Sunshine State Health Plan

Pediatric Care Manager (RN)

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. This position is seeking candidates in the Marion County area. 50% field visiting members doing care management. The other 50% is remote work from home. RN Florida Licensure Required. Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families.

Education/Experience: Requires a Degree from an Accredited School of Nursing or a Bachelor's degree in Nursing and 2 – 4 years of related experience. License/Certification: RN - Registered Nurse - State Licensure and/or Compact State Licensure required

Evaluates the needs of the member, barriers to accessing the appropriate care, social determinants of health needs, focusing on what the member identifies as priority and recommends and/or facilitates the plan for the best outcome Develops ongoing care plans / service plans and collaborates with providers to identify providers, specialists, and/or community resources to address member's unmet needs Identifies problems/barriers to care and provide appropriate care management interventions Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services Provides ongoing follow up and monitoring of member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs Provides resource support to members and care managers for local resources for various services (e.g., employment, housing, participant direction, independent living, justice, foster care) based on service assessment and plans, as appropriate Facilitate care management and collaborate with appropriate providers or specialists to ensure member has timely access to needed care or services May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators Provides and/or facilitates education to members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner Other duties or responsibilities as assigned by people leader to meet business needs Performs other duties as assigned Complies with all policies and standards

IntellaTriage

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

Posted on:

March 25, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

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

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

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

Millennium Physician Group

ACO Triage Nurse ( Remote Position )

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Florida

Millennium Physician Group is one of the largest comprehensive primary care practices with healthcare providers throughout Florida. At Millennium Physician Group, you will find an organization that focuses on family and building a strong network of people to care for the communities we serve. We are always searching for employees who have a strong customer service attitude, fantastic teamwork skills and a willing smile ready to share. Our promise is to provide you with the tools to do your job successfully, as well as providing a team atmosphere that empowers you to seek better ways to deliver care to our patients and their families. We also promise to care for you as an individual and help you grow in your role with Millennium Physician Group. If you are interested in joining an organization that puts an emphasis on team work and family, then Millennium Physician Group is the right choice!

Millennium Physician Group is currently looking for a professional, compassionate, knowledgeable and licensed individual to fill the position of Triage Nurse. H/She must be a Licensed Registered Nurse who will utilize best practices to provide effective triage processes and principles that provide for the safety and wellbeing of the patient. If you have RN Triage experience in a larger-sized medical practice, we encourage you to apply for this position. Work schedule includes: shifts including weekends and holidays EST zone

Registered Nurse licensed in FL License must always be kept current 5+ Years of clinical experience with 1+ year(s) of case management experience preferred ER/ICU/Triage experience is preferred. Telephonic triage experience

Participate in the After-Hours On-Call Team rotation Answer all incoming calls immediately and give correct advice Provide Post-Acute Care Outreach Assist Hospitalist's Patient Outreach Facilitate Prescription Refills Assist RN Care Management Teams with patient assessments and/or monthly follow-up calls, when needed Monitor Patients enrolled in the Patient Monitoring Program

Actalent

Remote Post Acute Clinical Review Nurse

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Maryland

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

The PAC Nurse is a telephonic position responsible for recommending discharge plans, assisting with transition of care, and managing the length of stay (LOS) for Long Term Acute Hospital (LTACH), Skilled Nursing Facility (SNF), and Institutional Rehab Facility (IRF) for their assigned and non-assigned post-acute care (PAC) facilities through collaboration. This role involves working closely with key facility personnel and internal Medical Directors, Market Engagement Directors, and Nurse Managers to develop and maintain timely discharge plans.

Current and unrestricted LPN or RN license Post-acute nursing experience (i.e. Inpatient Rehab Facility, Long-Term Acute Care Hospital, Skilled Nursing Facility) 3 years of concurrent review experience and/or discharge planning 2 years of utilization review/management experience 1 year of experience within Case Management or Transition-of-care role Excellent negotiation, influencing, problem-solving, and decision-making skills Strong communication (verbal/written), organizational, and interpersonal skills Ability to work independently, utilizing sound clinical judgment and critical thinking skills under minimal supervision Strong commitment to quality and standards Additional Skills & Qualifications: Comfortable speaking with providers/offices via phone Interqual experience Milliman/MCG experience Managed care experience Experience with evidence-based care guidelines (i.e. MCG/Milliman, Interqual) Associate's Degree or Diploma in Nursing/Practical Nursing Minimum 2 years clinical experience in a clinical setting Broad knowledge of health care delivery/managed care regulations High level clinical knowledge, communication, customer service, and problem-solving skills Ability to effectively interact with all levels of management and a highly diverse clientele Strong organizational and time management skills Work Environment: Work from home with equipment provided. The first 3 weeks are training, and attendance is mandatory. Training schedule: Monday-Friday 8:00am-4:30pm EST. Post-training schedule: Monday-Friday 11:00am-8:00pm EST (30-minute lunch break). Candidates from PST and MST time zones are welcome to apply to align better with the schedule. After completing the initial 90-day probationary period, candidates are eligible for up to 40 hours of PTO (1 week or 5 days) and 6 paid holidays throughout the duration of their 12-month contract. There is an opportunity to go permanent with a large managed care organization.

Collaborate with the PAC Medical Director as needed to ensure proper medical necessity decisions are being rendered. Partner closely with the PAC Medical Director in care planning and goal setting, reviewing discharge plans and length of stay status to ensure optimal outcomes. Act as a clinical resource for unlicensed Post-Acute Care Coordinators, providing clinical expertise and helping to clarify referral source directives. Receive/respond to requests from unlicensed staff regarding scripted clinical questions and issues. Act as the primary contact to the post-acute facility or facilities to which you are assigned to obtain all clinical information required and proactively obtain patient status updates. Work alongside the Supervisor and closely with Market Engagement Directors to efficiently address potential facility concerns, pushback, or gaps in process. Communicate customer service/provider issues to supervisor for logging and resolution. Conduct scheduled telephonic touch points with each facility point person to review each member within that facility and confirm appropriateness for continued stay. Authorize continued stay at SNF, IRF, LTACH, and Home Health care (if delegated) using approved medical care guidelines and collaboration with key facility personnel within the healthcare setting. Use clinical expertise to review clinical information and clinical criteria to determine if the service/device meets medical necessity for the member. Ensure case review and elevation to complete the determination is rendered within the contractual and regulatory turnaround time standards to meet both contractual and regulatory requirements. Participate in performance and operational improvement activities. Contribute to ongoing quality assessment/improvement activities, ensuring the collection of data for improvement analysis and preparing reports as requested. Assist the team in implementing and maintaining standardized operational processes to ensure compliance with company policies, legal requirements, and regulatory mandates. Participate in special projects and perform other duties as assigned. Participate in an annual Inter-rater Reliability Testing Process. Maintain a typical work schedule with occasional evening and weekend coverage based on business needs.

Revecore

Denial Prevention Nurse Consultant

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Tennessee

Ready to make a difference for hospitals while working from home? Start your next chapter at Revecore! For over 25 years, Revecore has been at the forefront of specialized claims management, helping healthcare providers recover meaningful revenue to enhance quality patient care in their communities. We’re powered by people, driven by technology, and dedicated to our clients and employees. If you’re looking for a collaborative and diverse culture with a great work/life balance, look no further.

Primarily responsible for thorough review of medical records and other medical documentation to determine appropriate billable services for hospital to construct an appeal for payment based on medical necessity or payer specific guidelines or criteria. Responsible for providing clients trending, revenue cycle fail point analysis, and best practice remediation recommendations. Training: Our comprehensive training begins on your first day and lasts 90 business days. It is led by instructors and incorporates interactive discussions and hands-on activities to accommodate diverse learning preferences.

College degree or diploma from school of nursing – must be RN Clinical nursing experience working in hospital environment, preferably in ER, Critical Care or diagnostic services Minimum 5 years of related experience and/or training in utilization review or patient accounting Are highly proficient with Interqual and MCG guidelines and demonstrate appropriate application to claim appeal argument. Understand patient accounting documents – UB04, EOB Have a working knowledge of Microsoft Office (Word, Excel, Outlook) Possess technical proficiency to work on multiple computer screens and software applications simultaneously Are able to read and interpret an extensive variety of documents such as medical records, patient care systems, instructions, policies and procedures in written (in English) and diagram form Can maintain strong performance in a fast-paced environment with productivity metrics Have strong analytical skills, attention to detail, and problem-solving skills to identify underpayments and discrepancies Have experience with healthcare billing software and databases (EPIC, Cerner, Meditech) How we’ll set you up for success: Extensive multi-week training with ongoing support from teammates following training. Access to a robust knowledgebase for continued reference in your role. Visibility to your individual performance metrics enables you to set goals. Computers and necessary work equipment are provided  Involved management who leans in to support your productivity metrics. Work at Home Requirements: A quiet, distraction-free environment to work from in your home.  A secure internet connection is required.  Home internet with speeds >20 Mbps for downloads and >10 Mbps for uploads.  The workspace area accommodates all workstation equipment and related materials and provides adequate surface area to be productive. 

Build strong, lasting relationships with clients, payors and Revecore personnel Analyze medical records or other medical documentation to validate services, tests, supplies and drugs performed for accuracy related to billing for services rendered Identify and interpret medical, radiological, laboratory or other tests and procedures as well as pharmaceutical drugs Review and understand managed care contracts, hospital billing statements/bills and insurance denials Research commercial and governmental payor policies, clinical abstracts and studies, and other documentation related to claims payment to evaluate and appeal denied claims. Perform research regarding denials and effectively communicate information to associates, colleagues, managers and clients Contact insurance company to obtain missing information, explain and resolve underpayments and/or denials and arrange for payment or adjustment processing on behalf of client Prepare and submit correspondence such as letters, emails, online inquiries, appeals, adjustments, reports and payment posting Perform denial trending for clients, identify fail points within the revenue cycle and on the payer side, and provide best practice recommendations to clients and Revecore managers. Maintain regular contact with necessary parties regarding claims status including payors, clients, managers, and other Revecore personnel Maintain confidentiality of information in compliance with company policy and HIPAA Attend client, department and company meetings Lead client meetings and perform consulting services to client’s as it relates to medical necessity of services performed and proper vetting of payers criteria

Convergence

REMOTE POSITION: Seeking Incentive-Minded LPN/LVN for Chronic Care Management, Remote Role and CCM Experience Required

Posted on:

March 25, 2025

Job Type:

Part-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Compact / Multi-State

We are seeking incentive-minded individuals who want to maximize their income based on productivity. Convergence Telehealth is currently recruiting full and part-time remote Care Management Team- Nurse Case Managers with a passion for delivering a high-quality customer experience, to support our clients. As a Care Management Team- Nurse Case Manager, you may be involved in chronic care management (CCM), remote patients monitoring (RPM) and transitional care management (TCM). You will coordinate discharge and follow up care for patients and work directly with patients, caregivers, physicians, and discharge teams on a daily basis. This will include managing a patient’s successful transition from hospital to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high risk medical, surgical, and/or trauma patients. You are responsible for managing the post-acute care of high-risk patients that are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions and working with complex and varied patients and situations. Shift is 8 hours within window of 8:00 AM-5:00 PM ET Monday - Friday - no holidays or weekend work. This is a remote position that can be based anywhere in the United States and pay is based on a base hourly rate plus incentive compensation once certain volume goals have been reached.

