resolve conflict using appropriate management techniques Cultivate and maintain positive relationships among practice employees, colleagues and external partners Reprioritizes continually throughout the day to fulfill patient and business needs Support the overall patient experience, by effectively managing clinical and non-clinical duties as well as patient expectations Quickly adopt new service offerings and patient care models Adhere to the core values of in all communications and interactions Assist with hiring, development, and evaluation of Practice employees Complete necessary tasks for clinic operations, including but not limited to taking inventory, following up on lab results, receiving incoming phone calls, ordering supplies and maintaining clinic cleanliness Business Acumen: Remain accountable to managing business needs including, but not limited to, budget, payroll, inventory, billing insurance, and payment collection Own the success of your practice through implementation of the clinic level business plan designed to meet identified business goals Assure complete and accurate payment for services through comprehensive documentation in the patient chart, verification of payment method (insurance, cash or combination) for each visit, and collection of payment as directed by the EMR Complete revenue cycle managements tasks including collecting payment at time of service for all visits and preparing nightly deposits. Autonomy: Work independently , prioritize and solve problems, take initiative, and advocate for their patients and their practice Actively participate in professional development thru professional groups, committees within the organization and/or additional external experiences Maintain self-awareness and professionalism of individual actions and how they impact the clinic, practice, and healthcare industry Continuing education, including what is required to maintain employment, is the responsibility of the provider.

HealthCare Support

Remote Utilization Review LVN - California License Required

Posted on:

April 13, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

LPN/LVN

State License:

California

HealthCare Support is actively seeking a Remote Utilization Review LVN - California License Required to fill an opening. Pay Details: $34 per hour Shift Details: Monday – Friday 8am to 5pm HI (Hawaii)

High School Diploma or GED Active and unrestricted LVN/LPN license in CA (can sit in another state PST or MST but need to be able to work PST hours) 1+ year of inpatient/concurrent review

Concurrent review for inpatient charts using MCG (Milliman Care Guidelines) and Medicare guidelines for inpatient case management Work directly with the provider(s) and Medical Director to facilitate quality service to the member and provider Identifies and refers members to the appropriate healthcare program (e.g. case management, disease management)

HealthCare Support

Licensed Behavioral Health Clinician – Remote

Posted on:

April 13, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Michigan

Healthcare Support is actively seeking a Licensed Behavioral Health Clinician to fill an opportunity with an Outpatient Collaborative Care company as a 100% Remote Telehealth Behavioral Health Clinician in the state of Michigan. Shift: Monday – Friday | 8-hour shift | Days

LPCC, LMHC, LMSW, LPC, LCSW or RN licensure within the state of Michigan 3+ years of experience in behavioral health intervention as an independently licensed clinician/therapist

Screen and assess patients for mental health and substance abuse disorders, and develop personalized treatment plans with appropriate follow-up care Provide evidence-based behavioral interventions (e.g., motivational interviewing, behavioral activation) and support psychotropic medication management, ensuring adherence and monitoring for side effects Track treatment responses, monitor clinical symptoms, and facilitate patient education, referrals, and care coordination through EHR and other clinical tools Actively participate in team consultations, process improvement initiatives, and meet performance metrics while maintaining collaboration with medical providers and psychiatric consultants

HealthCare Support

Bilingual Licensed Behavioral Health Clinician – Remote

Posted on:

April 13, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Florida

Shift: Monday-Friday, flexible 8-hr day shift | 100% remote HealthCare Support is actively seeking a Bilingual Licensed Behavioral Health Clinician to join a Psychiatric Collaborative Care company remotely.

Must have LPCC, LMHC, LMSW, LPC, LCSW, RN or Psychologist in the designated state (Florida) Must be fluent in English & Spanish Minimum of 3+ years of experience in behavioral health intervention clinical work, case management, and/or community care coordination. Experience working with various populations A license in the state to be independently billable is required. Current enrollment in the state’s Medicaid & Medicare is preferred but eligibility for such at a minimum is required Proficiency with MS Office Suite and ability to navigate web applications

Screen and assess patients for mental health and substance abuse disorders. Facilitate patient engagement, treatment plans, and follow-up care. Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate supported by the clinical technology software. Support psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment. Provide health behavior and social determinants of health interventions to improve functioning and improvements in medical outcomes. Systematically track treatment response and monitor patients (in person, video or by telephone) for changes in clinical symptoms and treatment side effects or complications.

HealthCare Support

RN/ LPN Prior Authorization Nurse

Posted on:

April 13, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Arizona

HealthCare Support is actively seeking an RN/ LPN Prior Authorization Nurse to fill an opening with a fortune 25 Healthcare company. Shift: M/F 8:30-5pm Location: Remote in AZ

Graduate from an Accredited School of Nursing. BSN preferred LPN or RN license in Arizona, RN strongly preferred 2+ years of Prior Authorization, Utilization Management, Utilization Review experience with reviewing outpatient services such as DME, Home health, nutrition, pain, hospice, sleep studies Milliman or IQ computer experience

Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.

HealthCare Support

Remote RN Certified Coder

Posted on:

April 13, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

California

HealthCare Support is actively seeking a Remote RN Certified Coder to fill a job opening. This role is fully remote, but you must be able to work EST hours.

Bachelor’s degree Certified Professional Coder (AAPC or AHIMA) Active unrestricted RN license 3+ years of experience with coding and reimbursement methodologies (e.g. CPT, HCPCS, ICD-10, CMS, etc.) 3+ years of RN experience Prior managed care experience Proficient in the use of MS Word, Excel, Access, and PowerPoint. Excellent written and verbal communication skills

This position will be working on a COC/ SPD project full time to help build out the coding for our benefit plans Determine which codes belong to the language in the benefit plans Review what peers have designated as correct coding Facilitate any discussions needed to get to a coding document Review audit results and make adjustments as necessary Participate in project meetings This individual will be working on a team with other certified coders and a few business analyst roles The shifts for the position: Monday to Friday, 8am to 5pm EST This is a contract position, through the end of 2025

Inhouse Recruiting Solutions

RN OASIS Reviewer/Coder

Posted on:

April 13, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

RN OASIS Reviewer/Coder (Remote) Location: Remote Company: Empower Empower is currently hiring a remote RN OASIS Reviewer/Coder.

Current RN license Minimum of 2 years of experience in OASIS review and ICD-10 coding Strong attention to detail and familiarity with Medicare documentation standards Prior experience with coding software and EMR systems Excellent time management and communication skills

This position is responsible for reviewing and coding OASIS assessments to ensure accuracy, compliance, and alignment with CMS guidelines. The reviewer will provide feedback to field staff and collaborate with internal departments to ensure high standards of documentation and reimbursement practices.

Athens Administrators

Telephonic Nurse Case Manager

Posted on:

April 13, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

Explore the Athens Administrators difference: We have been dynamic, innovative leaders in claims administration since our founding in 1976. We foster an environment where employees not only thrive but consistently recognize Athens as a “Best Place to Work.” Immerse yourself in our engaging, supportive, and inclusive culture, offering opportunities for continuous professional growth. Join our nationwide family-owned company in Workers' Compensation, Property & Casualty, Program Business, and Managed Care. Embrace a change and come make an impact with the Athens Administrators family today!

Athens Administrators has an immediate need for a full-time Telephonic Nurse Case Manager to support our Managed Care Department. The position can be located remotely from California, Colorado, Nevada, Texas, Oregon, Idaho, Arizona, or Oklahoma if technical requirements are met. This position will work M-F from 9am to 5pm Pacific time schedule regardless of time zone. Athens offices are open for business Monday-Friday from 7:30 a.m. to 5:30 p.m. The Telephonic Nurse Case Manager researches and recommends resources and creates flexible, cost-effective options for injured, catastrophically, or chronically ill individuals on a case-by-case basis to facilitate quality individualized treatment goals, including timely return to work if appropriate. This position will assist the unit in maintaining a successful program which may include helping develop workflows, reporting, staff recruitment and training.

A Master's or Bachelor's degree in nursing or an Associate's Degree in Nursing from an accredited school, along with equivalent work experience, is required CCM, CIRS, CRRN, COHN or other related designation preferred Master’s or Bachelor’s degree in related field with a CCM, CDMS, or CRC or other related designation preferred Active RN license from any US state required at time of hire Current RN licensure in CA required within one year of hire (if not already obtained) California RN application submitted within the first two weeks of hire. Athens reimburses licensing fees 3+ years’ workers’ compensation case management experience or related field required Strong clinical background in orthopedics, neurology, or rehabilitation useful Strong cost containment background, such as utilization review or managed care also useful Extensive clear and tactful communications required via writing, reading, telephone calls, note taking, letter writing, memoranda, etc. Strong negotiation skills The ability to work effectively with minimal direct supervision Well-developed verbal and written communication skills with strong attention to detail Excellent organizational skills and ability to multi-task Ability to type quickly, accurately and for prolonged periods Proficient in Microsoft Office Suite Ability to learn additional computer programs Reasoning ability, including problem-solving and analytical skills, i.e., proven ability to research and analyze facts, identify issues, and make appropriate recommendations and solutions for resolution Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization Seeks to include innovative strategies and methods to provide a high level of commitment to service and results Ability to be demonstrate care and concern for fellow team members and clients in a professional and friendly manner Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor. Athens’ operations involve handling confidential, proprietary, and highly sensitive information, such as health records, client financials, and other personal data. Therefore, maintaining honesty and integrity is essential for all roles within the company.

Organizes and review medical records to identify specific medical issues; Provides information and recommendations to appropriate parties. Maintains regular contact with all parties involved to facilitate communication and to provide medical and vocational management and coordination services. Arranges for prompt and appropriate medical treatment of an injured worker by qualified providers (choice of providers as per regulations). Schedules appointments to avoid delays in treatment by primary care physicians, specialists, or ancillary services. Assists the treating physician in developing a written treatment plan for the injured worker, including the identity and scope of treatment by any other providers to which referrals have been made. May be requested to attend doctor and/or attorney visits, hospital and/or long-term facility discharge planning conferences, et cetera for the purpose of determining appropriateness of care and developing an effective long-term care strategy as deemed necessary. Work with the medical providers to track progress and to modify the treatment plan as necessary until maximum medical improvement is achieved. Obtains medical reports and required work status forms. Ensures all parties receive appropriate reports. Develops Independent Medical Evaluation Plan. Provides assessment, planning, implementation, and evaluation of patient's progress Facilitate authorization/certification of procedures, diagnostic testing, physical therapy/occupational therapy and durable medical equipment as per regulations to ensure appropriate treatment is not delayed. Cooperates with the treating physician to obtain a full or conditional release to return to work before injury becomes a lost time claim. Work with the treating physician to update any conditions as medical treatment progresses Assesses the injured worker and his/her support system and family. Makes appropriate referrals throughout the continuum of care including educational, financial, and psychological or other human services as indicated Coordinates with the employer to develop a modified duty job for the injured worker who cannot immediately return to his/her full pre-injury employment, ensuring the job is consistent with any physical restrictions assigned by the treating doctor. Educates the employer on the tangible and intangible benefits of accommodating the injured worker to keep him in the work force. Where a return to work with the same employer is not possible, provide vocational services to the injured worker to identify vocational goals and develop an early return to work plan. Research medical and community resources for patients with catastrophic or chronic diagnoses, such as but not limited to, AIDS, cancer, spinal cord injury, diabetes, head injury, back injury, hand injury, burns, et cetera. Maintains constant contact with the adjuster assigned to the file through telephone calls, email, and written reports. For each customer be aware of the limits of decision-making authority delegated by the adjuster to the case manager and respect these limits. Satisfy the documentation and reporting requirements of each customer. Maintains continuing education requirements per state license requirements. Maintains an updated and working knowledge of workers’ compensation and federal laws that impact the delivery of health care and return to work May be requested to attend doctor and/or attorney visits, hospital and/or long-term facility discharge planning conferences, et cetera for the purpose of determining appropriateness of care and developing an effective long-term care strategy as deemed necessary. Assist the overall unit with development of workflows, best practices, reporting templates, and training needs as deemed necessary. Requires regular and consistent attendance May be asked to travel to other branches for training or file reviews as needed. Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP)

Healthcare Shares

Registered Nurse Advisor at Healthcare Venture Capital Fund - Healthcare Shares

Posted on:

April 12, 2025

Job Type:

Part-Time

Role Type:

Primary Care

License:

RN

State License:

New York

We are a Healthcare Venture Capital fund focused on investing in social impact healthcare startups.We seek a Registered Nurse Advisor to provide clinical expertise, strategic insights, and guidance on evaluating healthcare investments.

As a Registered Nurse Advisor, you will play a key role in evaluating healthcare startups, engaging with founders, providing clinical expertise, and helping us connect with other healthcare professionals interested in venture capital and entrepreneurship. The Registered Nurse Advisor will work alongside physicians, dietitians, and other healthcare advisors to ensure that startups bring clinically sound, patient-centered innovations to market.

Registered Nurse (RN) with clinical, telehealth, or startup experience in hospital care, outpatient care, telemedicine, or patient advocacy. Passion for healthcare innovation, digital health, and entrepreneurship. Strong understanding of clinical workflows, patient engagement, and healthcare technology from a Registered Nurse perspective. Ability to critically evaluate startups, assess business models, and identify real-world clinical challenges in nursing and patient care. Interest in networking with founders, investors, and other healthcare professionals. Previous experience in healthcare startups, consulting, or advisory roles is a plus but not required.

Startup Evaluation: Assess healthcare startups in digital health, telemedicine, medical devices, patient engagement, and chronic disease management, providing insights from a Registered Nurse perspective. Founder & Investor Engagement: Advise healthcare entrepreneurs, investors, and executives on nursing-related startups, business models, and patient care innovations. Community & Network Growth: Connect with Registered Nurses, physicians, and healthcare leaders who may be interested in joining our investment network or supporting early-stage healthcare startups. Due Diligence & Market Research: Provide input on nursing industry trends, regulatory challenges (Medicare reimbursement, insurance, clinical workflows), and patient adoption hurdles for potential investments. Advisory Board Participation: Join investment discussions and offer strategic guidance on portfolio companies requiring nursing expertise, clinical validation, and workflow integration. Collaboration with Healthcare Advisors: Work closely with physicians, Registered Dietitians, and other healthcare professionals to ensure that investments align with nursing best practices and patient care standards.

Naven Health

Quality Assurance Chart Review Nurse - Naven Health (Remote - National)

Posted on:

April 12, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Tennessee

Delivering an exceptional infusion experience, everywhere. Delivering on our unyielding commitment, always. Naven Health is a nationwide home infusion nursing network and clinical platform focused on delivering specialized, truly exceptional infusion care. With over 1,600 team members, including over 1,500 nurses, we are a company aligned to the values of the nurses at our center – to provide an exceptional infusion experience, everywhere. Naven Health delivers home infusion services for a broad range of specialized therapies, as well as clinical trial services and special programs for pharmaceutical manufacturers. Joining the Naven Health team means being a part of a dynamic and growing organization that is dedicated to our customers, our teammates, and the patients we serve.

The Quality Assurance Chart Review Nurse is responsible for the review of assigned clinical records. The Quality Assurance Chart Review Nurse works closely with the Quality Assurance Team to identify documentation discrepancies and deficiencies in the patient’s clinical records. The Quality Assurance Chart Review Nurse utilizes audit tools and systems to collect data for the Quality Department under the direction of the Senior Manager of Quality, Regulatory, & education.

Basic Education and/or Experience Requirements: Nursing degree or certificate Active and unrestricted license as an LPN/LVN or RN IV certified for LPN/LVN candidates 3 years of clinical nursing experience 1 year of home infusion experience Basic Qualifications: Ability to work remotely and achieve target goals. Proficiency in electronic medical records and computer systems (Microsoft Excel, Teams, Forms, etc.) Proven strong Communication Skills – verbal, written, presentation Strong clinical background with direct knowledge of care in the home Physical Demand Requirements: Ability to work on a personal or laptop computer for extended periods of time Travel Requirements: (if required): N/A Preferred Qualifications & Interests (PQIs): Previous experience as a Quality Assurance Nurse or Chart Review Auditor Knowledge and understanding of TJC Accrediting Standards for Home Health Knowledge and understanding of Clinical Practice Guidelines for infusion therapy.

Conducts chart reviews to ensure compliance with regulatory, accreditation, policy, and standard operating procedures and standards. Reviews clinical documentation for accuracy, completeness, and adherence with clinical best practice guidelines. Provides feedback to clinical leadership regarding documentation discrepancies, deficiencies, and areas of improvement. Participates in Quality Improvement Activities by conducting Focused Reviews and Compliance Monitoring Audits for Performance Improvement Projects. Supervisory Responsibilities Does this position have supervisory responsibilities? (i.e. hiring, recommending/approving promotions and pay increases, scheduling, performance reviews, discipline, etc.) No X

Optum

Clinical Quality LPN - Remote in EST

Posted on:

April 12, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

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.