Qualifications: Current and valid practical or vocational nurse license Excellent communication skills, problem solving and conflict resolution skills Ability to balance high quality care coupled with achieving high productivity Computer skills in word processing, database management, and spreadsheets Compact license required 3+ years of relevant CCM experience Preferred: Previous experience in one or more of the following: Case Management, Transitional Care Management, Remote Patient Monitoring and Chronic Care Management ACMA certification as a case manager Bilingual in Spanish is highly desired but not required Knowledge/Skills/Abilities: Work environment May work beyond normal working hours, on weekends and holidays, when necessary. Is subject to frequent interruptions. Field based work required. Occasional overnight travel will be required as times with field based assignments. Physical effort/demands (With or Without the Aid of Mechanical Devices) Ability to move (sit, stand, bend, lift) intermittently throughout the workday. Ability to lift, push, pull, and move a minimum of 50 pounds. Mental effort/demands (With or Without the Aid of Mechanical Devices) Ability to function independently and have flexibility, personal integrity, and ability to work effectively with staff and support agencies. In good health and demonstrating emotional stability. Ability to cope with the mental and emotional stresses of the position. Communication (With or Without the Aid of Mechanical Devices) Must be able to read, write and speak the English language in an understandable manner. Sensory requirements (With or Without the Aid of Mechanical Devices) Ability to see and hear or use prosthetics that will enable these senses to function adequately to assure that the requirements of this position can be fully met. SERVING WITH H.E.A.R.T Honesty Excellence Accountability Respect Teamwork

Identifies patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning. Works collaboratively with the team on post discharge care plan Interprets screening and selective laboratory/diagnostic tests. Initiates and maintains communication and collaboration with physicians, social workers, care team leaders, staff nurses, other care giving disciplines, and patients/families to develop, implement, and evaluate a transition plan of care for each patient. Conducts a comprehensive patient/family assessment and transition/home care planning evaluation upon program enrollment to initiate and maintain the patient's transitional plan of care. Assesses financial and insurance resources to maximize the health care benefit to the patient. Monitors the achievement of clinical outcomes and communicates with inpatient teams, primary and specialty physicians and staff, regional providers, and community resources (Home Health) regarding unanticipated variances. Assesses complexity of care needs and potential/actual issues or gaps in care. Arranges post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services.

Wellbox Health

LPN Care Coordinator

Posted on:

March 25, 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.

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

UnitedHealthcare

Behavioral Telephonic Case Management Nurse - Remote in New York

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

New York

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

If you possess a New York RN license, you’ll have the flexibility to work remotely* as you take on some tough challenges. The Health and Social Services Clinical Coordinator RN (HSS Clinical Coordinator RN) opportunity is 100% remote.

Required Qualifications: Current, unrestricted NY RN license 4+ years of relevant clinical work experience 3+ years of experience managing needs of complex populations (e.g., Medicare, Medicaid) 1+ years of relevant community case management experience coordinating care for individuals with complex needs Experience working directly with individuals with behavioral health conditions (mental health / substance use disorders) Demonstrate knowledge of Medicare and Medicaid benefits Ability to navigate a Windows environment, utilize Outlook, and the ability to create, edit, save, and send documents utilizing Microsoft Word  Preferred Qualifications: Bachelor’s Degree Certified Case Manager (CCM) Experience / additional training or certifications in Motivational Interviewing, Stages of Change, Trauma-Informed Care, Person-Centered Care Experience working in managed care Case Management experience

Serve as primary care manager for members with complex medical/behavioral needs Engage members telephonically to complete a comprehensive needs assessment, including assessment of medical, functional, cultural, and socioeconomic (SDOH) domains Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medication management and member safety in alignment with evidence-based guidelines Identify gaps or barriers in treatment plans Partner and collaborate with internal care team, providers, community resources/partners and leverage expertise to implement care plan Coordinate care for members and services as needed (home health, DME, etc.)  Provide education and coaching to support Member self-management of care needs in alignment with evidence-based guidelines; HEDIS/STAR gap closure Provide psychoeducation regarding conditions, medications/ medication adherence, provider/ treatment options, healthcare system utilization Help identify presence or exacerbation of behavioral health symptoms that may be influencing / impacting physical health Provide guidance / consultation to other team members regarding physical/behavioral health conditions, best practice, and evidence

CenterWell Home Health

Care Manager- Telephonic Nurse PT - After Hours & Weekends

Posted on:

March 25, 2025

Job Type:

Part-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

CenterWell Home Health specializes in personalized, comprehensive home care for patients managing a chronic condition or recovering from injury, illness, surgery or hospitalization. Our care teams include nurses, physical therapists, occupational therapists, speech-language pathologists, home health aides, and medical social workers – all working together to help patients rehabilitate, recover and regain their independence so they can live healthier and happier lives.

Clinical call center. High volume. Fast paced. This position is part time 20 hours/week, scheduled weekdays after business hours and weekends. The Clinical Care Coordinator helps to ensure optimal continuity of care for patients transitioning into and out of our services. They are responsible for being highly knowledgeable regarding post-acute levels of care, and an expert regarding CenterWell Home Health services including home health, hospice, and palliative care. The Clinical Care Coordinator is expected to communicate with the CenterWell Home Health clinical team and help facilitate timely patient follow-up for patients in need of (additional) services when appropriate. The Clinical Care Coordinator is under the general supervision of the Manager of Care Coordination and under established performance criteria. This is a work-from-home telephonic nurse position

Required Qualifications: Licensed Registered Nurse (RN) with compact state licensure in state of residence with no disciplinary action 3 - 5 years of clinical acute care experience Comprehensive knowledge of Microsoft Office applications including Word, Excel, Outlook, Teams and One Note Must be passionate about contributing to an organization focused on continuously improving consumer experiences High speed internet (no hotspot, DSL or satellite) Preferred Qualifications: Experience with case management, discharge planning and patient education for adult acute care Managed care experience Home Health Care experience Telephonic triage experience Bachelor's degree HCHB experience preferred

Act as CenterWell Home Health representative in supporting patients who have been discharged from service or for those who may need post-acute services. Able to navigate healthcare options; care services post-acute offerings, Medicare coverage, billing issues, as well as accessing healthcare resources. Utilize a variety of tools and methods to quickly provide patient options and education including but not limited to sites of service, specialty offerings, post-acute care, and other related questions. Appropriately handle a variety of customer issues including location lookup, directions, and complaints. Makes clinical level of care determination based on discussion, medical records, and any other pertinent clinical data. Matches these needs to a service site location or, if not available, look up and provide alternative services. Act as customer advocate throughout the referral process to ensure timely response and to maximize referral to admission conversion rate. Follow-up and track referral and admission outcomes. Maintains awareness and orientation to department performance objectives, meets standards, and assures patient satisfaction goals are met. Assists in the admissions process by acting as an ambassador for patients who meet the admissions requirements. Focus on placing the right patient to the right care setting at the right time Adheres to and participates in Company’s mandatory training which includes but is not limited to HIPAA privacy program/practices, Business Ethics and Compliance programs/practices, and Company policies and procedures. Reviews and adheres to all Company policies and procedures. Provide education regarding Home Health, Hospice, and Palliative Care Services. Assist with clinical eligibility review for alternate services Participates in special projects and performs other duties as assigned.

ChenMed

Registered Nurse, Telehealth, Part Time (Spanish Bilingual)

Posted on:

March 25, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

We’re ChenMed and we’re transforming healthcare for seniors and changing America’s healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We’re growing rapidly as we seek to rescue more and more seniors from inadequate health care. ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people’s lives every single day.

We’re unique. You should be, too. We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team. The Registered Nurse, Virtual Care, CareLine, is responsible for providing telephonic emergency triage and directional patient care advice for general and specific illnesses, health related issues, client counseling, patient advocacy, health education and referral and resource management to ChenMed patients and their families. Providing on-call coverage, the incumbent in this role provides remote clinical advice and assessments within license and as possible given the technology and medium. He/She collaborates with primary caregivers and others on the interdisciplinary care plan team to provide a team approach of care. The shift for this opening is as follows: Tuesdays 1700-2100 Wednesdays 1700-2100 Thursdays 1700-2100 Saturdays 0800-1600

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

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

ChenMed

Nursing Quality Specialist, Virtual Care Excellence, Telehealth (Remote)

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

We’re ChenMed and we’re transforming healthcare for seniors and changing America’s healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We’re growing rapidly as we seek to rescue more and more seniors from inadequate health care. ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people’s lives every single day.

We’re unique. You should be, too. We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team. The Virtual Care Excellence Specialist is responsible for helping to ensure the quality and patient experience expectations of the Dedicated Care Line Team’s clinical interactions. This will be accomplished through the timely performance of live and recorded call monitoring, participation in regularly scheduled calibration events, the dedicated support of Care Line staff through peer reviews and feedback sessions and the identification of quality trends and process opportunities that promote appropriate and consistent clinical outcomes, ensuring a VIP experience for all callers. This position is remote and will work the below schedule: Monday-Friday 1200-2000 Eastern time.

Compact Multistate Nursing License required Bachelor’s degree or above required Minimum of three (3) years of clinical work experience required Minimum of 3 years experience training and coaching preferred Healthcare-related quality improvement experience preferred Minimum of 1 year of virtual care experience strongly preferred

Acts as a positive champion of all clinical quality and patient experience initiatives Works in a focused and efficient manner to help streamline workflows for the virtual care team and optimize outcomes for our patients Partners with management to translate quality data into meaningful policies and procedures that ensure patient safety and consistent care Participates actively in initiatives that promote value-based care priorities including clinical accuracy, patient satisfaction, and access to care Relies on evidence-based practices and leverages technology to elevate the quality of virtual care interactions Empowers peers to deliver optimal patient outcomes through the facilitation of call audits, timely feedback sessions and peer support activities Advocates for the voice of the patient, ensuring their needs are met throughout the virtual care journey Demonstrates and promotes a culture of collaboration, professional development, and a commitment to excellence Contributes to a positive work environment that fosters open communication, innovation, and accountability for exceeding patient expectations Perform other duties as assigned and modified at manager's discretion.

Summit Health

Transitional Care Coordinator - CMA or LVN

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Arizona

We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care. Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians. When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care. Please Note: We will only contact candidates regarding your applications from one of the following domains: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com.

At VillageMD, we're looking for a Transitional Care Coordinator to help us transform the way primary care is delivered and how patients are served. As a national leader on the forefront of healthcare, we've partnered with many of today's best primary care physicians. We're equipping them with the latest digital tools. Empowering them with proven strategies and support. Inspiring them with better practices and consistent results. We're creating care that's more accessible. Effective. Efficient. With solutions that are value-based, physician-driven and patient-centered. To accomplish this, we're looking for individuals who share our sense of excellence, are ready to embrace change, and never settle for the status quo. Individuals who have the confidence to lead but the humility to never stop learning. Could this be you? Integral to our Care Management team, the Transitional Care Coordinator is accountable for collaborating with the care team to consistently communicate and document high risk patient profiles to provider and practice care teams. As a new member of VillageMD, you’ll work closely with our multidisciplinary care team to connect the dots of collaborative patient care while incorporating patients’ personal health and lifestyle goals.

Skills for success: Achieving objectives by effectively managing multiple tasks at one time Maintaining an organized and systematic workflow that results in goals being met Flexibility in an ambiguous and dynamic environment, maintaining a positive and “can do” attitude A passion for changing the way healthcare is experienced for complex and/or disadvantaged patients and communities Demonstrated strength-based approach to collaborative problem solving Effective engagement of diverse populations (age, ethnic groups, socio-economic levels, etc.) with exhibited cultural sensitivity A willingness to learn on your own and take initiative Demonstrated honesty and following through on commitments The ability to problem-solve on the spot and identify issues that need escalated A low ego and humility; an ability to gain trust through good communication Experience to drive change: 3+ years of experience in a medical office or health care setting 2+ years working as a, Licensed Practical Nurse LPN, or state equivalent, Medical Assistant (MA), Pharmacy Tech or Community Health Worker (CHW) preferred Comfort with technology including the Microsoft suite of products Prior experience using electronic health record including data capture, data mining and reporting

Outreach and engage patients whom are high risk, post-discharge, and/or requiring additional care management support, ensuring they have Primary Care Provider (PCP) follow up appointments scheduled and all care gaps are closed Collaborate with care team members and external vendors to support patient care (ie: receipt of durable medical equipment (DME) and home health services Request medical records from a variety of physicians and healthcare systems enabling the continuity of care for both PCPs and members of the interdisciplinary care team Outreach, screen and escalate patients to nursing and social work team members based on the unique needs of patients Assist nursing and social work team members with patient follow up, proving tools and resources at their direction Monitor stable patient populations at the direction of nursing and social work team members Address open care gaps with patients through collaborative relationships with patients, ensuring supporting adequate documentation is available with the patient’s medical record Coordinate with local community resources as needed to support both the physical and psychosocial needs of patients Collaborate with multi-disciplinary team members to provide best in class patient care and improved outcomes Participate in special initiatives at the direction of market leaders

Summit Health

Virtual Triage RN

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

New York

We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care. Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.

When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care. Please Note: We will only contact candidates regarding your applications from one of the following domains: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com.

Education/Certifications/Licenses: Associate Degree required; BSN preferred NY current state licensure as a RN Adult internal medicine experience required BLS Certified Completes competency skill checklist within first 3 months. Excellent interpersonal and communication skills, both written and verbal Strong computer skills, EMR experience strongly preferred Ability to multi-task and handle desktops of more than 1 provider Performance Standards for Specialty Knowledge, Skills & Abilities: Prior medical office experience Excellent customer service skills Ability to plan, prioritize, and complete delegated tasks in a reasonable span of time Strong in both verbal and written communication Strong knowledge of EMR, computer programs, and good typing skills Excellent data entry skills Knowledge of Excel a plus Bilingual Spanish a plus Completes competency skill checklist within first 3 months Remain fully and appropriately accessible during scheduled work hours Report on-site to designated work location as necessary when requested based on business needs Communicate regularly and effectively with team members and manager Maintain professional remote office environment free of background noise or distraction when on calls or attending virtual meetings Comply with all company rules, policies, practices and instructions that would otherwise apply if working on-site at work location Maintain a safe and secure remote work environment and patient confidentiality at all times

Review provider inboxes and schedule appointments Review medication refill requests and determine need for urgent renewal Respond to portal messages Triage patient calls to assess the severity of a patient’s condition Obtain/review relevant medical history Direct patient to the most appropriate level of care based upon the information provided (advise patient to seek emergency treatment, schedule an appointment for the patient with the primary care provider, APP or specialist, or recommend over the counter treatment for basic symptom management) Communicate status of the patient to appropriate/affiliated provider or specialist Educate the patient/family on disease or symptom management Review labs/imaging for critical values and communicate findings with provider in a timely manner Administer vaccines and medications Manage the clinical functions and support the department in the absence of the Associate Clinical Manager Administer tests/procedures/treatments- EKG, nebulizer, urinalysis, urine cultures, rapid flu/strep/covid, throat culture/nasal swab, urinary catheterizations Assist physicians as needed with clinical procedures Knowledgeable of MA/LPN workflow Knowledgeable of vaccine schedules, medications, drug calculations Assists the manager with analyzing reports, gaps and recommends opportunities for improvement

Highmark Inc.

Intake Coordinator

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

None Required

State License:

Pennsylvania

This job captures all inbound inquires for utilization management review from providers and pharmacies. The incumbent assesses the request, conducts all necessary research such as verifying benefit coverage for the member, and then creates the case (data entry) in Highmark's Utilization Management system for Prior Authorization clinical review. Ensures all accurate information is entered at the onset of the process to ensure adherence to all regulatory compliance requirements and service level agreements. The requests may come via fax, Predictal Availity portal and/or service form inquiry. At times may require follow-up communication with the requestor's office (physicians or pharmacists). This role may be required to make outbound calls and/or triage cases if inventory levels require support.

Required: 1 year of Customer Service experience 1 year of Healthcare Industry ​SKILLS: Possess good written and oral telephonic communication skills Ability to navigate through multiple systems simultaneously Knowledge of administrative and clerical procedures and systems such as word processing, managing files and digital fax Ability to interact well with peers, supervisors, and customers Problem-Solving Knowledge of principles and processes for providing customer service. This includes customer needs assessment, meeting quality standards for services. EDUCATION Required: High School/GED LICENSES or CERTIFICATIONS Required: None

Obtain requests from provider or pharmacy via fax, provider portal or service form inquiry. May obtain requests from provider or pharmacy by phone in some areas of the organization. Use multiple software systems and various resource sites to determine member plans and requirements. Gather all required documentation including verification of benefit eligibility. Build cases in the utilization management system. Use knowledge of process and judgement to evaluate identified cases that require additional notification to member, provider, and/or pharmacist. At times, outreach to providers and/or pharmacists may be required to obtain additional information. Ensure accuracy of data entry to prevent compliance and/or downstream process issues. Other duties as assigned or requested.

Highmark Inc.

Payment Integrity Clinician - (Remote)

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Pennsylvania

This job requires the ability to identify issues related to professional and facility provider claims data including determining appropriateness of code submission, analysis of the claim rejection and the proper action to complete the retrospective claim review with the goal of proper and timely payment to provider and member satisfaction. The incumbent is responsible for the implementation of effective Payment Integrity strategies on a pre-payment and retrospective claims review basis. Review process includes a review of medical documentation, itemized bills, and claims data to assure appropriate level of payment and resource utilization. It is also used to identify issues which can be used for education of network providers, identification and resolution of quality issues and inappropriate claim submission. The incumbent is expected to utilize specialized skills and knowledge to achieve successful and measurable outcomes. Will monitor and analyze the delivery of health care services in accordance with claims submitted, and analyzes qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction. Will be expected to identify potential discrepancies in provider billing practices and intervene for resolution and education or if necessary involve Special Investigation Unit or the Utilization Management area.

Required: Associate's Degree in Nursing Substitutions: None Preferred: Bachelor's Degree in Nursing Required: 3 - 5 years of related, progressive experience in a clinical setting Preferred: 1-3 years of experience in Managed Care RN’s with CIC coding experience RN's with claims experience. Required: Registered Nurse Preferred: Certified Medical Coder or related SKILLS: Demonstrated ability to solve issues that are complex in nature with minimal direction and latitude to proceed on some actions or decisions

Implement the pre-payment and retrospective review processes that are consistent with established industry and corporate standards and are within the Payment Integrity Clinician’s professional discipline. Effectively function in accordance with applicable state, federal laws and regulatory compliance. Implements all reviews according to accepted and established coding criteria, as well as other approved guidelines, payment and medical policies. Promote quality and efficiency in the delivery of review services. Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws. Practice within the scope of ethical principles. Identify issues which can be used to educate professional and facility providers and vendors for the purpose of streamlining and improving processes. Develop and sustain positive working relationships with internal and external customers. Act as a resource and subject matter expert to colleagues with less experience on a frequent basis to problem solve through Payment Integrity Review issues that would be considered of medium to high degree of complexity. Ability to visualize, articulate and solve complex problems representative of a broad range of service and claim scenarios. Other duties as assigned. Including, but not limited to additional project related responsibilities on a frequent basis that are considered small to medium in nature. Expectation is to drive the assigned project to completion which would include educating the Payment Integrity team. Project assignment is in addition to performing daily Payment Integrity job responsibilities.

EXL Services

Case Management Clinical Quality Analyst, Registered Nurse

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

The Case Management (CM) Clinical Quality Analyst oversees quality monitoring for the CM program, assessing staff performance and ensuring regulatory compliance. This role conducts audits, provides feedback, and collaborates with leadership to analyze performance data, identify trends, and recommend improvements. As a quality expert, they drive excellence in case management services through data-driven insights and continuous process enhancement.

Required: Current, unrestricted RN license in the state of residence and ability to obtain multi-state licensure required Case management certification highly desirable (CCM preferred) Clinical quality certification highly desirable (CPHQ preferred) Current DOD Security Clearance (preferred) or ability to obtain DOD Security Clearance US Citizenship status Bachelor’s degree in nursing from an accredited college, university, or school of nursing 5+ years of clinical RN experience in in a clinical role 3+ years of experience as a RN case manager at a health plan highly desirable 3+ years participating in performance improvement or quality improvement projects Proficient in Microsoft Office product suite (Word, Excel, PowerPoint, Outlook, Teams and shared folders) Experience working in an NCQA accredited Case Management program Preferred: Ability to apply continuous quality improvement concepts and methodologies to effectively monitor, assess, and communicate effectiveness of case management processes Experience with or strong working knowledge of NCQA Case Management accreditation standards Knowledge of payor issues, including TRIHEALTH benefits and contract limitations, provider network issues, and case management initiatives Strong and highly effective communication skills (verbal, written, presentation, interpersonal) Strong systems-oriented analytical, organizational, critical thinking, and analysis skills Knowledgeable in compiling, organizing, and analyzing data and proficiency with technology, spreadsheet analysis, reporting and graphing tools Ability to work effectively in a cross-functional team environment and adapt to changing program or organizational priorities Ability to manage multiple simultaneous work demands remotely in an effective and professional manner; ability to reset priorities to meet deadlines Knowledge of case management industry best-practices, patient-centered care concepts, current professional standards of case management, and accreditation standards

Collaborate with management team to develop or adapt audit tools and reports as needed to effectively conduct, document, and communicate audit activities. Contribute to the development of standardized auditing process and schedule consistent with department policy. Conduct routine case review audits to identify and address opportunities for improvement. Analyze, track, and trend staff audit results; prepare written feedback for manager to assist with performance improvement and staff development. Analyze individual trends based on monitoring results and provide recommendations to leadership team. Analyze satisfaction survey results and case management complaints to identify opportunities to improve beneficiary experience with the case management program and summarize results for CMQIC. Actively identify and make recommendations on ideas to improve the quality effectiveness and efficiency of departmental functions; meet regularly with management team to review issues and proposed solutions to gain commitment on recommendations. Work with operational teams to monitor the effectiveness and efficiency of any process changes made for quality improvement. Identify gaps in performance requiring additional training and collaborate with CM Trainer to develop mitigation plan. Evaluate current processes, compare to relevant accreditation standards and standards of practice, and identify gaps in compliance or performance, and recommend improvements. Participates in the development and distribution of accreditation best practices; organizes and participates in readiness assessments in preparation for accreditation survey submissions. Provide consultation to team on quality improvement processes and performance improvement methodologies.

Valor Healthcare, Inc.

Remote Senior Program Manager - Nurse Call Center

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

None Required

State License:

Virginia

Valor Healthcare is looking for a senior program manager to join our proposal team for a government contract to support the Global Nurse Advice Line (NAL) which is a service to Military Health System (MHS) eligible beneficiaries. Position Summary The Global NAL will provide access to telehealth registered nurses for triage services, self-care advice, and general health inquiries 24 hours a day, 7 days a week. The NAL also offers customer service and care coordination services to include, provider locator support, specified military treatment facility appointing services, urgent care referral submissions, and customized military treatment facility transfers to support the military treatment facility’s capability for eligible MHS beneficiaries. The ideal candidate will have extensive experience in supervisory healthcare call centers or nurse triage positions with strong leadership and communication skills in implementing programs and projects.

Minimum of 10 years of progressive project and/or program management experience, with a strong emphasis on healthcare call center or nurse triage program management. Proven experience in supervisory positions, with the ability to lead, motivate, and track performance in a heavy volume setting. Bachelor’s degree in healthcare management, business administration, communication, IT, social science, or related field. Demonstrated experience managing and implementing programs, including identifying, maintaining, and/or adjusting the resources; overseeing the formal planning, tracking, and reporting of program performance. Must have served in supervisory positions and show examples of how the individual has applied strong leadership, interpersonal, organizational, and communication skills in implementing programs and projects. US Citizenship is required.

Program Leadership: Lead and supervise a team of healthcare professionals, demonstrating strong leadership, interpersonal, organizational, and communication skills. Program Implementation: Manage the implementation of nurse triage programs, including resource identification, allocation, maintenance, and adjustments as needed. Formal Planning: Develop comprehensive plans for program execution, ensuring that all aspects are well-defined and tracked. Performance Tracking: Oversee the formal tracking and reporting of program performance metrics to ensure alignment with organizational goals. Quality Assurance: Maintain the highest standards of patient care and quality assurance within the call center operations. Regulatory Compliance: Ensure that all programs and activities adhere to relevant healthcare regulations and guidelines. Collaboration: Collaborate with cross-functional teams to ensure the success of healthcare programs and projects.

Valor Healthcare, Inc.

Remote Quality Assurance Program Manager - Nurse Call Center

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

None Required

State License:

Virginia

Valor Healthcare is looking for a Quality Assurance program manager to join our proposal team for a government contract to support the Global Nurse Advice Line (NAL) which is a service to Military Health System (MHS) eligible beneficiaries. Position Summary The Global NAL will provide access to telehealth registered nurses for triage services, self-care advice, and general health inquiries 24 hours a day, 7 days a week. The NAL also offers customer service and care coordination services to include, provider locator support, specified military treatment facility appointing services, urgent care referral submissions, and customized military treatment facility transfers to support the military treatment facility’s capability for eligible MHS beneficiaries. The ideal candidate will have extensive experience in quality assurance programs in call center or healthcare settings with strong leadership and communication skills in implementing programs and projects.