The Patient Navigator will be responsible for conducting outbound calls and answer inbound calls, off-season survey follow-up, provide patients with community resources, close gaps on HOS, etc. for all markets as needed. The Patient Navigator will support a variety of strategic activities, based on Member Experience data and performance metrics throughout the OptumCare enterprise. This individual will maintain the highest standards to ensure the members have the best healthcare experience by facilitating the process every step of the way, and will complete daily activities reports. Schedule: Monday – Friday (No weekends, no holidays). Must be flexible to work hours in different times zones as needed for a nationwide account. You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Current, unrestricted LVN/LPN license 3+ years of clinical experience as a LVN or LPN 3+ years of experience in the health industry and/or in a large complex matrixed organization Intermediate level of proficiency with MS Excel, Word, and PowerPoint– Project scope documents, project presentations, etc. Intermediate level of proficiency with SharePoint Preferred Qualifications: Experience in a call center HEDIS/STAR experience or participation with similar regulatory reporting

Conduct a high volume of outbound calls to assist members, evaluate current health status, discuss non-compliance to medication(s), schedule pharmacy telephonic appointments, and/or obtain important follow up information from providers. Calls are made primarily using an auto dialer requiring precision to detail and adaptability to type of response needed Answer inbound calls from members and assists them with their inquiries Identifies patients with the missing measures and works to close the measures through education/counseling, appointment setting, and other means as appropriate Follows system scripting and validates member demographic information Documents the provider or member’s record with accurate information obtained on the call Maintains education/knowledge base of HEDIS/STARs standards and guidelines Uphold UHG Cultural Values Ability to multitask and performs all other related duties as assigned

The Judge Group

RN - In-home Assessments

Posted on:

April 12, 2025

Job Type:

Contract

Role Type:

License:

RN

State License:

Compact / Multi-State

Our client is currently seeking a Remote Field RN to do In-Home Assessments in North New Jersey! Position Title: Remote Field Nurse (RN Ongoing Contract (W2, Weekly Pay, Temp to Hire potential) Location: North New Jersey (Hudson, Union, Bergen counties) Role Type: Remote Field Role – travel required for member assessments; not office-based. Hours: 8:00 AM-5:00 PM or 9:00 AM-6:00 PM, with 3-4 member assessments daily. Job Overview: We are seeking a highly motivated and detail-oriented Registered Nurse (RN) for a field-based position that involves conducting member assessments within the North New Jersey area. This is a remote role with travel requirements, offering autonomy and independence for organized self-starters with strong technical and computer proficiency.

Training & Compensation: Training for the first two weeks will take place onsite at the Hopewell location. Mileage reimbursement provided for travel. Qualifications: Active NJ RN license or Compact NJ license required. Valid driver's license and reliable transportation. Experience in Home Health or Med Surg preferred. Proficient in computer systems and technology. Exceptional organizational and note-taking skills. Strong ability to work independently.

Conduct assessments for PCA (Personal Care Assistant) and MDC (Major Diagnostic Category) services using established guidelines to ensure appropriate care and services are authorized. Evaluate the necessity, appropriateness, and efficiency of services provided. Collaborate with patients, families, physicians, hospitals, and other stakeholders to ensure services align with diagnoses and outcomes. Coordinate high-quality, cost-effective care across the continuum using clinical practice guidelines. Monitor medical care activities and outcomes for effectiveness and appropriateness. Advocate for members and families, ensuring resource utilization meets their needs. Refer members to MLTSS (Managed Long-Term Services and Supports) and educate them on SNP (Special Needs Plan) when appropriate. Accurately and comprehensively document assessments in compliance with organizational standards. Facilitate communication with multidisciplinary teams, ensuring efficient care management. Contribute to quality improvement initiatives to enhance member outcomes. Perform other duties and assigned tasks as directed by management.

The Judge Group

Remote Medical Policy Review RN

Posted on:

April 12, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

The Judge Group is currently seeking a remote Medical Policy Review RN for a fantastic client of ours! Are you passionate about ensuring appropriate and efficient utilization of medical benefits? Join our team as a Medical Policy Review Specialist, where you'll play a crucial role in the medical policy determination of claims and cases consistent with Plan Medical Policy. You'll also be responsible for researching and analyzing medical techniques, procedures, and products, and making recommendations for draft medical policy. Job Title: Medical Policy Determination Specialist Location: Remote but must reside in NJ, PA, NY, DE, or CT and have an active RN license in the state of NJ

Candidates must live in NJ, PA, NY, DE, or CT. Active NJ or NJ Compact RN license. Minimum 3 years RN experience in a clinical setting. Comfortable working with Claims systems - Horizon uses Nasco. Must have coding experience; certification not required. Demonstrated ability to work in a production-focused environment. Must be tech-savvy with strong Microsoft experience and knowledge of intranet and internet applications.

Provide timely and accurate responses to inquiries from the claim policy teams in relation to courtesy pre-d requests, claims pending for medical review, and appeal inquiries. Prepare cases for Medical Director Review and/or outside consultant review and response where appropriate. Process pends for which the Medical Policy Inquiry Resolution team has authority to do so. Identify opportunities for development of or revisions to Horizon Medical Policy based on case review. Identify areas and pursue solutions where medical policy is not being applied correctly in claim payment outcomes. Manage inventory assigned, document production in RMRS, and follow through on all assigned inquiries. Stay abreast of all mandates, policy changes, and workflow changes impacting outcomes. Perform special projects as assigned by management. Demonstrate knowledge and understanding of the laws, regulations, and policies that pertain to the organization unit's business and conform to these laws, regulations, and policies in carrying out the accountabilities of the job.

Assembly Health

MatrixCare Experienced Skilled Nursing Tracking Specialist

Posted on:

April 12, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Illinois

Become a part of the Quality Healthcare Team! Quality Healthcare, a member of the Assembly Health family of companies is looking for a Skilled Nursing Tracking Specialist. If you are looking for a company that is focused on being the best in the industry, love being challenged, and make a direct impact on our business, then look no further! We are adding to our motivated team that pride themselves on being client-focused, biased to action, improving together, and insistent on excellence and integrity.

Prior experience using MatrixCare. Experience working with nursing home facilities and Medicaid applications. Strong written and verbal skills with the ability to adjust the message to fit the audience. Possess strong organizational and time management skills. Ability to analyze and synthesize information to understand issues and identify options. Engage with a wide base of clients across the organization. Collaborate with interdepartmental team members to complete projects. Quality requires employees working from home, or otherwise remote, maintain broadband internet access at the address where remote work is being performed. Quality will require a valid speed test report. If you are unable to meet these requirements, please discuss with your recruiter.

Provide a viable payer source beginning from date of entry throughout the resident's stay. Process Medical Assistance applications and re-determinations. Utilize uTrack to enter all data. Interact with client and facility staff with professionalism in all facets of customer service. Prioritize and adjust workload based on the urgency and importance of issues. Escalate growing balances and/or unresolved time sensitive issues. Ensure facilities are operating according to procedure and compliance. Maintain timely communication with directors, administrators, and staff regarding potential issues at the facilities. Participate in team meetings, committees, and/or conference calls. Other responsibilities may include training of new Tracking Specialists.

Rightway

Bilingual Case Manager, RN

Posted on:

April 12, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Rightway is on a mission to harmonize healthcare for everyone, everywhere. Our products guide members to the best care and medications by inserting clinicians and pharmacists into a member’s care journey through a modern, mobile app. Rightway is a front door to healthcare, giving members the tools they need along with on-demand access to Rightway health guides, human experts that answer their questions and manage the frustrating parts of healthcare for them. Since its founding in 2017, Rightway has raised over $130mm from investors including Khosla Ventures, Thrive Capital, and Tiger Global at a valuation of $1 billion. We’re headquartered in New York City, with a satellite office in Denver. Our clients rely on us to transform the healthcare experience, improve outcomes for their teams, and decrease their healthcare costs.

Under the general supervision of the Sr. Clinical Manager, the Case Manager RN performs clinical triage, high-risk outreach, condition support, care planning, clinical education, and care coordination functions in supporting Rightway members with navigating, accessing, and best supporting their care needs. The Case Manager RN also serves as a trusted advisor for providing clinical guidance and directing to the most appropriate high-quality care providers with the objective of improving clinical outcomes while also reducing healthcare costs e.g. minimizing ED or other unnecessary care visits while increasing utilization of more appropriate care settings, such as primary care doctors.

RN, ADN, or BSN degree Must be fluent in Spanish Holds an active and in good standing RN license in a compact state 5+ years of direct patient care experience required, preferably in family medicine Triage nursing experience desired Population health, disease management, or similar experience required Care management or chronic condition support experience desired

Clinical triage to assess the severity of the member’s health concerns using evidence-based protocols and algorithms in directing care to the right healthcare resource in a timely manner without compromising quality or safety Leveraging data-driven analytics in conducting proactive outreach to engage members of clinical interest, e.g. e high-risk, high-spend, rising risk, and evidence of care gaps with the objective of engaging and assisting members in making more informed care decisions, supporting across their continuum of care and well-being journey with lifestyle and behavior changes. Engage members in clinical conversations to best understand their care needs, assess risks, preferences, and care barriers, and then guide and recommend appropriate next steps to improve health outcomes Identify and address barriers preventing members from accessing preventative care or establishing ongoing relationships with primary care providers Assist in scheduling appointments, referrals, and follow-up care to close gaps in preventative care and chronic disease support Clinical navigation support includes but is not limited to personalized condition education, care options, and planning, care compliance, medication adherence, shared decision support, and care coordination Leverages appropriate input and direction from the Rightway clinical lead to determine the best clinical options for more complex member healthcare needs. Accurately documents symptoms/complaints, nursing assessment, the guidance provided, and member/caller response. Acts in the best interest of the member by being a health advocate and supporter in the member’s healthcare journey. Coordinates the completion of screening services for high-risk members by providing care support, adherence follow-up, and care coordination support. Member’s trusted healthcare advisor, member experience, and retention focus e.g. longitudinal care education, guidance, and support Develops effective collaboration and working relationships across the Navigation team and organization. Maintains a member-centric, customer-driven professional attitude. Stay within the RN scope of practice by strictly following our care navigation protocols unless directed to do otherwise by a provider on the clinical team and documenting appropriately when a change occurs.

Summit Medical Consultants LLC

Triage Nurse (LPN) Remote - must reside in Colorado

Posted on:

April 12, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Colorado

Summit Medical Consultants is actively recruiting for a full-time Triage Nurse to join our Clinical Triage Team. Summit Medical Consultants is a rapidly growing Physician Practice. Founded in 2015, we have expanded to approximately 100 employees and are continuing to grow. Our mission is to provide patients and their families with robust clinical services throughout their Acute Inpatient Rehab, Skilled Nursing, Long Term Care and Assisted and Independent Living stays. We coordinate with the Hospitalists and Specialist physicians and surgeons, Physical, Occupational, Speech Therapists, Case Management and Psychiatry at the facility level to provide compassionate and coordinated care. Work Location: Remote - must reside in Colorado along the I-25 corridor from Ft. Collins to Pueblo.

Active LPN Colorado nursing license 2 years clinical nursing experience in the post-acute care setting preferred Proficient in utilizing Google Docs, Google Sheets, and electronic medical records (EMRs). Familiarity with messaging platforms and phone systems is highly desirable.

Prioritize and handle clinical phone calls within the LPN scope of practice in alignment with standing orders. Serve as a bridge between pharmacies and mid-levels/Physicians to resolve pharmacy-related concerns. Communicate with providers regarding questions or issues, recording detail in the EHR system. Monitor the message threads closely and promptly follow up according to established protocols. Process incoming paperwork and forward it to the designated provider for signature. Act as a liaison between patient families and providers, addressing messages, resolving issues, and offering support within the LPN scope of practice. Maintain professionalism and courtesy during phone interactions, adhering to outlined timeframes for returning calls. Participate in monthly Team Meetings, Triage Meetings and other instructed gatherings. Adapt to evolving workflows in a growing practice, recognizing that duties may change periodically to meet practice needs. Maintain frequent and prompt communication with the Triage Manager and all providers throughout the day. Conduct Chronic Care Management patient chart reviews, telephone calls, and related documentation. Immediately escalate any issues to the managers. Fulfill any additional duties and tasks as assigned and required. Provide a precise and detailed daily account of time allocation. Assist in various administrative tasks, as instructed and as necessary Rotate holiday coverage with the Triage Team. Department expectations: Serving as a central communication hub among providers, facility partners, patients, patient families and outside vendors. Address practice protocol appropriately and meticulously documents all interactions with patients, families, and facilities. Ensuring accurate documentation for prescriptions, verbal orders, and clinical telephone calls is a key responsibility for all Nursing team members. Assessing the quality of patient care delivered by the Nursing team and coordinating patient care services with patients, staff, physicians, and other departments is crucial. Work schedule is FT days 40 hr/week and at least two weekends a month. This description is intended to serve as an outline. Please note the above responsibilities are not an exclusive list. You will be given additional duties, tasks, and responsibilities in your employment. It will be your responsibility to complete all other tasks assigned.

Revive Mobile IV LLC

Mobile IV RN

Posted on:

April 12, 2025

Job Type:

Contract

Role Type:

License:

RN

State License:

Pennsylvania

THIS JOB IS FULLY MOBILE. **YOU MUST BE WILLING TO DRIVE AND ENTER CLIENTS HOMES,WORKPLACES, HOTELS, ETC. BENEFITS ARE NOT PROVIDED AS THIS IS A CONTRACT POSITION.

Looking for nurses who live within the city of York, PA Must be highly skilled in IV placement, comfortable working as a triage nurse Must have a minimum of 2 years of recent experience in daily IV placement Unrestricted licensure as a Registered Nurse (RN) in the State of Pennsylvania Two years of RN experience (ED, Critical Care or L&D experience preferred) Unrestricted Driver’s License Must follow directions well and be good at multi-tasking Access to reliable transportation and willingness to drive up to 45 minutes for appointments. Able to send/receive text messages, work with smartphone apps, and use GPS navigation Able to work collaboratively with co-workers and clients Able to work independently in all care settings BLS certification required Required to provider 15-20 hours of availability a week

https://www.indeed.com/viewjob?jk=5f30aef1ed2450e1&tk=1iojq6quvgqlg85m&from=serp&vjs=3

Elara Caring

Hospice Triage Registered Nurse (RN)

Posted on:

April 12, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

At Elara Caring, we have a unique opportunity to play a huge role in the growth of an entire home care industry. Here, each employee has the chance to make a real difference by carrying out our mission every day. Join our elite team of healthcare professionals, providing the Right Care, at the Right Time, in the Right Place.

Remote Hospice Triage RN Saturday & Sunday, 9:00 AM – 9:00 PM EST Must Have a Compact RN License and Reside in an Approved State Elara Caring is growing and currently seeking an experienced Hospice Triage Registered Nurse to join our remote team. This is a critical weekend role supporting patients and families during some of their most vulnerable moments, delivering compassionate, timely care over the phone. As a Remote Hospice Triage RN, you will serve as the first point of contact for patients and caregivers, providing clinical guidance, emotional reassurance, and care coordination — all from the comfort of your home. This position plays a vital part in our ability to deliver continuous, high-quality care beyond standard business hours.

Graduate of an accredited nursing program (Certificate, Diploma, Associate, or Bachelor’s degree) Active Compact RN License Must reside in one of the following states: Oklahoma, Texas, Louisiana, Illinois, Massachusetts, Ohio, Michigan, Indiana, Missouri, or Kansas Willingness to obtain licensure in non-compact states (MI, IL, MA); Elara will cover the cost Minimum of 1 year of hospice experience Minimum of 1 year of triage nursing experience Reliable high-speed internet HIPAA-compliant home office setup

Provide remote triage services to hospice patients in Oklahoma, Texas, Louisiana, Illinois, Massachusetts, Ohio, Michigan, Indiana, Missouri, and Kansas Maintain strict patient confidentiality in accordance with HIPAA Plan, direct, and participate in delivering professional services to hospice clients Identify changes in patient condition and coordinate appropriate care with physicians and team members Initiate and manage patient safety plans in collaboration with patients, families, and community resources Verify and implement the plan of care in line with physician orders and clinical standards Serve as the primary point of contact and supervisor for after-hours hospice services Manage incoming referrals, staff assignments, re-certifications, and communication between patients and care teams Complete required documentation related to patient death notifications Assess needs and coordinate spiritual and social work services Educate staff on hospice admission criteria and confirm patient eligibility Ensure compliance with Medicare, Medicaid, and other regulatory requirements Promote a respectful, supportive environment for patients and families Take on additional duties and projects as needed

Octiva

Telehealth Support Specialist

Posted on:

April 12, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

None Required

State License:

Texas

Octiva Healthcare provides a 24/7 extension of clinics with three tiers of services: support specialists for general inquiries, message-taking, and appointment scheduling; nurses for medical concerns; and clinicians for advanced medical care.

We are seeking a dedicated Healthcare Support Specialist to join our remote team. This role is pivotal in managing inbound patient calls, ensuring seamless communication, and providing exceptional service to our patients.

Skills and Qualifications: Excellent communication skills, both verbal and written, with a focus on patient interaction. Proficient in computer use, including experience with healthcare software and electronic health records. Strong problem-solving skills and the ability to troubleshoot technical issues. Ability to handle sensitive information with discretion and confidentiality. Experience in a customer service role, preferably within healthcare or a similar high-touch environment. Empathy and patience when dealing with sick or stressed patients. Comfortable working remotely with the discipline to manage time and tasks effectively. Additional Information: This position is fully remote, requiring a reliable internet connection and a quiet workspace. Must be available to work during standard business hours, with potential for some early or late shifts to accommodate patient needs. This role is essential in enhancing our patient experience by ensuring they have access to the care they need when they need it, all while maintaining the highest standards of customer service in a healthcare setting.

Patient Interaction: Manage and respond to inbound patient calls with professionalism and empathy. Address patient inquiries regarding appointments, medical procedures, and general health concerns. Appointment Management: Schedule, reschedule, or cancel patient appointments using our electronic health record system. Ensure all appointments are accurately recorded and patients are informed of their appointment details. Call Routing: Efficiently route calls to the appropriate members of our clinical care team, including doctors, nurses, or specialists, based on the patient's needs. Technical Support: Provide basic technical assistance to patients using telehealth services or accessing patient portals. Troubleshoot common issues to ensure patients can utilize our digital health platforms effectively. Documentation: Maintain accurate and confidential patient records. Ensure all interactions are logged correctly in compliance with HIPAA regulations. Customer Service: Deliver high-quality customer service, aiming to resolve patient concerns in one call when possible. Follow up on unresolved issues to ensure patient satisfaction. Team Collaboration: Work closely with clinical staff to relay critical information and ensure continuity of care. Participate in team meetings to discuss patient care improvements and operational efficiencies.

Octiva

24/7 Telemedicine Triage Nurse

Posted on:

April 12, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Octiva Healthcare is a telemedicine company that provides 24/7/365 clinical support to patients in need of timely care and advice. Our mission at Octiva is to provide around-the-clock healthcare that meets the highest standards of clinical excellence and patient experience. We ensure our services are accessible from any location and in any language, embracing a culture of compassion, clear communication, and strict compliance to security. Our goal is to be a constant in our patients' lives, available 24/7, delivering care with a personal touch.