Bachelor’s degree in healthcare management, business administration, communication, IT, social science, or a related field Minimum of 3 years of experience managing a QA program. Minimum 3 years of experience in a clinical setting required Minimum 3 years of experience in QA within healthcare or telehealth settings Proven experience in supervisory positions, with the ability to lead, motivate, and track performance in a heavy volume setting. Ability to develop and implement QA protocols and conduct regular reviews. Show examples of how the individual has applied interpersonal, analytical, organizational, and communication skills in managing a QA program. Demonstrate knowledge of QA best practices. Knowledge of quality metrics, auditing processes, and performance improvement methodologies. US Citizenship is required.

Responsible for monitoring the quality assurance and related processes. Coordinating QA initiatives and credentialing activities and reporting out to the business regarding updates and findings. The ideal candidate will be highly analytical and capable of communicating effectively with a wide variety of audiences. Program Leadership: Lead and supervise a team of healthcare professionals, demonstrating strong leadership, interpersonal, organizational, and communication skills especially in any QA areas. Program Implementation: Manage the implementation of nurse triage programs, including resource identification, allocation, maintenance, and adjustments as needed. Formal Planning: Develop comprehensive plans for program execution, ensuring that all aspects are well-defined and tracked. Performance Tracking: Oversee the formal tracking and reporting of program performance metrics to ensure alignment with organizational goals. Quality Assurance: Maintain the highest standards of patient care and quality assurance within the call center operations. Regulatory Compliance: Ensure that all programs and activities adhere to relevant healthcare regulations and guidelines. Collaboration: Collaborate with cross-functional teams to ensure the success of healthcare programs and projects.

Optum

Telephonic RN Case Manager - Remote from a Compact State - Case Management

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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.

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. As an RN Telephonic Nurse Case Manager, you will be responsible for clinical operations and medical management activities across the continuum of care from assessing and planning to implementing, coordinating, monitoring and evaluating. You will also be responsible for providing health education, coaching and treatment decision support for members. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. The schedule for this position includes 2 days per week where you will be expected to work until approximately 8pm, based on member availability.

Required Qualifications: Active, unrestricted RN license in a compact state 3+ years of clinical experience (any setting) Computer proficiency utilizing MS Office (Word, Excel, PowerPoint and Outlook), including the ability to type and talk at the same time while navigating a Windows environment Reside in a location that can receive a UnitedHealth Group approved high speed internet connection or can leverage existing high - speed internet service Access to dedicated work space from home for in home office set up Preferred Qualifications: BSN Certified Case Manager (CCM) ICU, Cardiology or Critical Care experience Telephonic case management experience Experience with discharge planning Experience in a remote position Bilingual - English/Spanish Solid working knowledge chronic medical diagnoses (CHF, COPD, diabetes, etc.) All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Making outbound calls to assess members' current health status Identifying gaps or barriers in treatment plans Providing patient education to assist with self-management Interacting with Medical Directors on challenging cases Coordinating care for members and services as needed (home health, DME, etc.) Educating members on disease processes Encouraging members to make healthy lifestyle changes Utilizing Milliman criteria to determine if patients are in the correct hospital setting Making "welcome home" calls to ensure that discharged member receive the necessary services and resources Documenting and tracking findings

Sedgwick Government Solutions

Clinical Quality Management Specialist II (Remote) 2025-1419

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Georgia

Sedgwick Government Solutions is a fully owned subsidiary of Sedgwick. Sedgwick is a leading global provider of technology-enabled risk, benefits, and integrated business solutions. Taking care of people is at the heart of everything we do. Millions of people and organizations count on Sedgwick each year to take care of their needs when they face a major life event or something unexpected happens. The company provides a broad range of resources tailored to clients' specific needs in casualty, property, marine, benefits, and other lines. At Sedgwick, caring counts; through the dedication and expertise of more than 27,000 colleagues across 65 countries, the company takes care of people and organizations by mitigating and reducing risks and losses, promoting health and productivity, protecting brand reputations, and containing costs that can impact the bottom line. www.sedgwick.com Privacy | Sedgwick Terms and Conditions | Sedgwick

Are you interested in empowering and sustaining positive and measurable differences in the health of individuals? Does the thought of joining a team of exceptionally talented quality specialists inspire you? Do you enjoy using your excellent analytical and writing skills to ensure client requirements are met by the consistent, reliable execution of work? Do you thrive in performing audits to ensure performance metrics are met and high-quality care is sustained? We believe in helping those with work-sustained illnesses and injuries to live their best life by providing case management and support to workers, providers, employers, and claims staff. As a Clinical Quality Management (QM) Specialist II, you will work remotely in your home office from Monday to Friday, 8AM - 5PM Eastern Time and be responsible for supporting the SGS Quality Management System and the activities of the SGS Quality Improvement committees. This role involves supporting the Clinical Operations teams to ensure compliance with QMS and client contracts. The Clinical QM Specialist II identifies requirements and creates processes to ensure consistent and reliable execution of work. They coordinate the creation of controlled documents such as Standard Operating Procedures and Work Instructions, perform audits to meet performance metrics, and address internal and client concerns. Additionally, the Clinical QM Specialist II tracks and mitigates risks, facilitates continual improvement by leading improvement projects, and supports contract managers and the analytics team in preparing quality assurance reports.

Bachelor's or Master's Degree preferred in Healthcare, Nursing, Health Administration, or a related field Registered Nurse, licensed in any state, with national certification in a relevant field 5 years related clinical experience with a minimum of two (2) years adult medical/surgical nursing experience and a minimum of two (2) years case management experience in the workers’ compensation arena OR have a minimum of one (1) year of adult medical/surgical nursing experience and three (3) years of case management experience in the workers’ compensation arena. At least 2 years experience with Quality Management including project management, quality improvement, corrective action, auditing, and/or staff education. Experience with Federal Employee Compensation Act (FECA) and FECA-related issues preferable, as applicable. Nationally recognized Quality-related professional certification such as Certified Professional Healthcare Quality or Six Sigma (preferred). Experience with quality-related certification/accreditation such as ISO 9001-2015 Quality Management System or URAC. Experience in Workers' Compensation, Disability Management, or related industrial health environment (preferred). Ability to pass a preliminary credit and background check

Supports the Clinical Operations Team serving as a clinical resource for all program business units for quality assurance, clinical escalation and training. Performs clinical document reviews, identifies deficiencies, errors and collaborates with clinical professionals on remediation. Work with internal partners, such as Training, Program Management, Case Management, Analytics, and Information Technology, to bring creative solutions to meet corporate goals, and achieve client requirements. Work with external stakeholders and clients to ensure contract requirements and program quality management activities are successfully carried out. Collaborate with SGS managers and teams regarding analysis, updates, and recommendations for modifications for procedures and processes to continually improve operations and protocols. Assist with the collection and summary of data in collaboration with SGS Quality Committees, identify opportunities for improvement, and present findings. Understands each contract's clinical quality assurance requirements and monitors compliance, in collaboration with the SGS, clinical leadership, analytics and management teams. Monitors and analyzes clinical outcomes in relation to goals and contractual requirements, in collaboration with the SGS analytics and management team. Supports standard and ad hoc audits, as directed by clinical leadership quality committees. Provides feedback and coordination of improvement of quality tools, such as job aids, work instructions, and audit checklists. Assists in the identification of program deficits and coordinates team training and monitoring of corrective actions. Deploys and oversees performance improvement activities. Tracks client complaints and issues to resolution, in collaboration with Manager. Identifies new areas that need quality monitoring, on a short-term or continuous basis. Assists in activities to prioritize improvement initiatives. Assumes responsibility for related duties as required or assigned.

Sedgwick Government Solutions

Quality Management Specialist (Remote) 2025-1418

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Georgia

Sedgwick Government Solutions is a fully owned subsidiary of Sedgwick. Sedgwick is a leading global provider of technology-enabled risk, benefits, and integrated business solutions. Taking care of people is at the heart of everything we do. Millions of people and organizations count on Sedgwick each year to take care of their needs when they face a major life event or something unexpected happens. The company provides a broad range of resources tailored to clients' specific needs in casualty, property, marine, benefits, and other lines. At Sedgwick, caring counts; through the dedication and expertise of more than 27,000 colleagues across 65 countries, the company takes care of people and organizations by mitigating and reducing risks and losses, promoting health and productivity, protecting brand reputations, and containing costs that can impact the bottom line. www.sedgwick.com Privacy | Sedgwick Terms and Conditions | Sedgwick

Are you passionate about ensuring quality and compliance in a dynamic environment? Join SGS as a Quality Control Analyst (QCA) and play a crucial role in supporting our Quality Management System (QMS) for a high-profile client. The Quality Management Specialist (QMS), you will work from your home office from Monday to Friday, 8AM - 5PM Eastern Time and be part of a collegial team that is responsible for supporting the Quality Management System (QMS) for a high-profile client. This role involves both clinical and non-clinical tasks to ensure compliance with QMS and client contracts. The QMS identifies requirements and creates processes to ensure consistent and reliable execution of work. They coordinate the creation of controlled documents such as Standard Operating Procedures and Work Instructions, perform audits to meet performance metrics, and address internal and client concerns. Additionally, the QMS tracks and mitigates risks, facilitates continual improvement by leading improvement projects, and supports contract managers and the analytics team in preparing quality assurance reports.

Bachelor's or Master's Degree preferred in Healthcare, Nursing, Health Administration, or a related field Registered Nurse, licensed in any state, with national certification in a relevant field Minimum of 1-2 years experience with quality improvement, corrective action, auditing, and/or staff education Familiarity with government contracting and requirements preferred. Demonstrated ability to ensure quality deliverables in accordance with the PWS, and to ensure that all required performance standards are met Experience with nursing and/or vocational rehabilitation case management in the FECA or other workers compensation arena preferred. A proven track record in meeting deliverable schedules and performance requirements for programs of a similar size and scope is required. Attention to detail, timetables, and commitment to completing tasks Proficiency in computer use, including Microsoft Office Word, PowerPoint, Excel, and Outlook, strong analytical skills in interpreting data, and the ability to multi-task effectively. Well organized, efficient, and able to work independently and within a team Reliable High-Speed Cable or Fiber Optic Internet service and Internet Router in established home office Excellent Communication Skills via Phone, E-Mail, Text, Verbal, Documentation Skills, ability to create and complete comprehensive, accurate, and constructive written reports Ability to pass a preliminary credit and background check Ability to obtain and maintain public trust federal security clearance(s) Ability to travel as required

Provides input to SGS managers and teams regarding analysis, updates, and recommendations for modifications for procedures and processes to continually improve operations and protocols. Assist with collection and summary of data in collaboration with SGS Quality Committees, identifies opportunities for improvement, and presents findings. Understands each contract's clinical quality assurance requirements and monitors compliance, in collaboration with the SGS analytics and management teams. Monitors and analyzes clinical outcomes in relation to goals and contractual requirements, in collaboration with the SGS analytics and management team. Performs standard and ad hoc audits of case management activities, as directed by quality committees. Provides feedback and coordination of improvement of quality tools, such as audit checklists and instructions. Assists in the identification of program deficits and coordinates team training and monitoring of corrective actions. Assists with performance improvement activities. Tracks client complaints and issues to resolution, in collaboration with the Account Managers. Identifies new areas that need quality monitoring, on a short-term or continuous basis. Assists in activities to prioritize improvement initiatives. Investigates and incorporates national best-practice interventions into SGS processes in conjunction with clinical management. Ensures that documentation produced and/or processed complies with federal regulations and contractual requirements. Assumes responsibility for related duties as required or assigned.