**Please see pay range before applying** Octiva Triage Nurse – Fluent Spanish Speaking Required Active Califonia RN license Required at time of Application Compact License Required Triage Nurse The ideal candidate has a strong background in clinical nursing and outstanding patient communication skills. The Triage Nurse is a part of the clinical care team which includes nurses, advanced practice providers, and physicians. This position practices nursing via the telephone, utilizing your nursing skills and training , input from physicians, and approved telephone nursing guidelines and protocols. The functions of this position include electronic prescription refill, triage to the most appropriate level of care, providing nursing advice and self-care treatments, identifying resources, and performing nurse follow-up activities. All duties and responsibilities fall within departmental and organizational guidelines and are within the scope of practice as defined by the Board of Registered Nursing and in compliance with state laws and medical nursing standards of care.

Education: Graduate of accredited school of nursing required. BSN preferred. On-the-job training in triage Experience: Two to five years of practical RN experience; outpatient experience preferred. One to two years of practical experience in a physician’s office or medical office setting preferred. Telehealth experience strongly preferred. Performance Requirements: Knowledge: Knowledge of telephone-based clinical assessment techniques Knowledge of medical practice telephone triage Knowledge of medical symptomology and what constitutes urgent/emergent care Knowledge of medical terminology and abbreviations Professional knowledge of clinical nursing protocols Skills: Skill in using a variety of EMRs Skill in using computerized medical information database during evaluation as guide to appropriate decision Skill in making triage decisions and responding quickly and calmly in emergency situations Other Requirements: Fluent in Spanish and English, written and verbal Compact RN License

Evaluate patients on the telephone, offer nursing advice, and triage to the appropriate level of care, including referral to an emergency room or local urgent care, transfer to our own telemedicine provider, or scheduling an appointment with their regular physician. Perform telephonic evaluation of each patient with symptoms to determine the risk of serious illness or injury, and the appropriate next step in care. Follow clinical protocols and guidelines implemented by Octiva Healthcare and/or our partner clinics. Access patient’s medical chart through each clinic’s Electronic Medical Record in order to review needed information and to document treatment plan and advice provided. Perform all other duties as required or assigned.

Blue Cross Blue Shield of Michigan

Care Manager RN - Multi State License

Posted on:

April 12, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

This opportunity is also available for individuals that reside in the following areas with a compact license: Colorado, Georgia, Indiana, Kentucky, Massachusetts, Minnesota, Mississippi, Ohio, Pennsylvania, Virginia, Washington, Louisiana, and Iowa. 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. Fully remote telephonic position. This position requires outbound calls to members to engage them into the program with continuous telephonic outbound calls for ongoing care plan goals. Members may also request to interact via our digital app, instead of telephonically. As a care manager you will need to use motivational interviewing skills to engage members into the free program. Currently Care Managers are calling members that do not know they have been identified for the program and we are looking at opportunities for other team members to make these outreaches in the future. Note: All specialties are needed including Pediatrics, also working hours up to 8pm EST may be expected. 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.

Licenses and Certifications • RN - Registered Nurse - Multi-State-Licensure, RN - Must reside and be licensed in the same state that is part of the Nurse Compact Department Preference Must have exemplary computer skills and be able to utilize multiple systems when interacting with members/providers – Strongly Preferred QUALIFICATIONS: Nursing Diploma or associate 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. 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. Must have intermediate computer knowledge, typing capability and proficiency in Microsoft programs (Excel, OneNote, Outlook, Teams, Word, etc.).

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. 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).

Commonwealth Care Alliance

Per DIEM, RN instED

Posted on:

April 12, 2025

Job Type:

Role Type:

Triage

License:

RN

State License:

Massachusetts

instED provides on-demand, urgent care in the home for medically complex patients. The RN, instED Clinical Resource Center will receive referrals for services, conduct intake assessments, provide triage to ensure referrals are clinically appropriate, and respond clinical questions related to referrals and services. The InstED RN will engage telephonically with patients, clinicians, and care partners who call with urgent clinical needs for a medically diverse group of patients across the continuum of care. Supervision Exercised: No, this position does not have direct reports.

Working Conditions -Remote work environment Must be able to work a flexible schedule. RN coverage is Monday thru Sunday 0800-2200. The shifts can be full shifts or half-shift. Weekends and Holidays are required (instED provides services 365 days per year) Required Education: Bachelor’s degree in Nursing Required Licensing: Current, active MA RN license; will need CT, licenses also (at instED expense) Required Experience: 5+ years of relevant nursing experience Triaging patients with complex medical histories across the lifespan Desired Experience: Experience in urgent care,primary care, or emergency department preferred Call center triage experience preferred Quality and process improvement experience preferred Required Language(s): English Desired Language(s) Fluency in Spanish a plus

Intake: Receive referrals for an instED visit, both electronically and telephonically, from patients, clinicians, and care partners Ensure complete and accurate information for the visit request Obtain comprehensive data collection electronically and/or via telephone from referring provider or patient directly Triage per instED triage guidelines and protocols, assessing patients and applying solid decision-making to achieve highest patient outcomes Deliver competent, safe, compassionate and individualized telephonic nursing/triage care for patients with complex medical histories Triage: Make clinically-appropriate recommendations for action/interventions Triage and prioritize referrals for acuity and sequencing of visits Identify emergent situations and provide clinical advice appropriately Analyze data to identify and determine expected outcomes Develop a plan with instED team to identify strategies to attain expected outcomes Exercise sound clinical judgment, along with excellent working knowledge of instED, to appropriately disperse accurate level of resources needed for achieving the best patient outcomes Follow-up: Communicate with patients and care partners to provide education and instructions regarding any recommended follow-up care. Follow-up services may include, but are not limited to, follow-up call by Provider, Tele-health re-visit, PCP evaluation, re-deployment of paramedic or other clinical provider, and phone teaching with teach-back to ensure understanding Ensure appropriate teaching has occurred with patient and or family Provide follow-up and encounter summary with referring provider and Primary Care Provider Complete accurate and appropriate documentation in real time Demonstrate strong focus on patient experience, with commitment to service excellence from intake through discharge Secondary responsibilities: Quality Assurance Work with the instED team to develop metrics and standards for Quality Assurance within the Clinical Resource Center Participate in Quality Assurance activities in other areas within the instED delivery model Ongoing Program Support: Participate in the development and design of the instED Now platform offering feedback and suggestions for improvement

MPF Federal

Call Center Nurse (RN-BSN) - Remote

Posted on:

April 12, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Ready to Bring Your Acute Care Skills Home? Join Our Remote RN Team Supporting Our Military Communities! Are you a seasoned ER or Med-Surg nurse looking for a meaningful, mission-driven role that lets you care for others without the scrubs and long drives to the hospital? MPF Federal is hiring Remote Telehealth Triage Nurses (RNs) to join our 24/7 Nurse Advice Line—supporting veterans and their families—all from the comfort of your home. This isn’t just a job; it’s your chance to use your clinical expertise, empathy, and critical thinking skills to guide patients through their toughest moments—all while achieving better work-life balance. Pay & Perks $35.00/hr base rate Evening, night, weekend, and holiday differentials may apply 100% Remote – Work From Home All schedules include Saturday and Sunday and do not rotate Shifts Available (Choose Your Schedule!) Day Shifts: 8:00 AM – 6:30 PM (10-Hour) Evening Shifts: 3:30 PM – 12:00 AM (8-Hour) Night Shifts: 12:00 AM – 8:30 AM (8-Hour) Split Shift: 6:00 AM–10:00 AM & 5:00 PM–9:00 PM Next Start Date: May 19th 6 Weeks Paid Training | Monday–Friday, 8:00 AM – 4:30 PM

5+ Years of Recent Hands-On Acute Care RN Experience ER or Med-Surg strongly preferred Current Compact RN License in good standing from the state you are physically in BSN Degree from an accredited American university Confidence with phone-based care and multi-screen computer systems Strong clinical judgment, emotional intelligence, and documentation skills A mission-first mindset and passion for serving military-connected communities Bonus Points If You Also Have: Experience with behavioral health, mother-baby, and/or peds Past work in telehealth, triage, or call center nursing Familiarity with military healthcare systems or VA patients Tech & Work Environment: Must have a hard-wired Ethernet internet connection (Wi-Fi only, satellite, or radio internet is not acceptable) Quiet, distraction-free home office space with a door for HIPAA compliance Metrics-driven environment – you’ll need to meet quality, handle time, and documentation goals Federal Requirements: Must be a U.S. Citizen Ability to pass a Public Trust Background Check & Drug Screening per federal guidelines Must be willing and able to obtain licenses in all 50 states (we support you here!)

Triage Symptoms: Assess callers using evidence-based protocols Deliver Immediate Care Advice: Recommend next steps, from self-care to urgent care, calmly and confidently Offer Health Education: Counsel patients on medications, test results, and chronic condition management Crisis Triage: Handle behavioral health, emergency, and complex calls with empathy and grace Document Interactions: Accurately chart calls in our EHR and follow compliance protocols Team Collaboration: Work closely with a supportive leadership team and fellow remote RNs

Ohio State University Physicians, Inc.

RN Triage - OBGYN

Posted on:

April 12, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Ohio

Looking to join our dynamic team at Ohio State University Physicians where excellence meets compassion!? With over 100 cutting-edge outpatient center locations, dedicated to providing exceptional patient care while fostering a collaborative work environment, our buckeye team includes more than 1,800 nurses, medical assistants, physicians, advanced practice providers, administrative support staff, IT specialists, financial specialists and leaders that all play an important part. As an employee of OSUP, you'll be an integral part of a team committed to advancing healthcare, education, and professional growth. Our culture At OSUP, we foster a culture grounded in the values of inclusion, empathy, sincerity, and determination. We meet our teams where they are, coming together to serve each other and our community.

Associate Degree in Nursing and current Ohio Registered Nurse license. CPR/BLS certified. Knowledge of triage procedures along with clinic, physician office and/or urgent care experience. Preferences: Bachelor’s Degree in Nursing. Two or more years of nursing experience. Phone triage experience. Experience in clinical specialty where assigned. ACLS certified.

The Registered Nurse (RN) provides telephonic triage skilled nursing services and advice to patients, and assists in clinic when needed, under the direction of a physician or midlevel provider, and provides a variety of related services to maintain a safe, therapeutic environment. The functions of the Registered Nurse are to collect patient health data, analyze the data to determine diagnoses, develop a plan of care that prescribes interventions to attain the expected outcomes, identify expected outcomes individualized to the patient, and routes patient accordingly while working collaboratively with the healthcare team. Performs professional nursing work of considerable difficulty including the care of patients as outlined by physicians and the objectives and policies of the organization. Provides patient and family health education and health assessment.

Monogram Health Inc

Bilingual MH First Triage RN - Weekend Day Shift

Posted on:

April 11, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Monogram Health is a next-generation, value-based chronic condition risk provider serving patients with chronic kidney and end-stage renal disease and related metabolic disorders. Monogram seeks to fill systemic gaps and transform how nephrology, primary care and chronic condition treatment are delivered. Monogram’s innovative, in-home approach utilizes a national nephrology practice powered by a suite of technology-enabled clinical services, including case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs across the healthcare continuum. Monogram has emerged as an industry leader in championing more significant health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease by increasing access to evidence-based care pathways and addressing social determinants of health. Monogram Health believes in fostering an inclusive environment where employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams and welcome those from all backgrounds and varying experiences.

The MH FIRST RN is pivotal in providing critical support to field teams facing urgent and complex patient concerns. The Registered Nurse has expertise that will ensure patients receive the care, resources, and support they need, especially during high-stress situations and environmental crises. SHIFT: Weekend Day Shift 7A-7P with 4 additional hours during the week.

Maintain a current and valid compact RN license, allowing you to practice across state lines. Availability for Weekend Day Shift: 7:00 AM – 7:00 PM (Saturday and Sunday), plus 4 additional hours during the week Minimum of 3 years of clinical nursing experience, with a preference for emergency care, critical care, or triage backgrounds. Availability to adjust shift flexibly in response to peak coverage or staffing needs. Demonstrate the ability to communicate calmly and confidently during high-stress situations. Build strong relationships with team members and patients through effective rapport-building. Exhibit meticulous attention to detail and outstanding organizational skills. Show unwavering dedication to patient safety and delivering high-quality care.

Utilize licensing and crisis management skills to assess and address urgent needs. Assess care plan requirements and assist in their implementation. Utilize proficiency in documentation and technology to streamline member care. Offer valuable support and guidance to patients and their families in critical situations. Primary point of contact for patients, Monogram field staff, and care center personnel needing immediate support. Provide seamless transitions by providing comprehensive handoffs to incoming staff. Conduct chart auditing during non-peak call volumes. Emergency/disaster outreach as events occur. Support service level agreement (SLA) compliance for annual assessments and care plans. Assist in post-hospital outreach to ensure patient needs are met, with no outstanding needs that could result in readmissions.

Accompany Health

RN Case Manager, Transitions of Care

Posted on:

April 11, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Michigan

Transitions of Care (TOC) RNs are a key part of our Accompany Health care model which also includes Physicians, Advanced Practice Clinicians, Community Health Workers, Patient Experience Navigators, RNs, Social Workers, Behavioral Health Clinicians, Psychiatrists, and Pharmacists. Together this team is responsible for providing and coordinating holistic, patient-centered care for an intimate panel of patients with complex medical, behavioral health, and social needs. As a TOC RN, you will help ensure our patients have the care they need after a vulnerable time period post-discharge from the Emergency Department or hospital. As a TOC RN, you will care for patients virtually via video, telephone, or text. As part of the central nursing team, you will help provide transitional care for patients in various cities. You will contact patients who have recently been discharged and conduct a clinical assessment and medication reconciliation, and will help patients who require additional care with scheduling follow up appointments as needed. You will also occasionally contact local hospitals when needed to collaborate with the inpatient team to coordinate safe discharge planning. As part of the TOC role, you may also help provide proactive outreach virtually for some of our complex patients who have frequent admissions. You will support the local care team responding with compassion and empathy, uncovering barriers and connecting patients with appropriate care and resources that can keep them safely at home and out of the hospital when possible.

What makes you a fit for the team: Passionate about caring for complex, historically underserved patients with co-occurring chronic and behavioral health conditions in an integrated, multi-disciplinary model anchored in home-based and tech-enabled virtual care. Committed to providing the highest quality, outstanding clinical care to all patients, regardless of their needs. Strong proficiency in using technology and delivering a high caliber of care virtually. Excellent communicator, collaborator and team player who enjoys working in an integrated, multi-disciplinary model. Committed to providing the highest quality, outstanding clinical care and willing to go the extra mile for all patients. Possess high attention to detail as well as adaptability, and is excited to be a part of and contribute to the development of a rapidly evolving, innovative care model. Enjoys continuously learning and adapting workflows to improve patient care. Desired skills and experience Required: Active, unrestricted Registered Nurse license in home state and willingness and certification in good standing and the ability to get licensed in requested states such as Michigan, Colorado or Massachusetts within 90 days of hire date. 3+ years of experience providing clinical services to Adult and/or Geriatric individuals with co-occurring chronic medical and behavioral health conditions, particularly in virtual settings. Demonstrated ability to help a patient adapt new habits, change behaviors, and motivate towards achieving health goals. Comfort with electronic medical record documentation and excited about how technology can support your work and drive ongoing improvement towards new and better care Experience and comfort working within an interdisciplinary care team, and specifically communicating with clinical and non-clinical team members. Preferred: Experience in adult internal medicine, family medicine, geriatrics, palliative care, and virtual care. Experience in transitions of care management for patients being discharged from hospitals, skilled nursing facilities, and behavioral health facilities, including performing detailed medication reconciliation, patient education, and connection/navigation to appropriate services. Experience in behavioral health settings and/or caring for patients with serious mental illness and/or substance use disorder. Experience in trauma-informed care and practices. Experience as an active participant in continuous quality improvement projects. Experience in value-based care organizations

Providing post-discharge follow up care for patients virtually via video, telephone, or text Providing patients with education on their care plans and medications. Effectively interpreting and utilizing electronic data tools and analysis to organize daily activities and provide high quality of care Collaborating closely with local Accompany Health teams to ensure continuity of care Establishing and fostering trusting relationships with your patients and ensuring that care is appropriately aligned with their goals and values Collaborating with external hospitals when necessary to collaborate on discharge planning and advocate for patient care aligned with their goals Providing feedback on program design and workflows to ensure we are providing the best patient care possible. Timely and appropriate documentation. Roles and responsibilities may evolve as our care model develops. Occasional in person team building time

Accompany Health

Clinical (Telephonic) Behavioral Health Triage RN

Posted on:

April 11, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Michigan

Triage RNs are a key part of our care model which also include Physicians, Advanced Practice Clinicians, Community Health Workers, Patient Experience Navigators, RNs, Social Workers, Behavioral Health Clinicians, Psychiatrists, and Pharmacists. Together this team is responsible for providing and coordinating holistic, patient-centered care for an intimate panel of patients with complex medical, behavioral health, and social needs. As a Triage RN, you will be part of the central urgent care team, supporting patients across multiple markets. You will provide care primarily through virtual modalities—video, phone, and text—and serve as the first line of clinical support for patients reaching out with urgent medical or behavioral health concerns. You’ll respond with empathy, clinical expertise, and a trauma-informed approach to deliver both physical and behavioral health care support in real time. This role plays a critical part in helping patients remain safely at home by avoiding unnecessary emergency visits and ensuring timely, appropriate care. As our behavioral health RN, you will collaborate closely with Medical Directors, fellow triage RNs, Behavioral Health Clinicians, and other members of the interdisciplinary team to support safe, coordinated, and holistic care for our patients. The shift for this role will be Monday-Friday 10:00 am-7:00 pm EST, or 3:00 pm-11:30 pm EST. To ensure sufficient clinical coverage, our expectation is that our care team will cover shifts up to 3 holidays per year.

What makes you a fit for the team: Passionate about caring for complex, historically underserved patients with co-occurring chronic and behavioral health conditions in an integrated, multi-disciplinary model anchored in home-based and tech-enabled virtual care. Experienced in both clinical triage and behavioral health support, with a calm and compassionate approach to high-pressure situations. Demonstrated ability to assess and manage patients experiencing behavioral health crises, including active suicidality, aggression, severe mood instability, psychosis, and acute substance use episodes—while maintaining clinical focus and ensuring appropriate triage and escalation. Strong understanding of Trauma-informed care principles and ability to apply them in high pressure situations. Strong communicator and collaborator who thrives in an interdisciplinary, tech-enabled care model. Flexible, solutions-focused, and motivated to improve care delivery through innovation and teamwork. Committed to providing equitable, dignified, and person-centered care in all interactions. Possess high attention to detail, and is excited to be a part of and contribute to the development of a rapidly evolving, innovative care model. Enjoys continuously learning and adapting workflows to improve patient care. Desired skills and experience Required: Active, unrestricted Registered Nurse license in home state in good standing, with the ability to get licensed in requested states such as Michigan, Colorado & Massachusetts within 90 days of hire date 3+ years of clinical experience, including experience with patients who have behavioral health conditions or co-occurring diagnoses particularly in virtual settings Strong triage, assessment, and critical thinking skills across both medical and behavioral presentations. Experience in crisis response, de-escalation, and trauma-informed care, preferably in a community mental health setting, integrated behavioral health setting serving a high volume of severe mental illness, psychiatric emergency room or crisis center, or other high acuity mental health clinical setting Demonstrated ability to help a patient adapt new habits, change behaviors, and motivate towards achieving health goals Comfort with electronic medical record documentation and excited about how technology can support your work and drive ongoing improvement towards new and better care Experience and comfort working within an interdisciplinary care team, and specifically communicating with clinical and non-clinical team members Preferred: Experience in urgent care, emergency medicine, and clinical triage. Familiarity with substance use recovery models and social determinants of health. Board certification in Psychiatric-Mental Health Nursing (PMH-BC) Experience providing care in virtual settings Prior work in value-based care or integrated care teams. Comfort supporting individuals with untreated or symptomatic mental illness and/or addiction. Experience as an active participant in continuous quality improvement projects. Experience in value-based care organizations

Provide inbound telephonic clinical triage and virtual care to patients experiencing both medical and behavioral health symptoms or concerns. Deliver high-quality assessments via phone, video, and text—escalating to appropriate providers or team members when necessary. Serve as primary triage support for behavioral health crisis and complex cases including: Conducting risk assessments using tools such as the Columbia Suicide Severity Rating Scale (C-SSRS) to evaluate suicide risk. Assessing for homicidal ideation, including intent, plan, and access to mean. Evaluating for mania and psychosis, including hallucinations, delusions, and disorganized thinking. Provide immediate de-escalation, crisis counseling, and safety planning for patients in distress. Coordinate with crisis response teams, law enforcement, and emergency departments when necessary. Triaging patients who are intoxicated or under the influence of substances, with appropriate escalation and coordination for care and safety. Setting and maintaining firm, clear, and professional boundaries with patients exhibiting traits of personality disorders, including those with repeated urgent outreach or inappropriate behavior, while ensuring clinical safety and adherence to team protocols. Support patients in behavioral health distress using trauma-informed care, crisis de-escalation, and recovery-oriented communication. Coordinate care and collaborate with Accompany Health Medical Directors, APCs, triage RNs, Behavioral Health Clinicians, and interdisciplinary team members to ensure appropriate resolution for patient triage concern. Use sound clinical judgment to determine appropriate levels of care and help divert unnecessary ER utilization when safe. Support and education, in collaboration with the Behavioral Health team, of the interdisciplinary team on management of patients with acute behavioral health issues. Document all patient encounters accurately and timely in the EMR and other care tracking systems. Build therapeutic rapport with patients and contribute to ongoing care planning in alignment with their goals and values. Collaborate with the team to improve workflows and best practices across both clinical and behavioral triage services. Providing post-discharge follow up care for behavioral health patients virtually via video, telephone, or text. Attending relevant RN conferences, complex care conferences, multidisciplinary case conferences, and behavioral health case conferences to provide integrated care to our patients. Participate in occasional in-person team-building or training activities. Roles and responsibilities may evolve as our care model develops.

Diana Health

Temporary Remote Patient Representative (Contract)

Posted on:

April 11, 2025

Job Type:

Contract

Role Type:

License:

None Required

State License:

Tennessee

Diana Health is a network of modern women’s health practices working in partnership with hospitals to reimagine the maternity and women’s healthcare experience. We are restructuring the traditional approach to care to create an experience that is good for patients and good for providers. We do that by combining a tech-enabled, wellness-focused care program that women love with a clinical system that helps us drive continuous quality improvement and ensure work-life balance for our care team. We work with clients across all life stages to empower and support them to live happier, healthier, more fulfilling lives. With strong collaborative care teams; passionate administrators and a significant investment in operational support, Diana Health providers are well-supported to bring their very best to the work they love. We are an interdisciplinary team joined together by our shared commitment to transform women’s health. Come join us!

We are looking for a full-time remote Patient Representative excited about creating a high quality patient experience and contributing to the smooth operations of multiple busy women’s health practices. This individual is outgoing and detail-oriented, and has strong problem-solving skills to tackle challenges with empathy and creativity.

Work Schedule (Eastern Standard Time Zone): Must be available Monday through Friday, hours between 9:00a-6:00p Experience / Qualifications: Minimum of two years of medical receptionist or customer service experience and/or training Excellent communication skills Ability to solve practical problems in various situations Must have the ability to multitask Diana Health Culture: Having a growth mindset and striving for continuous learning and improvement Positive, can do / how can I help attitude Empathy for our team and our clients Taking ownership and driving to results Being scrappy and resourceful

Serve as overflow support to multiple practices by, answering and working incoming calls and messages Answer and triage incoming phone calls and app messages from our current patients Act as the second line of call for incoming calls from new patients Answer incoming phone calls from other stakeholders (e.g., external medical provider offices, start incoming referral requests) Check and respond to voicemail and after hours messages Support patient scheduling: Schedule patients from incoming phone calls Conduct no show and cancelation follow-up Support schedule re-shuffles (e.g., when provider is called out) Work through appointment ticklers Support central communications intake and follow up through various mediums Other duties as assigned

Diana Health

Remote Patient Representative (Full-Time)

Posted on:

April 11, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

None Required

State License:

Tennessee

Diana Health is a network of modern women’s health practices working in partnership with hospitals to reimagine the maternity and women’s healthcare experience. We are restructuring the traditional approach to care to create an experience that is good for patients and good for providers. We do that by combining a tech-enabled, wellness-focused care program that women love with a clinical system that helps us drive continuous quality improvement and ensure work-life balance for our care team. We work with clients across all life stages to empower and support them to live happier, healthier, more fulfilling lives. With strong collaborative care teams; passionate administrators and a significant investment in operational support, Diana Health providers are well-supported to bring their very best to the work they love. We are an interdisciplinary team joined together by our shared commitment to transform women’s health. Come join us!

We are looking for a full-time remote Patient Representative excited about creating a high quality patient experience and contributing to the smooth operations of multiple busy women’s health practices. This individual is outgoing and detail-oriented, and has strong problem-solving skills to tackle challenges with empathy and creativity.

Work Schedule (Eastern Standard Time Zone): Must be available Monday through Friday, hours between 9:00a-6:00p Experience / Qualifications: Minimum of two years of medical receptionist or customer service experience and/or training Excellent communication skills Ability to solve practical problems in various situations Must have the ability to multitask Diana Health Culture: Having a growth mindset and striving for continuous learning and improvement Positive, can do / how can I help attitude Empathy for our team and our clients Taking ownership and driving to results Being scrappy and resourceful

Serve as overflow support to multiple practices by, answering and working incoming calls and messages Answer and triage incoming phone calls and app messages from our current patients Act as the second line of call for incoming calls from new patients Answer incoming phone calls from other stakeholders (e.g., external medical provider offices, start incoming referral requests) Check and respond to voicemail and after hours messages Support patient scheduling: Schedule patients from incoming phone calls Conduct no show and cancelation follow-up Support schedule re-shuffles (e.g., when provider is called out) Work through appointment ticklers Support central communications intake and follow up through various mediums Other duties as assigned

Sutter Health

RN-Clinical Referral Hospice, Work From Home

Posted on:

April 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

Sutter Care at Home Hospice is a non-profit healthcare organization dedicated to providing compassionate hospice care across nine locations in Northern California. Our centralized intake department manages all referrals for these locations, ensuring a seamless process for patients and their families.

The Hospice Clinical Referral Nurse serves as the initial point of contact for potential hospice patients, working closely with our clerical hospice coordinators. This role is pivotal in managing new referrals and ongoing follow-ups, acting as a liaison between patients, families, and referral sources.

Remote Work: Eligible for work from home with reliable power and internet services and if you meet eligibility to work remote (example, dedicated office with door that closes, cannot be a primary care-giver during business hours. On-Site Requirements: Occasional on-site work may be required for training or other purposes if within driving distance to the center. FULL-TIME DAY SHIFTS: Weekdays Varied / Rotating Weekends EDUCATION: Graduate of an accredited school of nursing CERTIFICATION & LICENSURE: RN-Registered Nurse license for state you reside RN-Registered Nurse of California (Required within 90-days of hire) TYPICAL EXPERIENCE: 2 years recent relevant experience PREFERRED EXPERIENCE: Preferred Experience acquired in home health or hospice environment SKILLS AND KNOWLEDGE: Must have the clinical knowledge and critical thinking skills to effectively plan and provide coordination of patient care consistent with standards and regulations Must have exceptional interpersonal and customer services skills Must be able to effectively solve unique problems as they arise or identify when to consult the supervisor Must have knowledge of current Hospice/Home Health admission criteria; Medicare, Medi-Cal, Commercial, State and Federal regulations Familiarity with ICD-10 coding preferred but not essential Must be able to demonstrate problem-solving abilities as well as telephone, interpersonal, verbal and written communication skills in English Commitment to teamwork and customer service, both internally and externally, is required Must have proven /proven data entry and general computer skills Must be able to demonstrate proficiency (after training and introductory period) in efficient use of electronic medical record systems Must be able to flex with the increased workflow when census is higher and recognize urgency of each task Must be flexible with schedule including, but not limited to, the ability to participate in department rotation for weekend coverage if needed Must be able to drive to designated SCAH location(s) for meetings, training, and needs as designated by business needs

Referral Management: Receive and process referrals for patient care, ensuring timely and consistent admissions. Communication: Make and take calls for new referrals and follow-ups, maintaining clear communication with patients, families, and referral sources. Collaboration: Work closely with referring hospitals, physicians, board and care facilities, skilled nursing facilities, and other healthcare providers. Data Entry: Enter referral information into the Electronic Medical Records (EMR) system and create initial orders to facilitate the start of care. This is a fast-paced work environment that requires our nurses to be able to work in 2 separate charting systems, manage emails, com Customer Service: Utilize and promote excellent customer service skills in all interactions. Team Interaction: Collaborate with referral center staff, home health, Advanced Illness Management (AIM), and hospice staff across offices.

CVS Health

Sr Analyst, Health Care Quality Management, Medicaid - Work From Home

Posted on:

April 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

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.

Required Qualifications: RN or LPN Clinical Role 3-5 years of claims and policy support experience in the health care industry Excellent verbal and written communication skills Experienced in root cause analytics and identifying solutions Familiarity in performing claim analytics to validate industry standards Must be familiar with claim editing software to propose system changes Preferred Qualifications: Certified Coder a plus or commitment to become a CPC in one year of employment. QNXT Claim System Medicaid and Duals Lines of Business experience a plus Education: RN- USA Only LPN- USA Only

The ideal candidate will manage up to four health plans to support compliance with clinical policy, regulatory and accreditation guidelines. Candidate will coordinate the identification of potential claim editing, clinical program enhancements as well as provide support management of savings opportunities and vendor implementation.

Orlando Health

Ambulatory Nurse Triage, OHMG Access Center - Downtown Orlando

Posted on:

April 11, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Florida

Orlando Health Medical Group is a comprehensive physician group serving patients from across the southeastern United States. With more than 200 practices and 1,200 physicians, Orlando Health Medical Group has a strong representation in over 55 specialties, including cardiology, vascular medicine, orthopedics, oncology, digestive health, neurology, neurosurgery, bariatric surgery, general surgery, bone marrow transplant and critical care medicine, as well as more than 30 pediatric subspecialties, women’s health, primary care and the largest hospitalist program in Florida. Orlando Health Medical Group is part of the Orlando Health system of care, which includes 24 award-winning hospitals and ERs, 9 specialty institutes, 14 urgent care centers, 100+ primary care practices and more than 60 outpatient facilities that span Florida’s east to west coasts and beyond. Collectively, we honor our 100-year legacy by providing care for more than 142,000 inpatient and 3.9 million outpatient visits each year. Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions. “Orlando Health Is Your Best Place to Work” is not just something we say, it’s our promise to you.

Under the direction of the Nurse Manager, Practice Manager and/or Practice Supervisor and as a member of the Care Team, the Ambulatory Triage Nurse (RN) will be responsible for handling high-volume calls from patients, medical facilities, and healthcare agencies to assist with acute concerns, medication questions, post-visit questions, and other care concerns and coordination that warrant timely triage by a nurse. This position includes a flexible work arrangement of work from home after onsite in the call center for designated period. Working hours and locations vary based on department. Department: Orlando Health Medical Group Access Center Department Location: Downtown Orlando

Education/Training: Graduate of an approved school of nursing. Licensure/Certification: Maintains current RN license in the State of Florida. Maintains current BLS certifications Experience: Three (3) years of clinical experience in area of specialty or five (5) years of clinical experience when covering multiple specialties/service lines. Previous experience working with EPIC EMR required.

Triages and provides thorough and sounds assessments of incoming urgent and non-emergent patient calls with acute symptoms, acting as an extension of the provider. Communicates and coordinates with the specialty and/or providers, or whom he/she designates, on patient care as needed. Provides guidance and instruction on acute intervention of stable and unstable patients over the phone using the nursing process. Develops, coordinates implementation of, and evaluates a plan of care for each call presented using Schmitt-Thompson protocols. Documents all call inquiries according to Orlando Health policies and procedures. Demonstrates the knowledge and critical thinking skills necessary to provide developmental, cultural, and age-appropriate care. Able to navigate in a fast-paced environment utilizing interpersonal skills to maximize caller reassurance. Demonstrates proficiency in multiple technology programs used by Orlando Health. Demonstrates interpersonal and communication skills with office staff, nurses, providers, contact center team, and leaders. Proficiencies in recognizing a change in patient status and need to escalate care. Coordinates with provider or nurse leader as needed. Assists with scheduling patients in a same day/next day appointment spot when indicated by disposition and level of care indicated. Adheres to the standards required in the role in regard to break times and phone time as well as weekend and holiday requirements. Provides patient services with the ultimate goal of providing the highest level of quality care and customer service. Refills prescriptions following Orlando Health policy and provider requirements. Communicates the plan of care clearly to the patient and ensures the patient fully understands prior to ending the call. Enrolls or updates patient MyChart information, if needed, each call. Maintains punctual attendance as in accordance with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards. Serves as a patient advocate while using available resources to help formulate ethical decisions for positive patient outcomes. Acts as a professional role model for orientees while being flexible to meet the needs of a training schedule. Works independently and efficiently with minimal supervision. Performs other administrative tasks as assigned. Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards. Maintains compliance with all Orlando Health policies and procedures. Utilizes appropriate support, expert resources, or personnel to resolve complex or difficult situations. Excellent time management skills with the ability to prioritize demands to meet patient service standards and deadlines. Ability to effectively handle stressful situations professionally and calmly with exceptional customer service skills. • Strong patient service skills including, but not limited to, listening, understanding, and responding in a calm and easy to understand manner. • Attends required meetings and contributes on committees and projects as requested. • Participates in professional development activities and maintains professional license(s) and affiliation(s).

BJC HealthCare

Utilization Review Registered Nurse - PRN

Posted on:

April 11, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Missouri

BJC HealthCare is one of the largest nonprofit health care organizations in the United States, delivering services to residents primarily in the greater St. Louis, southern Illinois and southeast Missouri regions. With net revenues of $6.3 billion and more than 30,000 employees, BJC serves patients and their families in urban, suburban and rural communities through its 14 hospitals and multiple community health locations. Services include inpatient and outpatient care, primary care, community health and wellness, workplace health, home health, community mental health, rehabilitation, long-term care and hospice. BJC is the largest provider of charity care, unreimbursed care and community benefits in the state of Missouri. BJC and its hospitals and health service organizations provide $785.9 million annually in community benefit. That includes $410.6 million in charity care and other financial assistance to patients to ensure medical care regardless of their ability to pay. In addition, BJC provides additional community benefits through commitments to research, emergency preparedness, regional health care safety net services, health literacy, community outreach and community health programs and regional economic development. BJC’s patients have access to the latest advances in medical science and technology through a formal affiliation between Barnes-Jewish Hospital and St. Louis Children’s Hospital with the renowned Washington University School of Medicine, which consistently ranks among the top medical schools in the country.

Join a stable work from home team. This is a great opportunity for a local remote position. Schedule PRN (As needed) Shifts will fall between Monday-Friday 8 a.m. - 4:30 p.m with assigned Sunday shifts. No patient communication. The position will support all units/staff (commercial, behaviioral health, inpatient, ect) Ensure that the administration of hospital resources are appropriate, efficient and fall within the parameters of the patient's payment structure while providing safe and quality care. Evaluate the cost and quality of medical services provided by the medical team. Ensure appropriate utilization, which includes the evaluation of potential under and over-utilization according to patient's presentation and documentation. Education of medical providers and other health care professionals on the appropriate and cost-effective use of health care resources.