Sedgwick Government Solutions

RN Telephonic Triage Nurse Case Manager (Remote) 2025-1395

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Sedgwick Government Solutions is a fully owned subsidiary of Sedgwick. Sedgwick is a leading global provider of technology-enabled risk, benefits, and integrated business solutions. Taking care of people is at the heart of everything we do. Millions of people and organizations count on Sedgwick each year to take care of their needs when they face a major life event or something unexpected happens. The company provides a broad range of resources tailored to clients' specific needs in casualty, property, marine, benefits, and other lines. At Sedgwick, caring counts; through the dedication and expertise of more than 27,000 colleagues across 65 countries, the company takes care of people and organizations by mitigating and reducing risks and losses, promoting health and productivity, protecting brand reputations, and containing costs that can impact the bottom line. www.sedgwick.com Privacy | Sedgwick Terms and Conditions | Sedgwick

Overview Are you looking to make a difference by providing high-quality care with a personal touch that impacts the lives of workers? Would you like to be part of a team focused on empowering and sustaining health by supporting the occupationally injured? Do you have the professional nursing, case management experience, and licenses necessary to help further establish Sedgwick Government Solutions as a leading case management company? Do you have experience with workers' compensation? We believe in helping those with work-sustained illnesses and injuries to live their best life by providing care, health management, and support through our highly skilled team of home-based Telephonic Triage Nurse Case Manager RN.

Hold a current, active unrestricted license to practice nursing within the United States, Puerto Rico, and other US territories; Compact License Preferred Bachelor of Science in Nursing preferred. 5 years related clinical experience in medical case management, workers' compensation, occupational health, AND/OR a comparable field. with a minimum of two (2) years of adult medical/surgical nursing experience AND a minimum of two (2) years of case management experience in the workers’ compensation arena OR, have a minimum of one (1) year of adult medical/surgical nursing experience and three (3) years of case management experience in the workers’ compensation arena. Preference is given to Nurses with National Certification in case management or related fields. National Certification may be obtained within 12 months of the date of hire Responsible for having reliable High-Speed Cable or Fiber Optic Internet service and Internet Router in established home office Attention to detail, timetables, and commitment to completing tasks Computer literacy, including MS Word, Excel, and Outlook Experience with Microsoft Windows and computer savvy Ability to utilize a case management system, Electronic Medical Record, or other electronic platform Ability to utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services. Demonstrated ability to use Microsoft applications and demonstrate basic electronic technology understanding Must be well organized, efficient, and able to work independently and within a team Must have Excellent Communication Skills via Phone, E-Mail, Text, Verbal, and Documentation Skills and provide 24-hour follow-up to all communication Prior to hiring and training able to pass a preliminary credit and background check

As a Telephonic Triage Nurse Case Manager RN, you will work independently in your home office setting while still being part of a supportive team nationwide. Through the application of a unique mix of experience and certification, you will support federal workers with diagnoses in the fields of occupational-related injuries and illness, emphasize timely facilitation and coordination of diagnosis, and be involved in the acute phases of treatment and support. Your broad responsibilities will include developing a case management plan for each injured worker throughout the various stages of recovery while tracking in a database patient improvement goals. You will implement integrated medical disability case management services with the goal of preventing, minimizing, or overcoming a disability as well as providing medical expertise and serving as the critical communication link between the parties involved in any medical disability case.

Managed Resources, Inc (MRI)

Clinical Appeals Nurse (medical necessity)

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

Full-time | Remote | Permanent Managed Resources is a leading consulting group assisting healthcare organizations nationwide in optimizing its revenue cycle management through review, recovery and educational programs. Please read the below description and apply if you meet the requirements and would like to hear more about this opportunity with Managed Resources! Purpose: Our Clinical Appeals Review services consists of reviewing and appealing for reconsideration of medical services that may have been denied, either in part, or in whole, during the initial claims determination phase. Denial of payment may be based on insufficient medical record documentation to support the level of care, billing/coding disputes, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment rendered is not Medically Necessary. Reports to: Assistant Manager of Clinical Appeals Accountabilities: Write quality appeal letters to achieve maximum overturn rate. Ensure workload is completed in an efficient and timely manner.

RN License is required Certification in Case Management, Legal Nurse Consulting, or Coding a plus. Five years of acute hospital experience is mandatory. Possess knowledge and experience with national clinical criteria applied in case management including InterQual and Milliman standards. Working knowledge of billing codes, Revenue Codes, CPT’s, etc. Experience with case management software such as Midas preferred. Experience and knowledge of managed care contracts, account receivables and revenue cycle functions. Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standards. Experience and success in appealing managed care denials and underpayment decisions. Ability to examine financial and clinical data trends and provide recommended action steps to resolve.

The Clinical Appeals Review Nurse will review the case, and determine the potential for a Provider Appeal, on the denied claim. The request for reconsideration will be written in an objective narrative form, utilizing appropriate formatting, English grammar, current nationally accepted criteria, medical literature if applicable, healthcare statutes and clinical judgment. Once completed, the letter will be forwarded to the Clinical Appeals Manager for review and approval and then to the payer source for reconsideration. The Clinical Appeals Review nurse will provide the application of current prudent clinical judgment for the case's purpose. The diagnosis, treatment of an illness, injury, and/or disease of its symptoms, will be in accordance with generally accepted standards of medical practice. The clinical review of the denied stay will be evaluated in terms of type, frequency, extent, site and duration of patient’s illness and/or injury or disease. The clinical review of the case will not be based on convenience factors for the patient, facility, physician, and/or other health care professionals. The Clinical Appeal Review Nurse will receive appropriate documentation which includes previous determination information and complete medical record for review. The review will be written in a narrative, professional manner, with an appropriate review of the clinical facts. The letter will include the medically appropriate reasons for the reconsideration of the denial. Once the review is completed, the Clinical Appeal Review Nurse will forward the reconsideration letter to the corporate office, through a secure website, for review by the Clinical Appeals Manager. Once approved, the letter is mailed with attached medical records to the appropriate entity. The Clinical Appeals Review Nurse will then update the applicable logs for appropriate follow up purposes including payor requested reports.

Vega Consulting Solutions, Inc

Utilization Management RN /LPN

Posted on:

March 24, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Maryland

Our direct Healthcare client in Baltimore is seeking a Utilization Review Specialist. This is a 9-month ++ contract. MUST HAVE AN ACTIVE RN / LPN, MCG, and Altruista/ HealthEdge. Job Summary Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist, will analyze clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.

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. Education Level: Bachelor's Degree Education Details: Nursing Experience: 5 years Clinical nursing experience 2 years Care Management Preferred Qualifications: Working knowledge of managed care and health delivery systems. Working knowledge of nd Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource. Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint, Proficient Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient Licenses/Certifications: RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req or CNS-Clinical Nurse Specialist Pref

50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, CareFirst Medical Policy, all guidelines and departmental SOPS to manage their member assignments. 30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination. 20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.

TriWest Healthcare Alliance

Applied Behavior Analysis - Quality Monitor Clinician

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Arizona

Taking Care of Our Nation’s Heroes. It’s Who We Are. It’s What We Do. Do you have a passion for serving those who served? Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®! Our job is to make sure that America’s heroes get connected to health care in the community. At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, *IL, KS, LA, MD, *MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veteran, Military Spouse or Military Affiliated are encouraged to apply! Reviews medical documentation and claims to ensure Applied Behavior Analysis (ABA) provider compliance with contract and program requirements for the Autism Care Demonstration (ACD) in the TRICARE West Region. The role helps to ensure quality care is delivered for TRICARE beneficiaries by identifying evaluating medical records and claims retrospectively for potential quality, safety, utilization, or billing issues by using organizational, national, and TRICARE standards for consistency. Supports activities of peer review and quality and safety committees.

Required: Registered Nurse or Licensed Clinical Social Worker, with current unrestricted license in appropriate state U.S. Citizenship Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation. 3 years clinical experience (pediatrics, and/or behavioral health) Preferred: Bachelor’s degree in nursing or other health care field 1 year experience in clinical document auditing 1 year experience with data analysis and reporting Experience with Applied Behavior Analysis (ABA) or with General knowledge of Medicare, TRICARE, or other government healthcare programs

Clinical review of ABA provider documentation to assess quality and adherence to program requirements. Identifies Potential Quality Issues (PQIs) by performing a timely review of the medical records. Identifies opportunities for provider education and accomplishes outreach to providers/groups with inconsistencies or errors identified. Assists the company with the initiation of progressively more severe administration action, commensurate with the seriousness of the identified problems Administrative review of ABA claims for detection and prevention of fraud and abuse to the TRICARE Program and beneficiaries, to include a review of suspect billing practices and document risks to determine improper payments in the ACD program. Identification and initiation of recoupments of claims dollars paid Develops peer review cases and other quality improvement activities for monitoring deviations from accepted standards of care and suggesting corrective action plans. Collaborate with Clinical Quality Management (CQM) on Practice Pattern Analyses if applicable. Identifies focused review topics to Clinical Quality Management Leadership. Performs focused study data collection, reporting, analysis, and makes recommendations for improvement. Refers cases for review as appropriate to Program Integrity, Case Management, Care Coordination, Population Health Improvement, Disease Management, Congressional Relations & Customer Grievances and other TriWest departments. Participates on quality committees. Reviews Potential Quality Issues with Medical Directors when appropriate. Performs other duties as assigned. Regular and reliable attendance is required.

TRILLIUM HEALTH RESOURCES

Population Health Program Nurse

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

North Carolina

Trillium Health Resources is a local governmental agency (LME/MCO) in North Carolina that manages serious mental health, substance use, and intellectual/developmental disability services. Serving in 46 counties, we help individuals and their families strengthen well-being and build foundations for a healthy life. Join our team as we empower others to live their best lives by providing access to quality healthcare. We offer a challenging, engaging work environment where staff take home more than a paycheck. Every day, we see the results of our dedication – in the smiles of children on our accessible playgrounds and in the pride on the face of an adult cooking a meal for the first time. Working at Trillium Health Resources is more than just a job; it is an opportunity to make a direct impact on the communities we serve. At Trillium, we know that empowering others begins with supporting and developing our team. That’s why we offer competitive benefits and work-from-home flexibility so that our employees thrive outside of the office. We’re also committed to building a diverse, inclusive culture where all employees have the potential to grow professionally and personally.

Trillium Health Resources has a career opening for a Population Health Program Nurse! This position works to identify members that are appropriate for population health programs utilizing data informatics along with providing interventions and education to promote health prevention and promotion. This role demands a combination of clinical expertise, strong communication skills, and a deep commitment to advocating for vulnerable populations. Apply today!

Education: Registered Nurse. Registered Nurse (RN). Fully licensed by the North Carolina State Board of Nursing required. Experience: Minimum of two (2) years of experience working with the MH/SU/IDD population and at least three (3) years as a Registered Nurse. Knowledge of Quality Management, Utilization Management, and discharge planning procedures as well as experience using data analytics for population health management preferred. License/Certification: Registered Nurse (RN). Fully licensed by the North Carolina State Board of Nursing required. Must have a valid driver’s license. Location: Remote within North Carolina. Must reside in NC to be considered for remote status.

Enroll identified Trillium members into appropriate population health programs. Support the build-out and management of future population health programs as indicated. Engage members by identifying mission/goals and objectives of the program along with assisting in completing a thorough clinical background. Work collaboratively with members of the multidisciplinary team to develop tools and interventions designed to achieve optimal patient outcomes. Coordinate and facilitate with Care Management staff timely implementation of assessments, care plans, and appropriate interventions for identified member populations following established policies and procedures. Use a collaborative approach to assist the member with self-management goals and identifying barriers by addressing the total individual. Provide telephonic and/or in-person coaching and support to the members to encourage their efforts, identify barriers to progress and adjust the care plan as needed. Communicate and coordinate with other members of the interdisciplinary team as needed to ensure appropriate linkage to services. Monitor referrals, both internal and external, into population health programs ensuring members are enrolled following policies and procedures. Assist with performance tracking of KPIs and other quality performance measures of population health.

Apria Healthcare LLC

Chronic Account Manager - Remote

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

North Carolina

Apria Healthcare’s mission is to improve the quality of life for our patients at home. We are looking for empathetic, thoughtful, and compassionate people to meet the needs of our patients. Already an industry leader in healthcare services, we provide home respiratory services and select medical equipment to help our patients sleep better, breathe better, heal faster, and thrive longer.