2 years of staff nurse experience performing care for hospitalized patients. 2 years of utilization review (UR) experience reviewing hospital admissions for medical necessity Must live within one hour of the BJC Learning Institute in St. Louis. Have both Missouri and Illinois RN licenses. If candidate only has one RN license, (MO or IL) the application process for the 2nd license can be started after receiving the job offer. EPIC experience is a plus! Education: Nursing Diploma/Associate's - Nursing Experience: 2-5 years Supervisor Experience: No Experience Licenses & Certifications: RN Preferred Requirements Education: Bachelor's Degree

Uses clinical and analytical skills to review and interpret diagnostic test results to determine appropriateness of patient's level of care. Uses Interqual Criteria to determine level of care for all elective inpatient hospitalizations to assure services are provided in the appropriate setting.

OrthoVirginia

Triage Team Member

Posted on:

April 11, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Virginia

OrthoVirginia, Virginia's largest provider of expert orthopedic and therapy care, is currently seeking a Full-Time Triage Team Member to join our team! Along with a collaborative, team-oriented work environment, our outstanding employment package includes: competitive salaries, excellent medical, dental, and vision benefits, paid time off (PTO), a generous 401k incentive plan, short-term and long-term disability insurance, life insurance, and a company-wide wellness program. Position Summary The Triage Nurse will assist with patient care over the telephone in a multi-specialty medical practice.

Medical office or triage experience is preferred. LPN license preferred.

Answering incoming triage calls, utilizing the Electronic Medical Record to answer patients' questions. Triaging providers as needed through the EMR, generating documents in the EMR, responding to patient requests in a timely manner. Completing medication and insurance authorizations and digital filing of documents requiring provider review. This position may also provide coverage or rotate into the Clinical Team Member position to perform direct patient care in the clinic.

CVS Health

Case Manager, Registered Nurse

Posted on:

April 11, 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.

This is a remote work from home role anywhere in the US with virtual training. Shift schedule is 8:30am - 5pm within time zone of residence. American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.

Required Qualifications: 5+ years’ experience as a Registered Nurse with at least 1 year of experience in a hospital setting A Registered Nurse that holds an active, unrestricted license in their state of residence, and willingness to receive a multi-state/compact privileges and can be licensed in all non-compact states 1+ years’ current or previous experience in Oncology, Medical Surgical, Transplant and pediatrics. 1+ years’ experience documenting electronically using a keyboard Preferred Qualifications: 1+ years’ Case Management experience or discharge planning, nurse navigator or nurse care coordinator experience as well as experience with transferring patients to lower levels of care 1+ years' experience in Utilization Review CCM and/or other URAC recognized accreditation preferred 1+ years’ experience with MCG, NCCN and/or Lexicomp Bilingual in Spanish preferred Education: Diploma or Associates Degree in Nursing required BSN preferred

This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues Assessments utilize information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives 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 conversations Identifies and escalates member’s needs appropriately following set guidelines and protocols Need to actively reach out to members to collaborate/guide their care Perform medical necessity reviews

CVS Health

Registered Nurse, Case Manager - Remote

Posted on:

April 10, 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.

This is a remote work from home role anywhere in the US with virtual training. Shift schedule is 8:30am - 5pm within time zone of residence. American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.

Required Qualifications: 5+ years’ experience as a Registered Nurse with at least 1 year of experience in a hospital setting A Registered Nurse that holds an active, unrestricted license in their state of residence, and willingness to receive a multi-state/compact privileges and can be licensed in all non-compact states 1+ years’ current or previous experience in Oncology, Transplant or Specialty Pharmacy 1+ years’ experience documenting electronically using a keyboard Preferred Qualifications: 1+ years’ Case Management experience or discharge planning, nurse navigator or nurse care coordinator experience as well as experience with transferring patients to lower levels of care 1+ years' experience in Utilization Review CCM and/or other URAC recognized accreditation preferred 1+ years’ experience with MCG, NCCN and/or Lexicomp Bilingual in Spanish preferred Education: Diploma or Associates Degree in Nursing required BSN preferred

This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues Assessments utilize information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives 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 conversations Identifies and escalates member’s needs appropriately following set guidelines and protocols Need to actively reach out to members to collaborate/guide their care Perform medical necessity reviews

Acentra Health

Clinical Assessor, Mid - Registered Nurse (RN) - PRN (Remote U.S. with Maine RN Licensure)

Posted on:

April 10, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact. Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra Health is looking for a Clinical Assessor, Mid - PRN (Remote U.S. with Maine RN License) to join our growing team. Job Summary: The purpose of this position is to complete needs-based eligibility determinations for Katie Beckett program, program for children with complex medical needs. Work Location: Remote within the U.S. with the Maine RN Licensure as listed in the "Required Qualifications/Experience" section below. Work Schedule: Flexible. Work Hours: PRN (as needed).

Required Qualifications/Experience: Active, unrestricted Registered Nurse (RN) with Licensure issued by the State of Maine Department of Professional & Financial Regulation Board of Nursing or an RN compact state license. 1+ years of Nurse work experience with children with complex medical needs. Computer proficiency with MS Office (Word, Excel, PowerPoint, Outlook, MS Teams).

Conduct assessments to determine if the beneficiary meets medical eligibility. Ensure timely completion of new, expedited, annual, change of status, mediation/appeals, reconsideration review, and derivative assessments. Interview family members and informal caregivers present during the assessment. Submit completed assessments via state-approved interfaces. Participate in the beneficiary's mediation and appeal processes. Respond to state inquiries regarding conducted assessments. Actively participate in staff meetings, case consultations, peer reviews, and internal audits as assigned. Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

Yoh, A Day & Zimmermann Company

Clinical Review Nurse

Posted on:

April 10, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

California

We welcome you to be a part of the largest global staffing companies to meet your career aspirations. Yoh’s network of client companies has been employing professionals like you for over 65 years in the U.S., UK and Canada. Join Yoh’s extensive talent community that will provide you with access to Yoh’s vast network of opportunities. Medical, Dental & Vision Benefits 401K Retirement Saving Plan Life & Disability Insurance Direct Deposit & weekly EPayroll Employee Discount Programs Referral Bonus Programs

Clinical Review Nurse (RN) (WORK FROM HOME) needed for a remote contract opportunity with Yoh’s client!

Top Skills You Should Possess: Minimum three years acute care clinical experience required Minimum two years of experience in appeals and grievances casework required Active California Registered RN license required. Bachelor’s degree preferred Minimum three years acute care clinical experience required Minimum two years of experience in appeals and grievances casework required Utilization Management or Quality Management experience preferred Experience using standardized clinical guidelines preferred Milliman Care Guidelines (MCG), Managed Care and NCQA experience preferred Have a cleared TB test prior to or within seven days of hire. Current CPR and first aid card prior to or within six months of hire is preferred. Excellent verbal and written communication skills. Ability to work within guidelines and protocols to achieve decisions independently. Excellent computer skills.

Conducts investigations and reviews of member and provider medical necessity grievances and appeals. Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity. Extrapolates and summarizes medical information for Medical Director, consultants or other external review. Apply clinical medical necessity guidelines, policy and procedures, and EOC benefit guidelines. Prepares recommendations to either uphold or overturn and forwards to Medical Director for approval. Ensures that appeals, grievances and disputes are resolved timely to meet regulatory requirements. Apply expedited criteria to recommend the appropriateness of urgent requests. Documents and logs appeal/grievance/dispute information on relevant tracking systems. Generates written correspondence to providers, members and regulatory entities. Interact with members, providers and/or other staff to ensure resolution of plan recommendations. Recognize potential quality of care concerns and refer to the Medical Director for review. Utilize leadership skills and serves as a subject matter expert for appeals/grievances/disputes/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues. Perform other duties and special projects as assigned.

Zolon Tech Inc.

RN Care Managmnt Coordinator

Posted on:

April 10, 2025

Job Type:

Contract

Role Type:

Care Management

License:

RN

State License:

Pennsylvania

This position will be remote but candidates must reside in a tri-state area to be eligible for potential conversion.

Post acute experience required Must have a PA, NJ or DE RN license. Registered Nurse (RN) license Minimum 3 years of acute care clinical experience (hospital or healthcare setting) Experience in discharge planning and/or utilization management Strong communication and problem-solving skills Proficient in computerized applications Organized and team-oriented

Ochsner Health

Revenue Cycle Precertification Nurse - LPN - Remote

Posted on:

April 10, 2025

Job Type:

Full-Time

Role Type:

License:

LPN/LVN

State License:

Louisiana

We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate. We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways. At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters. Come make a difference at Ochsner Health and discover your future today!

This job ensures the financial security of scheduled inpatient and outpatient (excluding ED) accounts for the company's patients by obtaining/initiating prior authorization of ordered services based on payer requirements, after benefits and eligibility have been determined. Coordinates with physician and/or staff for appropriate level of care setting and essential clinical documentation to support medical necessity of services ordered and works collaboratively with Case Management to establish level of care for direct admits and inpatient stays. Also acts as a resource for the Revenue Cycle staff within Pre-Service and performs duties under general supervision and following moderately complex procedures and guidelines.

Education: Required - Licensed Practical Nurse (LPN) diploma. Work Experience: Required - 3 years of hospital based experience in the delivery of patient care. Preferred - Ambulatory Experience. Certifications Required - Current LPN license in the state of practice. Knowledge Skills And Abilities (KSAs): Proficiency in using computers, software, and web-based applications. Effective verbal and written communication skills and ability to present information clearly and professionally. Excellent customer service skills and ability to gather and disseminate information with a diverse range of people, either in person or over the phone. Excellent interpersonal skills including and ability to work collaboratively with other departments and functional areas and handle high-pressure, difficult situations. Good organizational and time management skills and ability to work with minimal supervision. Excellent decision making, critical thinking, and analytical skills and ability to pay strong attention to detail. Proficiency in application of medical necessity criteria, standards of practice, and research regarding pre-certification guidelines. Ability to prioritize tasks and manage multiple tasks with efficiency and quality. Working knowledge of terminology associated with CPT and ICD-10 coding, Medicare guideline, HMO and PPO contracts and other insurance billing processes.

Secures clinical documentation and performs pre-service medical necessity reviews to obtain prior authorizations. Maintains professional and technical knowledge and certifications. Ensures all regulatory requirements are met within department. Assists in the day-to-day operations of the department. Consistently supports the company and its business services goals and core values. Performs other duties as assigned.

Tandigm Health

Clinical Documentation Nurse - RN

Posted on:

April 10, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

Tandigm Health, a transformational leader in population health management, is looking for an RN - Clinical Documentation Nurse in the greater Philadelphia area. We offer a competitive compensation and benefits package and are proud to share a culture of diversity and inclusion. ESSENTIAL FUNCTIONS: Tandigm Health is looking for a Clinical Documentation Nurse – RN (Accurate Coding and Education Chart Reviewer), Local, Remote who will perform thorough chart reviews to inform providers of potential inferred, embedded, and missing diagnoses not previously identified. In this role, you will be a team player and excellent communicator, who works closely with practices to review medical records to ensure continued high standards in documentation and coding. You will have experience using the CMS/RAF model, coding guidelines, and knowledge of ICD-10 guidelines and are a seasoned nurse with at least 5 years of general clinical experience and clinical chart/claims review experience. You will be a valued member of our local Philadelphia, PA Clinical Team, licensed in the State of Pennsylvania, working together to improve healthcare outcomes. This is a remote position, based in the suburban Philadelphia, PA five county region.

REQUIREMENTS: Bachelor’s Degree in Nursing required (8 or more years of additional experience beyond the required years of experience may be substituted in lieu of a degree) Current, active, and unrestricted Pennsylvania Registered Nurse Licensure 5 years of General Clinical experience required Two years of clinical chart or claims review experience with strong attention to detail Knowledge of CMS/RAF model, coding band guidelines along with ICD-10 guidelines Knowledge of health plan and regulatory requirements. Strong technical skills including computer and software skills such as Microsoft Word, Excel, and Outlook Experience with at least one EMR and chart abstraction tool Preferred: Additional Quality Assurance auditing experience Additional Chart Review experience Additional Clinical Documentation Improvement experience CPC/CRC certification ESSENTIAL TECHNICAL/INTERPERSONAL SKILLS/OTHER: Embraces and exemplifies core values of Tandigm Health Ability to anticipate and analyze factors Strong oral and written communication skills Possesses leadership qualities, such as: Ability to mentor, counsel, coach, teach; Ability to hold providers accountable & educate same on new methods and practices; Ability to listen; Able to resolve conflict; Ability to accept input from others; Ability to give clear direction and provide feedback; Ability to accept coaching from other. Able to develop effective strategies for implementation of improved coding and documentation practices. Values team members and a strong team player Possesses high ethical standards Ability to work independently Current and active Pennsylvania Driver's License Access to a reliable vehicle and Automobile Liability Insurance

Consistently exhibits behavior and communication skills that demonstrate Tandigm’s commitment to superior customer service, including quality, care and concern with each and every internal and external customer. Obtains access and reviews all Medicare Advantage charts assigned, both remotely and onsite at Physician practices. Reviews all portions of the medical records including but not limited to problem lists, past medical and surgical history, medication lists, specialty and primary care notes, imaging, hospital records, labs and vital signs. Documents newly found diagnoses and/or screenings and reports out to practices as needed. Brings clinical questions to the ACE Medical Director as needed. Provides in-person debriefings to the practices and internally using all required reports including newly suggested chart review diagnoses. Records debriefing comments/ feedback for ACE team Recommends ongoing chart review process to ensure continued high standards in documentation and coding. Attends and participates as requested in regional and corporate meetings that pertain to ACE coding and documentation. Attends courses as needed to improve knowledge of accurate coding and documentation. Uses, protects, and discloses Tandigm’s patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards. Performs additional duties as assigned

HarmonyCares

Telephonic RN Nurse Care Manager-Remote in Montclair, NJ

Posted on:

April 10, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

New Jersey

HarmonyCares is one of the nation’s largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health and HarmonyCares Hospice. Our Mission – To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care. Our Shared Vision – Every patient deserves access to quality healthcare. Our Values – The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other. Why You Should Want to Work with Us Quarterly Bonuses Health, Dental, Vision, Disability & Life Insurance, and much more 401K Retirement Plan (with company match) Tuition, Professional License and Certification Reimbursement Paid Time Off, Holidays and Volunteer Time Paid Orientation and Training Day Time Hours (no holidays/weekends) Great Place to Work Certified Established in 11 states Largest home-based primary care practice in the US for over 28 years, making a huge impact in healthcare today! More details about the benefits we offer can be found at https://careers.harmonycares.com/benefits.

The Nurse Care Manager works closely with HarmonyCares Medical Group (HCMG) in home health care continuum and specialty services to maximize the health of the HCMG patients. This position will manage a caseload of high-risk patients where he/she is responsible for managing their care and barriers. These duties will include Transitional Care Management, Chronic Care Management of the HCMG patients.

Required Knowledge, Skills and Experience: Active R.N. License 2 or more years of direct home health experience or care management Ability to perform extensive telephone assessment Knowledge of Medicare regulations and home care and hospice standards Must be self-motivated, independent, structured, organized, very detailed and able to meet deadlines Works closely with all providers to include Physicians, Nurse Practitioners (NP), Physician Assistants-(PA) regarding: Criteria for home care referrals Case conferencing to coordinate care, improve documentation and communication Patient education materials Assists with documentation to support eligibility of patient under the care of hospice or home care (which may include chart audit worksheet, Labs, diagnostics, History and Physical, Fast Scale, Mortality Risk Scale, etc.*) Participates in developing and enhancing tools and company initiatives that promote patient services Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner Maintains communication with the Regional Director - Care Management regarding compliance, job performance and significant patient care issues as they arise Maintain productivity expectations related to patient visits, telephonic outreach assessments and other duties as assigned Preferred Knowledge, Skills and Experience: Bachelor of Science May be required to obtain multi-state licensing 1 year experience of discharge planning 1 year leadership and/or supervisory experience

Provides clinical coordination Prioritize patients based on the severity and urgency of their conditions. Triage is crucial in high acuity settings to ensure that the most critical cases receive immediate attention Demonstrate strong clinical skills, critical thinking abilities, and effective communication Prioritize nursing interventions based on the severity of the patient's condition Collaborate with the patient and multidisciplinary team to develop an individualized care plan based on the identified goals and needs and allocate tasks and interventions to the appropriate team members based on their experience Collaborates in patient care planning process to assess, monitor and evaluate options and services to meet health needs Implements a comprehensive clinical care management plan for each patient. Analyses variances from plan and initiates steps to resolve such variances Spend quality time with our patients and families identifying gaps in care, providing education, and partnering with our continuum in an effort to reduce unplanned hospitalizations and help ensure the right care at the right time In this role you may work with. . . Regional Director – Care Management Providers, Nurse Practitioners, Physician Assistants HCPC/Hospice/Home Health Staff Clinical Liaisons HCMG Patients Patient’s Families Community Agencies Care Givers

Atrium

Care Transitions Nurse (Remote) - 154916

Posted on:

April 10, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

The Care Transitions Nurse (Remote) will be responsible for performing clinical evaluations, observing shifts in health status, and managing patient care transitions. Providing guidance to patients and their families over the phone regarding their medical conditions and treatments as a Care Transitions Nurse (Remote).

Required Experience/Skills for the Care Transitions Nurse (Remote): Must be able to work 11:30 AM – 8:00 PM EST. OCN Certification is highly preferred. 5+ years of Nursing experience with 3 years of Oncology Nursing or Case Management. CCM is required. Education Requirements: Bachelor of Science in Nursing.

Assist members with care coordination and care management following admissions. Coordinate discharge plans with hospital case managers and follow up care with providers. Collaborate with non-medical Care Team members to address the factors affective patients’ health. Carry out phone based evaluations, encompassing pain management and medication reviews.

IDR Healthcare

Case Management Nurse

Posted on:

April 10, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Louisiana

Remote Case Manager RN 13+ week contract with high likelihood of extending. We are looking for a skilled Registered Nurse eager for the opportunity to make a difference in patients’ lives. You will play a critical role in providing access to comprehensive care for underserved patients our network reach. Also, helping patients improve their quality of life in the home and slow the progression of multiple chronic illnesses, enabling positive health outcomes. Your Impact: As a Registered Nurse you will be responsible for the delivery of personalized and compassionate care to patients. Our RN’s will become float resources in areas where we are rapidly growing. Primary duties include patient health assessment, creating strategies to improve or manage a patient's health, and introducing habits for health promotion. In part of completing this care for patients, your responsibilities will include maintaining accurate patient records, scheduling, and administering follow-up appointments to patients as required across multiple markets.

Active and unrestricted Registered Nurse Access to transportation, a valid driver's license, and car insurance Must be proficient with medical instruments and equipment required by the work Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community Sound understanding of all federal and state regulations including HIPAA and OSHA 2 or more years of direct patient care required

Works in virtual environment to conduct in-home assessments, which include comprehensive annual wellness exams, focused screenings, or other visits both in the patients' home and in the virtual environment Counsels and educates patients and families about benefits and programs available to help them live healthier lives Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan Completes all documentation and paperwork in a timely manner Maintains quality of care standards as defined by the practice Assists patients with enrolling to access educational videos Participates in the integrated care team meetings Knowledge of disease diagnosis and prevention Make assessment of patient's health status Implement a plan consistent with appropriate plan of care Follow-up and evaluate patient's status Other duties as assigned

Humana

Utilization Management Nurse- Compact License required

Posted on:

April 10, 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 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. Speedtest by Ookla - The Global Broadband Speed Test Use Speedtest on all your devices with our free desktop and mobile apps. 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.

Symetra

Disability Nurse Consultant - Remote

Posted on:

April 10, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Washington

At Symetra, we aspire to be the most inclusive insurance company in the country. We’re building a place where every employee feels valued, respected, and has opportunities to contribute. Inclusion is about recognizing our assumptions, considering multiple perspective, and removing barriers. We accept and celebrate diverse experiences, identities, and perspectives, because lifting each other up fuels thought and builds a stronger, more innovative company.

As a Disability Nurse Consultant, you’ll provide clinical support throughout claim administration for Absence Management, Life and Disability products. You will review medical records and other documentation for evidence supporting claimed diagnoses as well as resulting restrictions and limitations. You will also participate in educating the claim staff on assorted anatomy, physiology, treatment, diagnostic, and pathology topics relevant to claim management and industry trends.

High School Diploma required. Degree in nursing from an accredited college or university required. Active RN license(s) required Two years or full-time equivalent of direct clinical care required in an acute care setting required Previous clinical experience in disability/absence management, occupational health, psychiatric nursing in a disability management setting preferred Certification in case management, rehabilitation nursing or a related specialty preferred Excellent customer service and collaboration skills Capable of balancing priorities and deadlines with minimal supervision Clear, detailed, and concise communication both verbally and written Able to work as part of a team Excellent at multi-tasking Proficient in Microsoft Office suite of products Comfortable working in a fast-paced deadline driven environment

Perform clinical review of medical records and other documentation to determine diagnoses and resulting restrictions or limitations. Provide comments on anticipated duration Proactively contact healthcare providers to acquire additional information and insight into the specifics of a condition(s) under review and for consideration in clinical opinion to aid in claim management Perform clinical claim administration tasks within departmental metrics for productivity relating to turn around time, documentation, qualitative, quantitative, and customer service in support of LAD lines of business Communicate effectively with internal and external partners, collaborate in a team environment, demonstrate core values and clinical expertise Seek out additional training and project work outside of immediate claim reviews to improve knowledge and business processes

Virta Health

Enrollment Nurse

Posted on:

April 10, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Virta is an online specialty medical clinic that reverses type 2 diabetes safely and sustainably without the risks, costs, or side effects of medications or surgery. We also treat patients with pre-diabetes and obesity. Our innovations in the application of nutritional biochemistry, data science, and digital tools--combined with our clinical expertise--are shifting the diabetes treatment paradigm from management to reversal. Virta has developed a novel, team-based care model that delivers the Virta treatment exclusively through a telemedicine platform, with no brick-and-mortar clinics. Our clinical trial, which has already produced ten peer-reviewed publications, shows that the Virta treatment has lowered hemoglobin A1c values under the diabetes threshold while discontinuing diabetes medications. The American Diabetes Association has endorsed the core component of the Virta treatment, personalized carbohydrate restriction, as a first-line nutritional therapy for people with type 2 diabetes. We’ve been reversing diabetes for the last seven years, we see patients in all 50 states, and we are expanding our reach to patients with pre-diabetes and obesity. Join us on our mission to reverse diabetes and obesity in 1 Billion people. To achieve that mission, Virta is hiring RN’s to join our team.

We are hiring for fully virtual, full time roles with set hours, although some shifts will include early morning, evening, and weekend hours.

Associate or Bachelor of Nursing degree from an accredited school or university. Active RN license in a Nursing Licensure Compact with state residency. Eligible for nursing licensure in every U.S. state. Minimum of two years experience working with diabetes patients in a clinical setting Interest and knowledge of diabetes care, education and prevention. Knowledge of low carbohydrate nutrition and meal planning. CDCES preferred but not required. Interest and aptitude for working with a growth stage, tech-enabled healthcare organization. Occasional (2-3x/yr) travel to team and company events. An outstanding bedside manner: patients trust you and feel supported and empowered by your presence on the phone/video and your communication. Excellent communication, time management, and critical thinking ability necessary in this remote role. Team player: You work well with others, put your team first, and contribute toward the betterment of the Virta clinical team.

Conduct 20-minute clinical intake visits with prospective patients via video and/or phone. Intakes include verifying and documenting a clinical history, verifying medications, answering basic questions about Virta treatment, and identifying and flagging concerning history or labs for provider review. Educate patients about Virta and Virta’s treatment and help them prepare for their nutritional and behavioral journey with Virta, setting them up for clinical success. Full time RN’s are responsible for providing clinical support for our team of providers (MDs and NPs). Responsibilities include panel management, triage calls with patients, medication entry, and diabetes education regarding medication administration, sliding scale insulin, carb counting, etc. For full time RN’s work time will be split 60/40 between telemedicine visits with patients (15-20/day) and providers support activities such as those listed above. Exact FTE split to vary based on clinical needs and patient volume. This will be determined by nursing leadership. Commitment to providing care of the highest quality that delivers an exceptional experience for the patient.

Banner Health

RN System Patient Education Program Senior Manager

Posted on:

April 10, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Arizona

Great careers start with great training. The people of Banner Health are focused on delivering excellent care to our patients. In return, we are committed to excellence in personal development for all our team members. Apply today! You can be instrumental in training new Banner Health employees by becoming a Senior Patient Education Manager with Banner Health. This position is 40-hours per week and requires a minimum of 5 years' experience in an acute care setting. A minimum of 1-year experience in Patient Education is required for this position. This position is a system position and can be remote from any state Banner does business in. If you have any questions, please contact Debbie Hoekstra at 970-810-6347 or debbie.hoekstra@bannerhealth.com. Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care.

This position promotes and provides optimal care of the patient through leadership, coordination and development of processes related to patient education. Assists other leaders to establish, oversee, conduct and evaluate quality improvement for both the service and patient care. Enhances the program though coordination of daily operations, activities and associations with other departments services. Oversees and ensures compliance with local, state or national organizations for certification/validation.

MINIMUM QUALIFICATIONS: Master’s degree or knowledge as normally obtained through the completion of a master’s degree. Current RN licensure in state of practice required. Minimum of five years clinical experience in a high patient acuity area. Computer skills including basic office software (word processing, spreadsheets, presentations). Demonstrate proficient interpersonal, written and verbal communication skills, professional interaction with all individuals and public organizations. Ability to provide departmental leadership, training and staff development. PREFERRED QUALIFICATIONS: Additional certification(s) specific to clinical specialty. Additional related education and/or experience preferred. Anticipated Closing Window (actual close date may be sooner): 2025-08-07

Oversees ongoing daily operations related to patient education. Researches and recommends changes and improvements based on evidence-based practice. Develops, reviews and maintains patient education intranet, SharePoint and teams’ site. Develops and maintains a comprehensive, effective patient education program which meets industry standards. Ensures compliance with standards of care that are evidence based and meet regulatory guidelines related to disease specific certifications. Assures patient education materials are updated periodically. Collaborates with other departments regarding issues and practices as they relate to patient education. Ensures appropriate service interaction and communication with all staff, customers, and agencies internally and externally. Represents the department at management/leadership meetings as required. Coordinates relevant committee meetings. Oversees data collection systems and processes to provide statistical data regarding the program and patient outcomes related to patient education. Validates accuracy and current status of all protocols and operational guidelines. Oversees patient/practice quality improvement and departmental quality standards. Monitors care patterns for consistency with established protocols and opportunities for process improvement. Leads the system Patient Education Governance Oversight committee. Works with the director in the development and implementation of strategic workforce learning. Implements and coordinates patient educational goals and quality initiatives. Applies evidence-based practice in the design, delivery and effectiveness of education/training programs and outcomes. Supports patient education teams including in-house patient education, conferences, and orientation to program processes. Ensures and promotes the delivery of quality patient education by collaborating with; Service Line Leaders, Digital Health, Risk/Legal, Compliance, Marketing, Clinical Consensus Groups, External Vendors, and Informatics. Facilitates the standardization of patient education material across the continuum (Ambulatory, Inpatient and Emergency Room). Provides oversight, development, and/or assessment of patient education delivery platforms and content including incorporating the early adoption of technology. This is a highly collaborative position that assists with integration and standardization of patient education across the system, to ensure continuity and consistency regarding patient education messaging. Internal customers include but are not limited to leaders, medical staff and employees across the organization using the population health model. External customers include but are not limited to patients, practicing physicians, Banner approved vendors and regulatory agencies.

Banner Health

RN Triage

Posted on:

April 10, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Health care is constantly changing, and at Banner Health, we are at the front of that change. We are leading health care to make the experience the best it can be. We want to change the lives of those in our care – and the people who choose to take on this challenge. If changing health care for the better sounds like something you want to be part of, we want to hear from you. Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care.

Duties: The RN is expected to make sure equipment is operating correctly, able to sign in to necessary programs, and then be ready to handle inbound calls as scheduled. Our purpose is to triage current symptoms that callers are experiencing and provide accurate, detailed advice, as well as directing the caller on the appropriate level of care they should seek. Nurse Now primarily supports scheduling agents that schedule appointments for BMG Primary Care clinics. The RN may also schedule clinic appointments for the caller, as well as send communication to their provider. All nursing experience is accepted, ED and Pediatric experience is preferred. Background experience with inbound call center environment is a benefit. Location: This is a REMOTE position including training. Schedule: The hours are Monday - Friday 10:30 am to 7:00 pm. POSITION SUMMARY This position manages incoming member/patient calls to evaluate call purpose and acuity utilizing established protocols and nursing assessment. Recommends appropriate care disposition and follows up as necessary to promote positive outcomes for member/patient. This position also utilizes protocols to assess the situation and provides treatment recommendations, options and ultimate care resolution. This includes reviewing caller’s relevant health care information, as well as documenting the purpose, information and resultant disposition of the call. This position may provide education to the public or other health professionals and participate in continuous quality improvement projects. May also facilitate appropriate referrals to physicians, services, and facilities, and/or directs individuals to other departments or services that may meet the needs and treatment recommendations.

Must possess knowledge as normally obtained through the completion of a Bachelor's degree in nursing or related field. Must possess a current, valid RN license in state of practice, temporary RN license in state of practice, or compact RN licensure for current state of practice. Current BLS certification is required for state of practice. BLS certification is not required for remote workers or for team members working in the Insurance Division. Additional certification or continuing education may be required based on area of practice. Requires a proficiency level typically achieved with five years clinical experience. Requires excellent organizational skills and clinical knowledge regarding specialty care services, as well as care coordination of services, legal and financial aspects of diagnostic services and health services in specialty area. Must possess ability to make autonomous decisions utilizing excellent clinical judgment. Must possess highly effective interpersonal and communication skills. Must understand the principles of quality customer service. Requires effective communication and writing skills, good time management skills and knowledge of word processing and database software applications. Requires the ability to teach both clinical and non-clinical personnel regarding care and diagnostics services. Also requires a good understanding of process improvement. PREFERRED QUALIFICATIONS: Bachelor’s in nursing and/or recent telephone triage experience strongly preferred. Previous emergency nursing, pediatric nursing, maternal/child health, ambulatory, home health or critical care experience preferred. Bilingual ability a plus. Additional related education and/or experience preferred.

Evaluates member/patient call and needs following established protocols. Utilizes databases and best practice evidence available, as well as clinical judgment to determine purpose of the call. This also includes assessing the member’s status to provide appropriate direction toward resolution whether triaged to another source or treatment recommended. Utilizes multiple databases and electronic health systems (EHR) to research member history to provide appropriate coordinated care. Determines the acuity of situation/needs and triage callers to the appropriate level of care or call resolution. Effectively accesses symptom-based guidelines, as well as documents all calls for medical/legal purposes using appropriate tools. Documents assessment, planning, implementation and evaluation in a timely manner to ensure compliance with established policies and procedures. Documentation reflects objective/subjective data, nursing interventions and patients response and disposition plan. Actively participates in quality assurance and improvement processes to deliver excellent customer service to callers. Considers the patient/member’s physical, cultural, psychosocial, and spiritual and age specific needs when planning care or direction toward treatment or call resolution. Monitors member needs and proactively connects members with the appropriate services or contacts other departments or locations to assist with coordination of care of the patient. Provides direction and supervision to licensed and non-licensed personnel in the activities necessary to provide quality care and services. Customers are external community callers and healthcare providers as well as internal employees and physicians. Interacts with all levels of staff in a variety of departments, physicians, patients, families and external contacts, such as employees of other health care institutions, community providers and agencies, concerning the health care of the patient. Interacts with other health care providers in numerous settings in order to report and ask for or clarify information. Synthesizes and prioritizes data from multiple sources to provide support for the human response of the patient and family to changes in health status.

Wellbox Health

LPN/LVN - Remote Care Coordinator (MST/PST)

Posted on:

April 10, 2025

Job Type:

Full-Time

Role Type:

Primary Care

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. Position Type and Expected Hours of Work 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 in Pacific or Central time zones will also be considered.

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.

E.N.T. Specialty Partners

Triage Specialist

Posted on:

April 10, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

None Required

State License:

Texas

ENT Specialty Partners is looking for a reliable and caring medical assistant to be part of our team. The triage specialist performs essential functions in assessing, planning, implementing, and evaluating in the clinical triage areas. This position calls for high levels of independent judgment and problem-solving capabilities, as well as the ability to set patient care as a priority. Triage Specialists will assist the physicians by assessing patient issues and concerns over the phone, and directly messages to the appropriate physicians and making notes in the EMR. Hours: Full-time, Monday – Thurs 8:00-5:00 pm, Fridays 8:00 – 4:00pm, Remote

Prefer clinical ENT knowledge, coupled with the ability to proactively implement knowledge on procedures and techniques needed to assist patients over the phone to accurately answer questions from patients. Knowledge and correct usage of medical terminology. Knowledge and experience with E-Clinical Works EMR system is preferred. Ability to maintain confidentiality and professionalism as well as , effectively and clearly communicate in writing, over the telephone, and in person with physicians, office staff, and patients. Ability to work as part of a team and promote a positive work environment. Ability to listen actively by giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. Ability to comply with all facility policies, procedures and practices. Ability to report to work on time and as scheduled. Ability to communicate and represent the mission, ethics and goals of the organization. Ability to apply feedback, participate in performance improvement, and continuous quality improvement activities. Skilled in organization, attention to detail, task prioritization. Skilled in understanding patient needs to provide exceptional customer service.

Answers telephone calls and appropriately triages and screens telephone calls related to ENT patient care. Obtains and records accurate patient information, makes appropriate clinical assessment, and implements care in accordance with approved standing orders and protocols. Reviews test results to patients in a timely manor. Counsels patients on the phone concerning treatments, procedures, medications, diets, or physicians' instructions to patients. Treats patient concerns with proper care and triages concerns to the best of knowledge and ability. Maintains courteous, professional relationships with medical providers, staff, patients, and general public. Demonstrates independent critical thinking with the ability to multi-task in various departments including urgent situations and prioritizing work. Schedules patients with other doctors for consultation, as needed. Authorizes drug refills and provide prescription information to pharmacies, as needed. Other duties as assigned by Triage department manager.

Octiva

Telehealth Triage Nurse

Posted on:

April 9, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Octiva Healthcare is a telemedicine company that provides 24/7/365 clinical support to patients in need of timely care and advice. Our mission at Octiva is to provide around-the-clock healthcare that meets the highest standards of clinical excellence and patient experience. We ensure our services are accessible from any location and in any language, embracing a culture of compassion, clear communication, and strict compliance to security. Our goal is to be a constant in our patients' lives, available 24/7, delivering care with a personal touch.

Job Description **Please see pay range before applying** Octiva Triage Nurse – Fluent Spanish Speaking Required Active Califonia RN license Required at time of Application Compact License Required The ideal candidate has a strong background in clinical nursing and outstanding patient communication skills. The Triage Nurse is a part of the clinical care team which includes nurses, advanced practice providers, and physicians. This position practices nursing via the telephone, utilizing your nursing skills and training , input from physicians, and approved telephone nursing guidelines and protocols. The functions of this position include electronic prescription refill, triage to the most appropriate level of care, providing nursing advice and self-care treatments, identifying resources, and performing nurse follow-up activities. All duties and responsibilities fall within departmental and organizational guidelines and are within the scope of practice as defined by the Board of Registered Nursing and in compliance with state laws and medical nursing standards of care.