The Chronic Account Manager is responsible for selling Negative Pressure Wound Therapy (North Carolina) and related services in the assigned sales territory. This role works closely with branch staff to focus efforts on increasing sales. In addition, the Chronic Account Manager - NPWT will work with the Vice President of NPWT to develop and execute specific strategies to achieve sales, customer satisfaction, and profitability goals.

Education and/or Experience: Current licensure as a Registered Nurse or Licensed Vocational Nurse in appropriate state of practice with at least 1 year of related experience. OR College degree or previous relevant job experience required. 3-5 Years of Experience in selling “service” or “commodity products” with demonstrated success. External sales experience preferred. SKILLS, KNOWLEDGE AND ABILITIES: Customer/Patient-Focused: Starts with the customer/patient and works backwards. Invests the time and energy to understand the customer/patients’ objectives, then ties all activities directly to the achievement of those objectives. Action-Oriented: Thrives as a self-starter who proactively senses and responds to problems and opportunities and requires minimal supervision. Collaborative: Loves teamwork. Colleagues love having them on their team. Works well across functions and groups. An Effective Communicator: Writes and speaks clearly, concisely and with a spirit of partnership. Actively informs and inspires with messaging. Speaks plainly and is transparent with business colleagues. Energetic & Passionate: Passion and energy for health and well-being is deeply founded in their desire to help others and to be a positive role model. Relationship Builder: Excel in getting people involved and building a network of contacts that allow them to multiply their influence on the organization. Certificates, Licenses, Registrations or Professional Designations: Must possess a valid and current driver’s license and auto insurance per Apria policy; may be required to drive personal vehicle. Computer Skills: Intermediate skills in Access, Excel, PowerPoint, MS Project, Visio, Word Language Skills: English (reading, writing, verbal) Mathematical Skills: Intermediate level mathematical proficiency, with a strong ability to understand, interpret and develop spreadsheet data. PHYSICAL DEMANDS: While performing the duties of this job, the employee uses his/her hands to finger, handle or feel objects, tools or controls; reach with hands and arms; stoop, kneel, or crouch; talk or hear. The employee uses computer and telephone equipment. Specific vision requirements of this job include close vision and distance vision. Must be able to travel by plane and automobile (if applicable). WORK ENVIRONMENT: While performing the duties of this job, the employee rarely is exposed to fumes or airborne particles, toxic or caustic chemicals. The noise level in the work environment is usually low to moderate.

Generates clinical demand, facilitates discharge of patients from Acute Care settings. Conducts daily sales calls to high potential case managers, doctors, wound care centers and other sales targets in assigned accounts as determined by the Vice President NPWT. Creates and maintains call plans to qualify new and maintain existing referrals to grow the business. Enters call plan and outcomes into the CRM system. Partners with the Vice President NPWT to develop and execute specific strategies and tactics to achieve sales quota, customer satisfaction and profitability goals. Collaborates with case managers, payers, referral sources, home health agencies and Apria intake staff to facilitate discharges. Obtains supportive documentation for clinical and financial patient care management and coordinates logistics of equipment for home delivery with patients and branch staff. Provides patient/caregiver initial education and documentation around usage of equipment and/or supplies for wound care and other therapies. Provides continuing education programs as needed to on-site hospital and payer case managers. Communicates follow-up information to case managers after patient discharge. Identifies and develops strategic relationships within the institution that will enhance patient care. Liaise with other Sales Reps and equipment manufacturers. Identifies opportunities for improvement in patient care. Participates in the institution's quality assurance/performance improvement initiatives as requested. Performs other duties as required.

Point32Health

RN Care Manager - Tufts Health Plan SCO (Brockton and surrounding communities)

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Massachusetts

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier. We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Bilingual Preferred The Care Manager - Nursing (RN CM) will ensure that all members receive timely care management (CM) across the continuum, including transitions of care, care coordination and navigation, complex case management, population health and wellness interventions, and disease/chronic condition management per department guidelines. The nurse care manager possesses strong clinical knowledge, critical thinking skills, and ability to facilitate a care plan which ensures quality medical care for the member. The RN CM works closely with the member, the caregiver/authorized representative, and providers to meet the targeted member-specific goals. Based on national standards for CM practice, the RN CM focuses on empowering the member to support optimal wellness and improved self-management.

COVID Policy Please note: We encourage all Point32Health colleagues to follow CDC guidance about COVID-19 vaccines, boosters, isolation and masking. Point32Health reserves the right to adjust its requirements in response to COVID-19 trends in the communities we serve. Education, Certification and Licensure: Registered Nurse with current unrestricted license in state of residence May be required to obtain other state licensure in states where Point32Health operates Bachelor’s Degree in Nursing preferred National certification in Case Management desirable Experience (minimum years required): 5+ years’ relevant clinical experience Experience in home care or case management preferred Proficiency in second language desirable Experience in specialty areas such as oncology, neurology, chronic condition/disease management a plus Skill Requirements: Skill and proficiency in technical concepts and principles; computer software applications Skilled in assessment, planning, and managing member care Advanced communication and interpersonal skills Independent and autonomous with key job functions Ability to address multiple complex issues Flexibility and adaptability to changing healthcare environment Ability to organize and prioritize work and member needs Demonstration of strong clinical and critical thinking skills Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel): Must be able to work under normal office conditions and work from remote office as required. Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations. Ability to make face to face visits (member home, provider practices, facilities) as needed to meet the member needs and produce positive outcomes Valid Driver’s license and vehicle in good working condition as some travel required May be required to work additional hours beyond standard work schedule. Other duties as assigned and needed by the department

Administer assessments, collaborate with the member/caregiver and providers to develop a plan of care, implement member-specific CM interventions, and evaluate plan of care and revise as needed. Facilitate program enrollment utilizing key motivational interviewing skills Provide targeted health education, proactive strategies for condition management, and communication with key providers and vendors actively involved in the member’s care Perform both telephonic and face to face outreach to assess barriers to wellness, medical, behavioral, and psychosocial needs of the member. Collaborate with member/caregiver and the facility care team to coordinate a safe transition to the next level of care, which includes but is not limited to ensure understanding post-hospital discharge instructions, facilitate needed services and follow-up, and implement strategies to prevent re-admission Performs case documentation in applicable CM system according to department and regulatory standards Collaborates and liaises with the interdisciplinary care team, to improve member outcomes (i.e., Utilization Management, Medical Director, pharmacy, community health workers, dementia care specialists, wellness, and BH CM) Attend and present (as appropriate), high risk members at interdisciplinary rounds forum Maintain professional growth and development through self-directed learning activities Other duties and projects as assigned.

Ingenovis Health

Clinical Services Leader

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Ohio

Ingenovis Health companies are sending the best healthcare talent to every corner of this country where hospitals and patients need medical attention. Through a combination of smart and nimble planning, Ingenovis Health is transforming the industry, creating a home for healthcare professionals from all disciplines to further their careers and find where they’re most needed. With the collective strength of our wide-ranging ecosystem of companies, Ingenovis Health is better positioned to secure our place as the home of healthcare talent.

Development and implementation of Clinical Service programs designed to achieve the company’s financial, customer and patient satisfaction goals by ensuring all brands of the company consistently deliver the most qualified professionals to clients.

EDUCATION and/or EXPERIENCE: Must possess a minimum of a Bachelor of Science in Nursing (BSN) and have a valid, clear license as a Registered Nurse. Master of Science in Nursing (MSN), preferred. A minimum of five years’ experience in a clinician role with 3 years in a leadership capacity within a health system or staffing agency environment. Comfortable giving high level presentations and with client interactions. Demonstrated experience in successfully leading teams. SKILLS: Candidates and incumbents need to have the following skills: Excellent verbal and written communication skills Computer literate with knowledge of Microsoft Word, Excel, and Outlook Working knowledge of Workday and Bullhorn preferable. Good organizational skills and time management skills are necessary. Must have strong interpersonal skills with an ability to handle sensitive and confidential situations. Must also have experience in building and motivating teams (hiring, coaching, counseling, etc.). Strong decision making and problem-solving skills including the ability to extrapolate from written procedures and policies. Aware of hospital/health care delivery staffing requirements and patient care needs in a variety of settings. Good prioritization and multi-tasking skills and the ability to work in fast-paced environment including the ability to work under tight deadlines. Position continually requires professionalism, poise, tact, and diplomacy. Requires the ability to work inter-departmentally with communication, leadership, and cooperation. Must have a flexible work schedule, be able to work occasional extended hours and travel. BEHAVIORS: Candidates and incumbents need to display the following behaviors: An ability to develop and maintain business relationships. The ability to maintain a calm and professional demeanor during high stress situations. A disposition to function in a team environment and to maintain confidentiality. Willingness to support the team and work alongside team members as may be needed. LEADERSHIP & ORGANIZATIONAL RESPONSIBILITIES: Requires ongoing coordination, communication, and/or team problem-solving between departments or functional areas for work production or service quality. CONTACTS: This position requires constant contact with clients and frequent contact with job candidates. It also requires regular internal contact with the sales, recruiting, human resources, and information technology departments. PHYSICAL REQUIREMENTS & ENVIRONMENTAL CONDITIONS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodation may be made when requested by the employee to enable individuals with disabilities to perform the essential functions. This position requires the incumbent to regularly utilize written and verbal communication skills, active listening skills, and to speak clearly and concisely. This position requires the incumbent to experience periods of prolonged sitting and to occasionally stand, walk, carry items, climb, reach, and lift up to 20 lbs. This position requires the incumbent to operate office equipment such as telephones, computers, fax machines and copiers and to grasp objects utilizing manual dexterity including hand/finger coordination.

In conjunction with appropriate stakeholders, build a Clinical Services program designed to ensure patient safety. May participate in Executive Leadership Team meetings and provide input to critical decisions as needed. Develops and maintains department budget and ensures department structure that meets expectations for a growing and dynamic company while maintaining Clinical Services best practices. Responsible for hiring and training for the department and evaluating staff performance. Work closely with Human Resources and Legal departments, to define policy and best practice standards for the company and its field employees, and to determine disciplinary actions and reporting obligations. in conjunction with HR, Legal, and Compliance departments, manage and address concerns with field employees including professional liability occurrences and other legal matters and applicable Board concerns. Provide structure and implement Quality Assurance program that applies consistent performance management for field staff. Oversee company’s Joint Commission certification for HealthCare Staffing company; ensure compliance with all standards and requirements through ongoing reporting, audits, and onsite reviews. Responsible for establishing an effective clinical liaison program with client clinical leadership across all brands. Coordinate with other Executives to advance production goals through consistent and efficient internal policies. Consistently looks for and implements continuous improvement steps to improve quality and efficiency. Provides structure and advisement to ensure standards are in place for appropriate placement, evaluation, and management of clinical staff. Understand, recommend, and advise internal project implementation teams on engagement approaches to deliver compelling programs for travelers, and manage internal communications supporting the campaigns. Define, gather, and interpret our internal channel performance metrics and traveler feedback to improve program(s) and communications effectiveness. Study and analyze data from multiple listening posts, including but not limited to NPS surveys, engagement surveys, social media groups, online forums and first party data. Partners with HR/Work Comp to improve the clinician safety program with awareness of influential healthcare policy. Cultivate national partnerships to support sales and client relations and build resources of support for corporate and company brands. Provides clinical expertise that supports sales and potential new client engagements. Function as an advisor as needed for internal and external clients and partners regarding staffing and clinical excellence. May attend national and local conferences and events as deemed appropriate to promote corporate brands and expand network of clients and partners. Foster career development and learning opportunities for clinicians. Actively look for new and innovative ways to engage our travelers and make recommendations on strategic and ever evolving engagement programs and processes. Partners with internal teams to support efficient workforce integration, job actions, and rapid assignments. Actively contributes to Quality Improvement meeting decision matrix for clinician retention and support Oversee all other applicable needs for Clinical program.

Molina Healthcare

Telephonic Case Manager (RN) - Illinois ONLY

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Illinois

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.

Opportunity to join Molina Healthcare working with our Medicaid members as a Case Manager. This is open to Illinois licensed RNs across the state who have experience working with patients with respiratory diagnosis like asthma, pulmonary hypertension, or COPD. This is a fully remote opportunity conducting assessments by phone to determine the resources we need to provide as well as case management for the member. Our ideal applicant would be someone who has experience doing case management/discharge planning in a managed care organization (MCO) like Molina and has been a RN for at least 5 years. Hours are Monday – Friday, 8AM – 5PM CST. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note as well as experience using a clinical documentation software program.

Required Education: Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred. Required Experience: 1-3 years in case management, disease management, managed care or medical or behavioral health settings. 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. Preferred Education: Bachelor's Degree in Nursing Preferred Experience: 3-5 years in case management, disease management, managed care or medical or behavioral health settings. Preferred License, Certification, Association: Active, unrestricted Certified Case Manager (CCM)

Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment. Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. Conducts face-to-face or home visits as required. Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Maintains ongoing member case load for regular outreach and management. Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members. Facilitates interdisciplinary care team meetings and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns. 25- 40% local travel required. RNs provide consultation, recommendations and education as appropriate to non-RN case managers. RNs are assigned cases with members who have complex medical conditions and medication regimens RNs conduct medication reconciliation when needed.

Medavie

Bilingual Nurse

Posted on:

March 23, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Nebraska

Emergency Medical Care Inc. (EMC) is a wholly owned subsidiary of Medavie Health Services (MHS) that manages and operates ground ambulance, air medical transport and the medical communications operations in Nova Scotia through a performance-based contract with the provincial government's Emergency Health Services (EHS) Operations division and the Department of Health and Wellness. As well, EMC operates TeleHealth/811 medical communications for Nova Scotia and Prince Edward Island for the Department of Health. We access all communities in Nova Scotia in a timely and efficient manner with our fleet of more than 180 ambulances and support vehicles operating out of 60+ stations. We respond to 165,000+ calls annually across the province, which are actively managed through the EHS Operations Medical Communications Centre, the hub of all emergency (911) and non-emergency (hospital transfers) medical calls. The EHS Operations LifeFlight program provides even greater accessibility by responding to patients on scene or through inter-facility transports by our critical care team via helicopter, fixed wing, or ground ambulance. In addition, paramedics in Nova Scotia participate in various programs both urban and rural such as community-based paramedic programs, collaborative emergency centres, and emergency preparedness and special operations, to name a few. There are lots of opportunities waiting for you in Nova Scotia. Apply now to learn more about our service and available positions.

TeleHealth Nurses provide telephone triage and professional nursing care to patients through the use of information and communication technologies, and with the support of computer-based decision support software, clinical guidelines, protocols and other resources. TeleHealth Nurses work from their private home office. Working 8-hour shifts on a rotating schedule creates a good work-life balance. During a regular work day, the TeleHealth nurse may receive up to 40 calls per shift. No two calls are the same - the TeleHealth Nurse will encounter a wide variety of health care concerns including but not limited to the fields of pediatrics, obstetrics, and geriatrics. TeleHealth leaderships provide on the job training, frequent feedback and coaching. We understand the challenges that come from working remotely so we ensure that support is available for the nurses 24 hours a day, 7 days a week

Clinical nursing experience, preferably in an acute care environment, such as Emergency Department, general medical-surgical or intensive care unit, and/or relevant community health setting, such as public health. Minimum 3 years of clinical experience (5 years preferred). An active license and good standing as a Registered Nurse with the provincial nursing body legislated to regulate and license nurses and compliance with all applicable laws pertaining to the practice of nursing in the province. Diploma from recognized and/or accredited nursing school. Bachelor degree is preferred. Excellent communication, telephone and customer relation skills. Good critical thinking, sound clinical decision-making and problem-solving skills. Basic knowledge and competence in the use of computers and keyboarding. Reliable wired internet connectivity utilizing approved High Speed DSL, Cable or FiberOp. Appropriate home space meeting requirements as cited in "Work at Home" guidelines. Ability to travel if needed. Fluency in English (oral and written) is required and fluency in English and French (oral and written) is preferred.

Navigates the guidelines and search functions, applies established policies and guidelines, assesses the patient's condition/situation and documents the assessment. Reviews recommendations to the caller which are congruent with nursing guideline standards and clinical judgment. Provides information which is clinically relevant and empowers the caller to make appropriate decisions, including the decision to self-care. Accurately and completely documents clinical and other relevant notes within the computer software program in a timely manner throughout and immediately after the call. Liaises effectively between caller and third party in critical situations, such as need for ambulance transport, police intervention, suicidal caller, suspected or actual child abuse or other situations in which information is not consistent or may be disputed. Adheres to time utilization guidelines and ensures that personal workflow supports the service to better meet the demand for Telecare services.

Lucet

Manager, Care Management

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Akansas

At Lucet, we are industry leaders in behavioral health, dedicated to helping people live healthy, balanced lives. Our purpose is to advocate for and improve the overall well-being of those we serve, through balanced treatment of the mind and body. When you join Lucet, you become a valued member of our team, serving more than 15 million people across the U.S. Our employees have a passion for helping others - and it shows. From entry-level employees to senior leaders, we are inspired by our members, putting them first in everything we do. From day one, you'll see firsthand the impact you have on our members, knowing you can make a true difference in their lives.

The Manager, Care Management provides strategic leadership, oversight, and direction to the Care Management team and supports quality improvement activities. This role is responsible for achieving key outcome measures for the care management program, ensuring compliance with Lucet policies, regulatory and accreditation standards, and meeting contractual performance guarantees. This role collaborates with internal departments and external stakeholders to deliver high-quality, efficient services and contributes to the development and implementation of programs, policies, and systems to enhance care management processes. The Manager directly supervises clinical team members, coordinates efforts across multiple teams, and ensures performance is effectively tracked and reported. On-call evening, weekend, and holiday supervision for after-hours staff may be required as needed.Utilize the components of the case management process including elements of comprehensive assessment, identification of targeted barriers to improvement, linking to needed professional and community resources, development of care plan, implementation of care plan, documentation of outcomes, iterative care plan review and adjustment based on outcomes, health stabilization, and patient graduation

Required Qualifications: Current, unrestricted license issued by a state or territory of the United States to practice independently as a Clinical Social Worker, Marriage and Family Therapist, Professional Counselor, Clinical Psychologist or Registered Nurse in the state in which the business operation is located and/or other states as required by law, regulation or contract. For Registered Nurses, a Bachelor’s Degree in Nursing is required. 5+ years post-licensure experience in direct clinical care with patients in facility-based and/or outpatient psychiatric or chemical dependence treatment Previous experience in Case Management or Disease Management Strong leadership and team management skills with experience in performance management. Proficiency in care management tools and models, including case review and audit processes. Knowledge & ability to apply case management principles and concepts to their case management practice Extensive clinical knowledge base Knowledge of regulatory and accreditation standards for case management. Excellent communication, collaboration, and problem-solving abilities. Ability to comprehend medical policy and criteria and clearly articulate health information Experience and training in Motivational Interviewing or Health Coaching Strong computer and keyboarding skills (Microsoft Outlook and Word), including the ability to document while simultaneously while taking information over the phone Ability to obtain certification in Case Management (CCM) within 3 years of hire Ability to travel 10-30% Someone who embodies our values by: Serving everyone with compassion and leading with empathy. Stepping up and creating value by taking charge and acting when there is an opportunity. Adapting in a changing world by recognizing our responsibility to be agile and respond quickly. Nurturing growth and belonging by respecting and celebrating everyone for who they are. Competencies: Self-motivated and ability to lead team to achieve Lucet goals Ability to engage a wide variety of individuals, and excellent organizational skills Passion for improving lives through behavioral change and wellness Proven interest in professional development through specialization, certification, and/or advanced degree Maintains curiosity and an eagerness to explore new knowledge and try new ideas and approaches to case management Demonstrates consistency in professional demeanor in response to all situations regardless of the nature or circumstances of the situation Ability to manage multiple tasks in a fast-paced, changing environment Ability to assume a lead role in ensuring that all objectives are met Ability to work within a collaborative, team-oriented environment Working Conditions: Work is performed from home with company-provided equipment. Sitting for long periods of time is expected and use of fingers and hands for typing is necessary. A quiet workspace with minimal background noise for calls. High-speed internet service (cable or fiber optic) with minimum download Speed of 20 Mbps, Upload Speed of 5 Mbps, and Maximum Latency of 100 milliseconds (must be installed before starting).

Leadership - Lead the Case Management team, clearly communicating initiatives and motivating adoption of changes to enhance clinical outcomes and the value for customers. Clinical Supervision and Performance Management - Provide clinical and administrative supervision to CM team to support post-discharge stabilization and movement towards member self-management. Clinical and Program Expertise - Provide case consultation for complex situations, demonstrating clinical expertise in areas ranging from crisis intervention to routine matters. Collaboration and Integration - Foster coordination with health plan medical management and medical service providers, including primary care physicians and patient-centered medical homes.\ Quality Improvement and Compliance - Assist with the development and implementation of new software, programs, policies, and procedures to enhance care management services.

Lucet

Bilingual Care Manager (Spanish)

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Florida

At Lucet, we are industry leaders in behavioral health, dedicated to helping people live healthy, balanced lives. Our purpose is to advocate for and improve the overall well-being of those we serve, through balanced treatment of the mind and body. When you join Lucet, you become a valued member of our team, serving more than 15 million people across the U.S. Our employees have a passion for helping others - and it shows. From entry-level employees to senior leaders, we are inspired by our members, putting them first in everything we do. From day one, you'll see firsthand the impact you have on our members, knowing you can make a true difference in their lives.

The Bilingual Care Manager Clinician coordinates and oversees comprehensive behavioral health services, ensuring health plan members receive the appropriate level of care while optimizing resource utilization. This role blends care management strategies, such as assessing and developing personalized care plans, engaging members to foster self-management, and supporting recovery, with utilization management practices that include reviewing and authorizing behavioral health services based on medical necessity, treatment guidelines, and outcomes. This role is the single point of contact for a member through the continuum of care, increasing member engagement and continuity. By collaborating with healthcare providers, members, and community resources, this individual ensures that behavioral health services are delivered efficiently, effectively, and in accordance with established policies and procedures. The ability to work in a cross-functional manner, coordinating with all departments within Lucet, health plans, facilities and providers to promote strong health outcomes and stability for our members.

Required Qualifications: Fluent in both English and Spanish (verbal and written) Current, unrestricted state license issued by a state or territory of the United States to practice independently as a Clinical Social Worker, Marriage and Family Therapist, Professional Counselor, Clinical Psychologist or Registered Nurse in the state in which the business operation is located and/or other states as required by law, regulation or contract. 2+ years of direct clinical care experience Excellent verbal and written communication and interpersonal skills Strong computer and keyboarding skills (Microsoft Outlook and Word), including the ability to document while simultaneously while taking information over the phone Ability to comprehend medical policy and criteria to clearly articulate health information Ability to pass background check upon hire and throughout employment to include criminal felony & misdemeanor search, SSN validation/trace search (LEIE), education report (highest degree obtained), civil upper and lower search, 7-year employment report, federal criminal search, statewide criminal search, widescreen plus national criminal search, health care sanctions-state med (SAM), national sex offender registry, prohibited parties (OFAC) (terrorist watchlist), and a 10-Panel Drug Screen. Someone who embodies our values by: Serving everyone with compassion and leading with empathy. Stepping up and creating value by taking charge and acting when there is an opportunity. Adapting in a changing world by recognizing our responsibility to be agile and respond quickly. Nurturing growth and belonging by respecting and celebrating everyone for who they are. Competencies: Self-motivated and the ability to assume a role in ensuring that all objectives are met Ability to work independently to meet case load requirements and team objectives/goals Proven interest in professional development through specialization, certification, and/or advanced degree Maintains curiosity and an eagerness to explore new knowledge and try new ideas and approaches to case management Professional demeanor in response to all situations regardless of the nature or circumstances of the situation Able to manage multiple tasks in a fast-paced, changing environment Ability to work within a collaborative, team-oriented environment Working Conditions: Work is performed from home with company-provided equipment. Sitting for long periods of time is expected and use of fingers and hands for typing is necessary. A quiet workspace with minimal background noise for calls. High-speed internet service (cable or fiber optic) with minimum download Speed of 20 Mbps, Upload Speed of 5 Mbps, and Maximum Latency of 100 milliseconds (must be installed before starting).