Education: Graduate of accredited school of nursing required. BSN preferred. On-the-job training in triage Experience: Two to five years of practical RN experience; outpatient experience preferred. One to two years of practical experience in a physician’s office or medical office setting preferred. Telehealth experience strongly preferred. Performance Requirements: Knowledge: Knowledge of telephone-based clinical assessment techniques Knowledge of medical practice telephone triage Knowledge of medical symptomology and what constitutes urgent/emergent care Knowledge of medical terminology and abbreviations Professional knowledge of clinical nursing protocols Skills: Skill in using a variety of EMRs Skill in using computerized medical information database during evaluation as guide to appropriate decision Skill in making triage decisions and responding quickly and calmly in emergency situations Other Requirements: Fluent in Spanish and English, written and verbal Compact RN License

Evaluate patients on the telephone, offer nursing advice, and triage to the appropriate level of care, including referral to an emergency room or local urgent care, transfer to our own telemedicine provider, or scheduling an appointment with their regular physician. Perform telephonic evaluation of each patient with symptoms to determine the risk of serious illness or injury, and the appropriate next step in care. Follow clinical protocols and guidelines implemented by Octiva Healthcare and/or our partner clinics. Access patient’s medical chart through each clinic’s Electronic Medical Record in order to review needed information and to document treatment plan and advice provided. Perform all other duties as required or assigned.Qualifications:

Molina Healthcare Services

RN Inpatient Review Case Manager: California licensed - Remote

Posted on:

April 9, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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.

*** RN licensure must be valid for California. California is not a compact state. Candidates who do not live in California must have CA licensure and must be willing to work Pacific daytime Hours. Job Summary 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.

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: Must be licensed for CALIFORNIA Preferred Experience: Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. Prior experience managing transfers to higher level of care (HLOC) Preferred License, Certification, Association: Active, unrestricted Utilization Management Certification (CPHM). MULTI STATE / COMPACT LICENSURE WORK SCHEDULE: Mon - Fri / Sun - Thurs / Tues - Sat with some weekends and holidays.

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.

Enterprise Engineering Inc. (EEI)

Utilization Management Nurse

Posted on:

April 9, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

California

Job Title: UM / Registered Nurse (California License) – Must be licensed in California Remote Opportunity Work Hrs: (8am – 5pm PDT) would like to include evening, weekend and holiday coverage. Length of Contract: 6 months (Temp to Perm possibility) 5 Openings Remote Opportunity Ready to Hire ASAP. JD: The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure members receive the services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient-centered care across the care continuum. This position is not patient facing, they will be reviewing patient records and providing recommendations.

Associate's degree in Nursing, preferred Minimum 2 years of experience in medical management clinical functions. Working knowledge of MCG, InterQual, and NCQA standards

Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations Ensure discharge planning is timely and appropriately communicated to the transition of care teams, when applicable. UM experience should be more on an outpatient setting vs inpatient hospital. Familiarity on Medicare and Medicaid and MCG Meet or exceed productivity targets set forth Serve as a resource to non-clinical team members when applicable

SSM Health

RN-Clinical Documentation Specialist, First Reviewer | Remote

Posted on:

April 9, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Missouri

It's more than a career, it's a calling MO-REMOTE Worker Type: Regular Job Highlights: ***Must have prior CDI 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 accurate DRG assignment, 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. Imparts knowledge to providers and other members of the healthcare team. Maintains a level of expertise by attending continuing education programs. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service. Works in a constant state of alertness and safe manner. Performs other duties as assigned.

Alignment Health

Bilingual Spanish Care Coordinator (Must be located in California)

Posted on:

April 9, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

None Required

State License:

California

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

The Care Coordinator works in collaboration with the RN Case Manager as part of the interdisciplinary team. The Care Coordinator supports members with closing care gaps and addressing care coordination needs as directed by the RN Case Manager. As part of the Case Management team is responsible for the health care management and coordination of care for members with complex and chronic care needs. The Care Coordinator is responsible for CM Coordinator functions for the members enrolled in Case Management. Schedule: Mondays - Fridays Option 1: 8:00 AM - 5:00 PM Pacific Time (with 1-hour lunch) Option 2: 8:30 AM - 5:30 PM Pacific Time (with a 30- minute lunch)

Experience Required: Minimum 1 year experience working in Health Care such as Health Plan, Medical office, IPA, MSO. Minimum 1 year experience assisting members / patients with authorizations, scheduling appointments, identification of resources, etc. Preferred Education Required: High School Diploma or GED. Bachelor's degree or four years additional experience in lieu of education. Preferred: MBA Training Required: Preferred: Medical Assistant training, Medical Terminology training. Specialized Skills Required: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Communicates effectively using good customer relations skills. Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. Knowledge of Managed Care Plans Knowledge of Medi-Cal Basic Computer Skills, 25 WPM (Microsoft Outlook, excel, word) Mathematical Skills: Ability to add and subtract two digit numbers and to multiply and divide with 10’s and 100’s. Ability to perform these operations using units of American money and weight measurement, volume, and distance. Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations. Bilingual English / Spanish Licensure Required: None Preferred: Medical Assistant Certificate, Medical Terminology Certificate Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Reaches out to members telephonically to assist with referrals, authorizations, HHC, DME needs, medication refills, make provider appointments and follow ups, etc Creates cases, tasks, and completes documentation in the Case Management module for all Hospital and SNF discharges Complies with tasks assigned by nurse and, as appropriate and documents accordingly Works as a team with the Case Manager to engage and manage a panel of members Manages new alerts and updates Case Manager of changes in condition, admission, discharge, or new diagnosis Establishes relationships with members, earns their trust and acts as patient advocate Escalates concerns to nurse if members appear to be non-compliant or there appears to be a change in condition Assists with outreach activities to members in all levels of Case Management Programs Assists with maintaining and updating member’s records Assists with mailing or faxing correspondence to members, PCP’s, and/or Specialists Requests and uploads medical records from PCP’s, Specialists, Hospitals, etc., as needed Meets specific deadlines (responds to various workloads by assigning task priorities according to department policies, standards and needs) Maintains confidentiality of information between and among health care professionals Other duties as assigned by CM Supervisor, Manager or Director of Care Management

Alignment Health

Remote UM Nurse - Pre-Service (Must have North Carolina LVN / RN License)

Posted on:

April 9, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Compact / Multi-State

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

Alignment Health is seeking a remote Utilization Management (UM) Nurse - Pre-service (Must have North Carolina LVN / RN License) to join the UM team. As a UM Nurse, you will be responsible for reviewing requests for pre-certification for both inpatient and or outpatient services for all plan members. Works in collaboration with providers, Regional and Senior Medical Directors to assure timely processing of referrals to provide the highest quality medical outcomes that are most cost efficient. If you are looking for an opportunity to join an expanding company, learn and grow, be part of a collaborative team, and make a positive impact in the lives of seniors - we're looking for YOU! Schedule: Monday - Friday, 8:00 AM - 5:00 PM Pacific Time. Weekend rotation: 1 weekend day every 5-6 weeks for 4 hour or 8 hour shift between 8:00AM - 5:00 PM Pacific Time

Required: Minimum (3) years' nursing experience in clinical setting. Minimum (1) year experience UM experience with pre-service. Minimum (1) year experience with managed care (Medicaid and / or Medicare). Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.) Minimum (1) year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred Minimum (1) Experience with the application of clinical criteria, specifically MCG (Milliman Care Guidelines) Education Required: High School Diploma or GED. Preferred: Associates or Bachelor's degree in Nursing Licensure Required: Possess current, active and unrestricted LVN and / or RN license in North Carolina (Compact) Immediately upon hire, must obtain LVN and / or RN licensure in California (non-compact), Nevada, (Non-compact), Arizona (Compact), and Texas (Compact) which will be reimbursed by company. Preferred: CPHQ or ABQAURP, or Six Sigma certification Medical Terminology Certificate. Training Required: None Preferred: Medical Terminology. Six Sigma Specialized Skills Required: Knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology and referral system (Access Express / Portal / N-coder). Knowledgeable with CMS (Chapter 13) guidelines and regulations. Computer Skills: Word, Excel, Microsoft Outlook Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors. Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly. Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. Report Analysis Skills: Comprehend and analyze statistical reports. Preferred: Bilingual (English / Spanish) Transplant knowledge a plus Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Reviews pre-certification requests for medical necessity and refer to Medical Director any referral that requires additional expertise. Utilizes CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilizes Milliman Care Guidelines (MCG) to assist in determinations of referrals. Maintains goals for established turn-around time (TAT) for referral processing. Initiates single service agreements (SSA) when services required are not available in network. Maintains a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible. Verifies eligibility and / or benefit coverage for requested services. Verifies accuracy of ICD 10 and CPT coding in processing pre-certification requests. Contacts requesting provider and request medical records, orders, and / or necessary documentation in order to process related pre-service requests / authorizations when necessary. Reviews referral denials for appropriate guidelines and language. Assist medical directors in reviewing and responding to appeals and Grievances Contacts members and maintain documentation of call for expedited requests. Other duties as assigned.

Alignment Health

Inpatient Review Nurse (RN/LVN) Must have California Licensure

Posted on:

April 9, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

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

The Inpatient Review Nurse assists patients through the continuum of care in collaboration with the patient’s primary care physician, facility case manager, discharge planner and employing contracted ancillary service providers and community resources as needed. Assures that services are provided at the most appropriate, cost effective level of care needed to meet the patient’s medical needs while maintaining safety and quality.

Required: Minimum (3) years' general case management skills. Minimum (2) years' experience utilizing Milliman Care Guidelines to justify Inpatient versus Observation Length of stay: including review of diagnosis and length of stay. Minimum (2) consecutive years related experience in a managed care setting as an inpatient case manager Preferred: Experience with a senior population. Education Required: Successful completion of an accredited Licensed Vocational Nursing Program Preferred: Associates or Bachelors Degree Specialized Skills Required: Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others. Excellent critical thinking skills related to nursing utilization review Knowledge of Medicare Managed Care Plans Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors; Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. Report Analysis Skills: Comprehend and analyze statistical reports. Preferred: Knowledge and experience in complex / catastrophic case management preferred Licensure Required: Must have and maintain an active, valid, and unrestricted RN license in California (Non-Compact) Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company. Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, hand, or feel and talk or hear. The employee is frequently required to reach with hands and arms The employee is occasionally required to climb or balance and stoop, or kneel The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Performs reviews of inpatients with complex medical and social problems. Generates referrals to contracted ancillary service providers and community agencies with the agreement of the patient’s primary care physician. Performs follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting. Reviews inpatient admissions timely and identifies appropriate level of care and continued stay based on acceptable evidence-based guidelines used by AHC. Effectively communicates with patients, their families and or support systems, and collaborates with physicians and ancillary service providers to coordinate care activities. Identifies Members who may need complex or chronic case management post discharge and warm handoff to appropriate staff for ambulatory follow up, as necessary. Communicates and collaborates with IPA/MG as necessary for effective management of Members. Assigns and provides daily oversight of the activities and tasks of the CCIP Coordinator. Records communications in EZ-Cap and/or case management database. Arranges and participates in multi-disciplinary patient care conferences or rounds. Monitors, documents, and reports pertinent clinical criteria as established per UM policy and procedure. Monitors for any over utilization or underutilization activities. Generates referrals as appropriate to the QM department. Enters data as necessary for the generation of reports related to case management. Reports the progress of all open cases to the Medical Director, Director of Healthcare Services and Manager of Utilization Management. Performs other duties as assigned.

Conifer Health Solutions

Prior Authorization LVN Nurse - Remote

Posted on:

April 9, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Texas

The purpose of the Prior Authorization (PA) Nurse is to provide patients, physicians and health team member services related to the appropriate utilization of the organization resources. This position will identify, screen, coordinate, and process referral determinations of requested services. By utilizing the appropriate review criteria, policies and guidelines the PA nurse promotes quality and cost-effective medical care and ensure the member is receiving the appropriate care in the appropriate setting.

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. Three (3) to Five (5) years of acute care experience. Two years of managed care experience in Medical Management preferred. ICD-9 and CPT coding experience preferred. Experience in EZ-CAP preferred. Ability to communicate effectively both verbally and in writing. Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system. 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 preferred to perform the job. Minimum Education: LVN Preferred Education: BA or BS in Nursing Minimum Experience: 3 to 5 years of acute care experience or 2 Years Health Plan Utilization Review or equivalent work Preferred Experience: 5 years Health Plan Utilization Review and 5 years Acute Care or Experience with 1 year ICU / ER REQUIRED CERTIFICATIONS/LICENSURE: Include minimum certification required to perform the job. Licensure must be current and unrestricted in the appropriate jurisdiction. 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. Must be able to work in sitting position, use computer and answer telephone Ability to travel Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments 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. Office Work Environment TRAVEL: Approximately 5% travel may be required

Responsible for providing timely referral determination by accurate: Usage of the Milliman Care Guidelines Identification of referrals to the medical director for review Appropriate letter language and coding (denials, deferrals, modifications) Appropriate selection of the preferred and contracted providers Proper identification of eligibility and health plan benefits Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out. Responsible for maintaining compliance in turnaround time requirements as mandated by the ICE TAT Standards Responsible for working closely with manager to address issues and delays that can cause a failure to meet or maintain compliance. Meets or exceeds production and quality metrics. Work directly with the provider(s) and plan Medical Director to facilitate quality service to the member and provider. Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management). Attend all mandatory meetings and training. Maintains and keeps in total confidence, all files, documents, and records that pertain to the business operations. Collaborates, educates, and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria. All other job-related duties as it relates to the job function or as delegated by the management team.

Centene Corporation

Clinical Review Nurse - Prior Authorization - LVN/LPN

Posted on:

April 9, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Compact / Multi-State

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Compact Multi-State LVN/LPN License Required Position Purpose Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Education/Experience Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required

Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Complies with all policies and standards

Centene Corporation

Clinical Review Nurse - Correspondence

Posted on:

April 9, 2025

Job Type:

Role Type:

License:

RN

State License:

Missouri

Transforming the health of the communities we serve, one person at a time Healthcare is best delivered locally Our uniquely local approach allows us to help members access high-quality, culturally sensitive healthcare services. Commited to Corporate Sustainability The health of individuals drives our focus on the environment, removing social barriers to health, and prioritizing responsible corporate governance.

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement. Work Schedule: FRI - SAT - SUN - MON from 9am -11pm CST

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred.

Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards Contributes to correspondence letter template creation and maintenance with the correspondence team Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Coordinates with interdepartmental teams on training needed within the utilization management team based on trends Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices Performs other duties as assigned Complies with all policies and standards

CareNational

Field RN Case Manager

Posted on:

April 9, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Ohio

CareNational is looking for an experienced Field RN Case Manager in Toledo Region, OH! This is a contract position and ideal candidates will have at least 3 years of recent experience as a Field RN Case Manager. Pay Details: Pay Range: $44.12 / Hour Work Setting: Remote (Toledo region. Fulton, Wood, Ottawa, and Lucas Counties..) Position Details: Contract Length: 3 months Location: Toledo region. Fulton, Wood, Ottawa, and Lucas Counties. Mon-Fri 8am-5pm

RN Associate's Degree or higher RN with current unrestricted state licensure. Case Management Certification, CCM preferred P-Active RN License -3+ years of clinical experience Home Health preferred -Computer Skills (Microsoft office such as: Word, Excel, and outlook)

Curana Health

Nurse Practitioner - National After-Hours Team - PRN (Licensed in Texas or Louisiana)

Posted on:

April 9, 2025

Job Type:

Role Type:

Telehealth

License:

NP/APP

State License:

Texas

Curana Health is a provider of value-based primary care services for the senior living industry, including skilled nursing facilities, assisted & independent living communities, Memory Care units, and affordable senior housing sites. Our 1,000+ clinicians serve more than 1,500 senior living community partners across 34 states, and Curana participates in various innovative CMS programs (including owned-and-operated Accountable Care Organizations and Medicare Advantage plans). With rapid year-over-year growth since our founding in 2021, Curana is setting a new standard in innovative care delivery for seniors with high-risk, complex clinical needs, many of whom have been historically underserved by the healthcare system. Our mission: To radically improve the health, happiness and dignity of senior living residents.

The National After-Hours Call Team is responsible for providing telephonic care and direction to residents and facility staff during overnight, weekend, and holiday hours. This role is responsible for the delivery of medical care to Curana patients across multiple states in order to ensure high quality continuity of care and treatment in place when possible. In this home-based 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. This is a Per Diem, work from home position requiring various shift coverage with a mix of weeknights, weekend, and holiday coverage. While shift times can vary, we provide coverage to skilled nursing and senior living facilities on weeknights from 5pm- 8am local time, continuous coverage from Friday at 5pm to Monday at 8am. Holiday coverage is also provided beginning at 5pm of the end of the last business day to 8am of the resumption of business hours. Availability and Coverage expectations for this role Weeknight shifts between 5pm and 8am Every other weekend coverage for 10-12-hour shifts covering both day and night shifts Overnight and holidays are required for all After Hours Call Team Members Holiday scheduling is completed at the beginning of the year for advanced planning FT role is a salaried position and 40 hours a week.

Education and Experience: Master's Degree as a Nurse Practitioner Current unrestricted NP license in the state you reside and ability to obtain in other required locations within 60 days Nurse Practitioner national certification as ANP, FNP, or GNP Ability to obtain DEA licensure / Prescriptive Authority Background in acute and chronic disease management Clinical background in adult, family, or geriatrics 3+ years of experience as a NP Ability to gain a collaborative practice agreement, if applicable in your state(s) Ability to work scheduled shifts in accordance with scheduling policies Proficient computer skills including the ability to document medical information with written and electronic medical records Preferred Qualifications: Experience working in a nursing home, or with seniors in an acute care facility Understanding of Geriatrics, Chronic Illness, and acute disease management Understanding of Advanced Illness and end of life discussions Ability to develop and maintain positive customer relationships Adaptability to change Physical Demands and Environment: Ability to present to groups and remain calm under stress. Must be capable of performing the job functions of this position with or without reasonable accommodation. Travel: None Other Requirements: Maintain an orderly, confidential and safe work environment. Adhere to all Company and department policies and procedures. Perform other duties as assigned.

Available on Curana’s telephonic platform, both taking and placing calls to coordinate care for residents between facilities, hospitals, and clinics. Utilize EMR proficiently to provide acute care to residents during overnight and weekend/ holiday hours Primary Care Delivery Deliver cost-effective, quality care to members Manage both medical and behavioral, chronic, and acute conditions effectively, and in collaboration with a physician or specialty provider Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations Responsible for ensuring encounter is documented appropriately to support the diagnosis at that visit Utilizes practice guidelines and protocols established by Curana Must attend and complete all mandatory educational and training requirements

Curana Health

Case Manager, RN (70725)

Posted on:

April 9, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

Curana Health is a provider of value-based primary care services for the senior living industry, including skilled nursing facilities, assisted & independent living communities, Memory Care units, and affordable senior housing sites. Our 1,000+ clinicians serve more than 1,500 senior living community partners across 34 states, and Curana participates in various innovative CMS programs (including owned-and-operated Accountable Care Organizations and Medicare Advantage plans). With rapid year-over-year growth since our founding in 2021, Curana is setting a new standard in innovative care delivery for seniors with high-risk, complex clinical needs, many of whom have been historically underserved by the healthcare system. Our mission: To radically improve the health, happiness and dignity of senior living residents.

The Case Manager, RN position is responsible for providing telephonic case management services for Curana patients who have emerging health risks, are clinically complex, and who experience a care transition. The Case Manager works collaboratively with Curana Providers and other members of the interdisciplinary care team to promote quality and cost-effective care.

Required Skills and Knowledge: Ability to communicate with patients and caregivers in an effective and caring manner. Must have the ability to function independently and as a member of the interdisciplinary care team. Effective written and verbal communication skills. Exhibits knowledge of pathophysiology and accepted treatment protocols for common health diagnoses (i.e., diabetes, chronic heart failure, chronic obstructive pulmonary disease). Proficient in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding. Bi-lingual (English/Spanish) preferred. Education & Experience: Must hold an active unrestricted compact RN license. BSN preferred. Ability to obtain additional state licenses, as needed 2+ years of experience in nursing is required. Care settings may include inpatient, outpatient, or skilled nursing facilities. Case Management experience is strongly preferred. Certified Case Manager Certification preferred. Transition of care experience desired.

Perform initial and ongoing patient health assessments. Collaborate with the Curana care team, patients, and/or caregivers to develop patient-centered care plans. Serve as a health coach to educate the patients and/or caregivers about their disease process. Apply clinical judgment to incorporate strategies that reduce patient risk factors and barriers. Communicate patient health updates to the Curana providers and support staff. Schedule provider visits for at-risk patients. Monitor remote patient monitoring (RPM) data and notify Curana providers if adverse trends are identified. Support patients as they transition from the hospital to their place of residence. Implement and evaluate transitional care interventions to reduce the risk of readmission. Support Curana disease management programs such as dementia care management.

AccentCare

RN Triage Nurse/Weekends

Posted on:

April 9, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Texas

At AccentCare, our care is most compassionate when we empathize and engage with everyone, and we are at our best when we value diverse perspectives, foster open dialogue, and enact change. And we are stronger when each of us is empowered to grow, be our unique selves, and feel a sense of inclusion and belonging. AccentCare is proud of how we are building a culture and inclusive infrastructure to help elevate the voice of all our employees with a special focus on the underrepresented and marginalized. We offer equal employment opportunities regardless of a person’s race, ethnicity, sex, sexual orientation, gender identity or expression, religion, national origin, color, creed, age, mental disability, physical disability, or any other protected classification.

Find Your Passion and Purpose as a Hospice Triage Registered Nurse Reimagine Your Career in Hospice As a medical professional, you know that what you do impacts you as much as your patients and their families, and at AccentCare, we are united in our relentless drive to reimagine care because we want to provide the service we would seek for our own families. We think it’s really special to be a part of our patient’s health journey and create incredible memories while providing world-class patient care. Offer Based on Years of Experience Position: Triage Nurse RN Registered Nurse License for Texas required Office Location: Remote Territory: Texas Hours: Friday 4p-10p Sat 7a-7p Sun 7a-7p 1 weeknight 4p-10p Pay Range: $70,000-$80,000 Type: Remote

Be the Best Hospice Triage Registered Nurse You Can Be If you meet these qualifications, we want to meet you! Graduated from an approved school of professional nursing Excellent customer service, assessment, and verbal communication skills Computer skills Required Certifications and Licensures: Licensed to practice as a registered nurse in the state of agency operation

AccentCare

RN Triage Nurse/Part-time

Posted on:

April 9, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Texas

At AccentCare, our care is most compassionate when we empathize and engage with everyone, and we are at our best when we value diverse perspectives, foster open dialogue, and enact change. And we are stronger when each of us is empowered to grow, be our unique selves, and feel a sense of inclusion and belonging. AccentCare is proud of how we are building a culture and inclusive infrastructure to help elevate the voice of all our employees with a special focus on the underrepresented and marginalized. We offer equal employment opportunities regardless of a person’s race, ethnicity, sex, sexual orientation, gender identity or expression, religion, national origin, color, creed, age, mental disability, physical disability, or any other protected classification.

Position: Triage Nurse RN Registered Nurse Compact License Required Office Location: Remote Hours: Sat 7a-7p Sun 7a-7p With the possibility of another weeknight 5:30-10 (which day can be discussed on interview) Hourly Rate Range: $33 to $38 Type: Remote Find Your Passion and Purpose as a Home Health Triage Registered Nurse Reimagine Your Career in Home Health As a medical professional, you know that what you do impacts you as much as your patients and their families, and at AccentCare, we are united in our relentless drive to reimagine care because we want to provide the service we would seek for our own families. We think it’s really special to be a part of our patient’s health journey and create incredible memories while providing world-class patient care. Offer Based on Years of Experience

Be the Best Home Health Triage Registered Nurse You Can Be If you meet these qualifications, we want to meet you! Graduated from an approved school of professional nursing Excellent customer service, assessment, and verbal communication skills Computer skills Required Certifications and Licensures: Licensed to practice as a registered nurse in the state of agency operation

AccentCare

RN Call Center Triage Nurse - Remote

Posted on:

April 9, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Texas

At AccentCare, our care is most compassionate when we empathize and engage with everyone, and we are at our best when we value diverse perspectives, foster open dialogue, and enact change. And we are stronger when each of us is empowered to grow, be our unique selves, and feel a sense of inclusion and belonging. AccentCare is proud of how we are building a culture and inclusive infrastructure to help elevate the voice of all our employees with a special focus on the underrepresented and marginalized. We offer equal employment opportunities regardless of a person’s race, ethnicity, sex, sexual orientation, gender identity or expression, religion, national origin, color, creed, age, mental disability, physical disability, or any other protected classification.

Reimagine Your Career in Corporate Healthcare As a professional, you know that what you do impacts you as much as our patients and their families, and at AccentCare, we are united in our relentless drive to reimagine care because we want to provide the service we would seek for our own families. We think it’s really special to be a part of our patient’s health journey and create incredible memories while providing world-class patient care. Shift: Full-time Weekend Saturday & Sunday 12/hrs Start times: 9am-9:30pm CST or 11:30pm-10:00am CST Also 2 Days during the week: Monday-Thursday 3:30pm -12:00am CST or 11:30pm - 10:00am CST Bilingual in Spanish A+ Active RN License Salary: $32.00-$35.00/hr DOE This a work from home opportunity.

Be the Best Call Center Triage Nurse - Registered Nurse / RN You Can Be If you meet these qualifications, we want to meet you! Excellent customer service, assessment, and verbal communication skills Computer skills Required Certifications and Licensures: Licensed to practice as a registered nurse in the state of agency operation

Neovance

Telephonic Nurse Spec

Posted on:

April 8, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

North Carolina

The Nurse Specialist is responsible for supporting the operations of Neovance Patient Access patient support and access programs. This individual interacts primarily with patients and care partners who are receiving clinical support services from a program. Examples of this type of support may include contact center based-services, such as advising patients on dosing, guiding patients through product administration, providing approved recommendations to patients on managing side effects, discussing medication adherence with patients, or field-based services, such as on-site patient injection training Additionally, this individual may be responsible for preparing monthly and ad hoc project-specific reports. The Nurse Specialist also serves as a subject matter expert on programs and is first point of contact for clinical care program calls. The Nurse Specialist may be either contact-center based or field-based.

Qualifications (Minimum Required): Strong communication skills: Clear, concise written and oral expression. Customer service focus: Empathetic, exceptional service delivery tailored to individual needs. Problem-solving and initiative: Identifies issues, takes action, and proposes solutions. Collaboration and independence: Thrives in teamwork environments and works effectively alone. Project management: Good judgment, multi-project handling, urgency in meeting deadlines. Tech proficiency: Intermediate to advanced skills in Microsoft Excel, PowerPoint, Word, and program-specific systems. Training and enthusiasm: Energetic and innovative, passionate about developing ideas. Detail orientation and retention: Quick learner with a focus on accuracy and thoroughness. Therapy engagement support: Educates and empowers customers to stay engaged in their therapy journey. Experience (Minimum Required): The Telephonic Nurse Specialist will hold a current RN license in good standing in the state of practice. Will ideally hold a bachelor’s degree or evidence of continual work toward a degree is strongly preferred. Four or more years of healthcare or customer service experience is preferred. Physical Demands / Work Environment: The Telephonic Nurse Specialist will work under normal office The environment is energetic and fast paced. Must be able to sit for long stretches and adhere to scheduled breaks and The Telephonic Nurse Specialist will typically work an eight-hour workday within the program’s hours of operations, with an hour or half hour of unpaid Shifts vary by site and may start as early as 8:00 am Eastern Time and end as late as 8:00 pm Eastern Time, Monday to Friday. The actual schedule will be determined by the assigned program. Occasional overtime may be required. The Telephonic Nurse Specialist must be able to work from a virtual office, free of distractions or interruptions. Travel will vary based on the program assigned. Call center employees may be asked to travel occasionally to meet program needs

Makes scheduled outbound calls and responds to inbound calls from patients and other customers regarding clinical aspects of a product, product administration, and adherence to medical therapies or treatments or for other related issues. Conducts follow up calls or sends follow up correspondence as necessary according to the program’s guidelines. Reviews approved therapy or treatment-related information with callers and identifies potential barriers to treatment. Within guidelines approved by the program’s sponsor, helps identify solutions to improve access and to help patients remain on prescribed treatment. Provides approved information to patients and their caregivers in a clear, caring way so that they may make informed choices. Keep case notes and tracks cases effectively using proprietary computer system. Establishes appropriate activity plans to trigger next call, correspondence, or intervention. May provide pre-approved medical information or literature to customers based on the guidelines of the specific program. May conduct /behavioral interviewing and motivational coaching calls with patients to encourage them to be adherent to their medication as prescribed. Documents adverse events and provides reporting per Neovance and client policies and procedures All other duties as needed or

Medix™

Remote Triage Nurse - Weekends

Posted on:

April 8, 2025

Job Type:

Contract

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

The Clinical Triage Nurse, RN provides remote phone triage, assessing symptoms, advising on care, and coordinating with teams. This weekend-based role also reviews test results for providers. Requires strong clinical and communication skills for remote patient guidance. Schedule: Weekend Team: Fri-Sun, 8 AM - 8 PM. Training Schedule: Week 1: M-F, 8:30 AM - 5 PM EST (potential flexibility). Week 2: M-T, 8:30 AM - 5 PM EST; Fri-Sun, 8 AM - 8 PM EST. Week 3 Onward: Fri-Sun, 8 AM - 8 PM EST.

Required: RN license, Compact Multi State BSN or ADN Strong medical terminology/pharmaceutical knowledge. Excellent written/verbal communication. Preferred: 2+ years RN experience. Contact center/triage experience. EHR experience

Handle inbound calls/voicemails promptly. Provide empathetic, professional customer service. Triage/transfer calls appropriately. Conduct phone assessments using probing questions & EMR. Prioritize cases using evidence-based guidelines. Identify/escalate crisis situations. Educate patients/caregivers on health/follow-up. Communicate provider orders. Collaborate with care teams. Communicate compassionately. Analyze/report urgent test results. Perform data entry. Maintain clear team communication. Adhere to policies. Meet quality/productivity standards. Address patient complaints. Participate in quality initiatives.

CareSource

REMOTE - Triage Nurse - RN - Evening Hours and Every other Weekend - R8452

Posted on:

April 8, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Ohio

*Evening hours - 3pm-1:30am - every other weekend, every other holiday* *Shift differential* The Triage Nurse is responsible for using decision support software to perform telephonic clinical triage and health information service for CareSource managed health plans and external clients.

Education and Experience: RN license required Bachelor’s Degree in Nursing preferred Minimum of three (3) years of progressive clinical experience is required Triage, Emergency Nursing or Critical Care experience is preferred Behavioral Health experience is preferred Telephone Triage in a call center setting preferred Competencies, Knowledge and Skills: Beginning level computer skills Clinical assessment skills Communication skills Ability to work independently and within a team environment Attention to Detail Critical listening and thinking skills Proper grammar usage Proper phone etiquette Decision making/problem solving skills Customer service oriented Broad base of clinical knowledge Teaching skills Ability to remain calm under pressure and in life threatening situations Ability to multitask-simultaneously thinks, talks and types Understand and support philosophy of HMO and managed healthcare programs Licensure and Certification: Current, unrestricted RN licensure in state of practice is required; multi-state licensure is preferred Ability to obtain licensure by endorsement in non-compact states when applicable Working Conditions: General office environment; may be required to sit or stand for extended periods of time

Utilize assessment skills and the nursing process for care of healthy, as well as acutely or chronically ill or injured clients, including pediatric, adult, maternity, and geriatric members Function as patient advocate by facilitating accessibility to healthcare and provide collaborative service for other CareSource departments Educate members to assist them in making informed decisions regarding personal healthcare Assess health status and direct members to the most appropriate level of care Utilize critical reasoning in clinical decision-making Inform callers of preventative healthcare measures Identify and refer appropriate members for Case Management Provide information about benefits, services and programs that allows members to maximize healthcare resources Assess caller's needs and assists with issues related to member's care Manage telephone interactions with compassion and respect for cultural, educational and psychosocial differences of individuals Utilize multiple computer applications to document all information in an accurate manner Practice in compliance with AAACN,URAC and NCQA standards and regulatory requirements Keep abreast of trends in healthcare delivery and managed care Participate in self-managed team: daily operations, quality audits, preceptor/training resource, etc. Maintains and contributes to a collaborative professional and ethical work environment. Perform any other job duties as requested

ChartSpan Medical Technologies

Bilingual (Spanish) LPN Inbound Care Coordinator I

Posted on:

April 8, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Compact / Multi-State

Join our elite team of Clinical Inbound Specialists at ChartSpan, where we handle incoming clinical calls and play a crucial role in providing exceptional patient care. We're seeking a highly motivated clinician to join our esteemed Clinical Inbound Team.

A Clinical Inbound Specialist at ChartSpan goes beyond merely answering incoming calls. They are instrumental in ensuring the seamless operation of our daily activities. Check out the comprehensive list below to see the pivotal contributions of our Clinical Inbound Specialists

Adherence to attendance policy. Excellence in following established clinical protocols and procedures. Demonstrative quality scores reflecting clinical excellence. Ability to work the assigned inbound schedule. Flexibility and adeptness in switching tasks effectively. Eagerness to assist fellow co-workers and contribute to team success. Current active, compact LPN license. Bilingual/Fluent in Spanish.

Call Management & Patient Engagement: Respond promptly to all incoming patient inquiries via phone, email, or live chat. Patient Care Support: Assist in triaging patient clinical issues and connecting patients with a nurse promptly. Review and handle other patient-centered ancillary tasks such as reviewing and transcribing medical records, addressing and sourcing additional patient resources, and resolving urgent patient account matters. Collaboration and Assistance: Support Provider Relations Specialists as needed with patient and provider communication Assist Triage Nurse Team and Pharmacy Technicians in obtaining the necessary information for triage assistance and medication refills Obtain and send record requests via fax, ensuring accuracy and efficiency. Performance Metrics: Timeliness in call answering and additional patient inquiries via email or live chat (team and individual evaluation). Call Answer Rate. Idle Time. Average After-Call Work Time. Quality Scores. Hours worked and attendance

ChartSpan Medical Technologies

Remote LPN Inbound Care Coordinator

Posted on:

April 8, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Compact / Multi-State

Join our elite team of Clinical Inbound Specialists at ChartSpan, where we handle incoming clinical calls and play a crucial role in providing exceptional patient care. We're seeking a highly motivated clinician to join our esteemed Clinical Inbound Team.z

A Clinical Inbound Specialist at ChartSpan goes beyond merely answering incoming calls. They are instrumental in ensuring the seamless operation of our daily activities. Check out the comprehensive list below to see the pivotal contributions of our Clinical Inbound Specialists. Performance Metrics: Timeliness in call answering and additional patient inquiries via email or live chat (team and individual evaluation). Call Answer Rate. Idle Time. Average After-Call Work Time. Quality Scores. Hours worked and attendance.

Adherence to the attendance policy. Excellence in following established clinical protocols and procedures. Demonstrative quality scores reflecting clinical excellence. Ability to work the assigned inbound schedule. Flexibility and adeptness in switching tasks effectively. Eagerness to assist fellow co-workers and contribute to team success. Active, compact license as an LPN.

Call Management & Patient Engagement: Respond promptly to all incoming patient inquiries via phone, email, or live chat. Patient Care Support: Assist in triaging patient clinical issues and connecting patients with a nurse promptly. Review and handle other patient-centered ancillary tasks such as reviewing and transcribing medical records, addressing and sourcing additional patient resources, and resolving urgent patient account matters. Collaboration and Assistance: Support Provider Relations Specialists as needed with patient and provider communication Assist the Triage Nurse Team and Pharmacy Technicians in obtaining the necessary information for triage assistance and medication refills Obtain and send record requests via fax, ensuring accuracy and efficiency.