Clinical Expertise & Assessment: Apply expertise in medical necessity, diagnosis, medication management, and psychosocial factors. Conduct assessments to determine treatment needs, barriers, and ensure service compliance with state/federal regulations. Case Management & Care Coordination: Utilize case management processes, including assessments, care planning, and outcome adjustments to optimize member health. Collaborate with members and providers for crisis prevention, care coordination, and aftercare connections. Member & Provider Engagement: Build collaborative relationships with members and providers using motivational interviewing and communication strategies. Educate on mental health, substance abuse resources, and services, and facilitate post-hospital discharge planning. Compliance, Documentation & Professional Development: Stay updated on case management technology, maintain accurate documentation, and adhere to regulatory standards. Engage in audits, quality initiatives, and continuing education for licensure and certification.

Lucet

Clinician, C365

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Kansas

At Lucet, we are industry leaders in behavioral health, dedicated to helping people live healthy, balanced lives. Our purpose is to advocate for and improve the overall well-being of those we serve, through balanced treatment of the mind and body. When you join Lucet, you become a valued member of our team, serving more than 15 million people across the U.S. Our employees have a passion for helping others - and it shows. From entry-level employees to senior leaders, we are inspired by our members, putting them first in everything we do. From day one, you'll see firsthand the impact you have on our members, knowing you can make a true difference in their lives.

Please note that the schedule is Sundays - Tuesday, 7:00PM-7:00AM CST and Every other Wednesday, 7:00PM-7:00AM CST.

Required Qualifications: A current, unrestricted license issued by a state or territory of the United States as a Clinical Social Worker, Marriage and Family Therapist, Professional Counselor, Clinical Psychologist or Registered Nurse. Minimum of 3-5 years of direct clinical care experience with patients in facility-based and/or outpatient psychiatric or chemical dependency treatment Strong clinical skills Excellent verbal and written communication and interpersonal skills Strong computer and keyboarding skills (Microsoft Outlook and Word), including the ability to document while simultaneously while taking information over the phone. Ability to pass background check upon hire and throughout employment to include criminal felony & misdemeanor search, SSN validation/trace search (LEIE), education report (highest degree obtained), civil upper and lower search, 7-year employment report, federal criminal search, statewide criminal search, widescreen plus national criminal search, health care sanctions-state med (SAM), national sex offender registry, prohibited parties (OFAC) (terrorist watchlist), and a 10-Panel Drug Screen. Someone who embodies our values by: Serving everyone with compassion and leading with empathy. Stepping up and creating value by taking charge and acting when there is an opportunity. Adapting in a changing world by recognizing our responsibility to be agile and respond quickly. Nurturing growth and belonging by respecting and celebrating everyone for who they are. Competencies: Self-motivated and the ability to assume a role in ensuring that all objectives are met Ability to work independently to complete work assignments and team objectives/goals Maintains curiosity and an eagerness to explore new knowledge and try new ideas and approaches Excellent communication and interpersonal skills Professional demeanor in response to all situations regardless of the nature or circumstances of the situation Able to manage multiple tasks in a fast-paced, changing environment Ability to work within a collaborative, team-oriented environment Ability to work efficiently and effectively in a remote environment with other remote team members and a remote supervisor Working Conditions: Work is performed from home with company-provided equipment. Sitting for long periods of time is expected and use of fingers and hands for typing is necessary. A quiet workspace with minimal background noise for calls. High-speed internet service (cable or fiber optic) with minimum download Speed of 20 Mbps, Upload Speed of 5 Mbps, and Maximum Latency of 100 milliseconds (must be installed before starting)

The Clinician, C365 will be responsible for providing excellent clinical customer service by handling incoming telephone contacts from insured, EAP, uninsured callers, and providers. Depending on the nature of the call, the Clinician conducts clinical telephonic focused screenings, provides referrals to appropriate health care and community resources, conducts clinical precertification for appropriate level of care, promotes care transitions activities for members being discharged from higher levels of care, addresses routine inquiries, and strives to reduce obstacles to access to behavior health care. Mental Health Expertise & Service Delivery: Demonstrates expertise in mental health diagnosis and treatment, providing education, resources, and consultations to promote access to behavioral health services and optimize member outcomes. Utilization Review & Clinical Process Management: Manages utilization reviews, conducts peer reviews, and ensures compliance with clinical standards using standardized tools for documentation and authorization processes. Member Engagement & Support: Engages with members, families, and providers to assess needs, provide resources, and support behavioral health access, while working remotely with strong organizational skills.

Health Care Service Corporation

Utilization Management Coordinator - OK

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Oklahoma

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development.

This is a full time Telecommute (Remote) role: Must reside within 250 miles of the office or anywhere within the posted state. #LI-Remote

Registered Nurse (RN) with valid, current, unrestricted license in the state of operations. 3 years of clinical experience in a physician office, hospital/surgical setting or health care insurance company. Knowledge of medical terminology and procedures. Verbal and written communication skills. Willingness and ability to travel. PREFERRED JOB REQUIREMENTS: Utilization management experience. MCG Certification.

This position is responsible performing initial, concurrent review activities; discharge care coordination for determining efficiency, effectiveness and quality of medical/surgical services and serving as liaison between providers and medical and network management divisions. Collects clinical and non-clinical data. Verifies eligibility. Determines benefit levels in accordance to contract guidelines. Prepares reports on quality of care, identifies and reports cases. Provides information regarding utilization management requirements and operational procedures to members, providers and facilities.

Molina Healthcare

Remote Supv, Care Management BH team - TX ONLY

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Texas

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Required Education: Registered Nurse or equivalent combination of Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) with experience in lieu of RN license. OR Bachelor's or master’s degree in gerontology, public health, or social work with related case management experience. Required Experience: 3 or more years in case management, disease management, managed care or medical or behavioral health settings. Required License, Certification, Association: If licensed, license must be active, unrestricted and in good standing. Preferred Education: Bachelor's or master’s degree in Nursing, Preferred Experience: More than five years Case Management experience. Medicaid/Medicare Population experience with increasing responsibility. Preferred License, Certification, Association: Certified Case Manager (CCM), Certified Professional in Healthcare Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.

Oversees an integrated Care Management team responsible for case management, community connectors, health management, and/or transition of care activities to assist Molina Healthcare members with their healthcare needs. Care Management staff work to help members achieve optimal clinical, financial and quality of life outcomes, including safely and effectively transitioning Molina members from acute or inpatient care to lower levels of care and/or home in a cost-efficient manner. Functions as a hands-on supervisor, providing direction and guidance to the care management team to ensure implementation of activities that align with the model of care and that meet regulatory requirements. Manages staff caseloads and assigns cases appropriately regarding complexity of medical or psychosocial needs and case manager experience (RN, LSW, other allied fields). Oversees the staff use of the electronic case management documentation system in compliance with standard Molina processes, standard documentation styles, and HIPAA. Arranges training as needed. Manages, coaches and evaluates the performance of team members; provides employee development and recognition; and assists with selection, orientation and mentoring of new staff. Promotes multidisciplinary collaboration, provider outreach, and engagement of family and caregivers to enhance the continuity of care for Molina members. Oversees and/or participates in Interdisciplinary Care Team meetings. Works with the Manager to ensure adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators. Audits case management assessments and care plan development for completeness and timeliness according to state requirements. Monitors onsite hospital discharge visits and post-discharge visits to assure continuity of care and prevent unnecessary readmissions. May monitor the completeness of the Transition of Care (ToC) assessment and the timeframes for contact are per ToC protocols.

Personify Health

Utilization Review Nurse, RN

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Rhode Island

We’re Personify Health. We’re the first and only personalized health platform company to bring health, wellbeing, and navigation solutions together. Helping businesses optimize investments in their members while empowering people to meaningfully engage with their health. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

We are seeking a Utilization Review Nurse to join our dynamic team. This role requires weekend availability, and flexible scheduling to support a healthy work-life balance.

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including: Current RN license in the United States or U.S. territory. 1+ years of clinical experience required. You also take pride in offering the following Core Skills, Competencies, and Characteristics: Knowledge of medical claims and ICD-10, CPT, HCPCS coding. Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook Excellent verbal and written communication skills Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you

Under the supervision of a registered nurse (RN), provide professional assessment and review for the medical necessity of treatment requests and plans. Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and all post claim or post service reviews. Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. Refer requests that fall outside of established guidelines to advance review or senior care consultants. Process appeals for non-certification of services; complete non-certification letters when appropriate. Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program. Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality. Utilize MCG guidelines, medical policies, Medscape, and NCCN. Ability to meet productivity, quality, and turnaround times daily.

Texas Health Resources

Clinical Documentation Integrity Specialist

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

Clinical Documentation Integrity Specialist Bring your passion to Texas Health so we are Better + Together Work location: Remote Work hours: Monday – Friday from 8am – 5pm Department highlights: 100% remote work Flexible hours/scheduling Terrific work/life balance

Associate’s degree in nursing required or Bachelor’s degree in nursing required or Associates degree in HIM or other healthcare related field required Bachelor’s degree in HIM or other healthcare related field required 2 years related clinical experience (Quality, Risk, Compliance, UM, Case Management, etc) required or 5 years acute care hospital inpatient coding required RN upon hire required or RHIT, RHIA, CCS or other ( CCSP, CIC, COC, CPC, CCDS, CDIP) upon hire required

The Clinical Documentation Integrity Specialist is responsible for concurrently analyzing medical records to facilitate improvement in the overall quality and completeness of the medical record documentation to ensure accurate depiction of the level of clinical services provided and to completely describe the patient’s acuity and severity of illness. This involves extensive record review, interaction with physicians, HIM professionals, and other ancillary staff. Active participation in team meetings and ongoing education of staff in the complete, accurate and compliant documentation process is a key role. Accurate and timely record review: By enrolling and reviewing available new inpatients every day except weekends and holidays with re-reviews approximately every two days until the patients are discharged. Processing discharged patients utilizing the reconciliation process. Recognize opportunities for documentation improvement: By using strong critical thinking skills, and medical knowledge of disease processes with an exceptional ability to integrate knowledge. Ability to analyze complex clinical information to identify areas within the medical record for potential gaps in physician documentation. Identifies opportunities to justify the intensity of service and severity of illness, and shares this information in an interdisciplinary approach with physicians and staff, with the goal of obtaining documentation excellence supporting the care provided to the patient. Formulate clinically credible and compliant documentation clarifications: By utilizing the compliant clarification format and clinically credible indicators, sign/symptoms, risk factors, and treatment. Responsible for developing appropriate physician clarification tools and processes in accordance within Medicare (CMS), AHIMA and THR guidelines. Effective and appropriate communication with physicians: By providing necessary feedback and clinically credible clarifications with the ability to communicate clearly, proactively, and concisely when interacting with physicians. Provide education to physicians and other clinical providers to ensure their understanding of the clarification process and the desired outcome of documentation excellence for severity of illness and intensity of care. Providing feedback and education in proficient verbal and written formats. Timely follow up on all cases especially those with clinical documentation clarifications: Reviews accounts with open clarifications daily and seeks to obtain a documented answer for the clarifications before the patient is discharged. Performs subsequent reviews on all other accounts regularly through discharge, to ensure a thorough and quality review. Is able to prioritize work flow, demonstrates a strong ability to mulit-task, proactively prioritizes initiatives and effectively manages resources. Provides follow-up with providers to open clarifications up to 7 days post-discharge to obtain query response. Accurate input of data into software system: Utilize established guidelines after reconciling with the final coded data two to three times per week. Ensuring CDI database is maintained in a current fashion within expected timeliness guidelines. Communicates with management staff and resolve discrepancies: By identifying the opportunities and provide rationale with supported clinical criteria such as pathology of disease processes, diagnostic findings, lab values, and signs/symptoms and/or coding guidelines when applicable and forward such discrepancies to management staff in a timely manner for resolution. Participates in the analysis and trending of statistical data to identify opportunities for improvement. Identifies strategies for work process changes that facilitate complete, accurate clinical/physician documentation.

Thrive Health Care Services

Trauma Performance Improvement Coordinator

Posted on:

March 22, 2025

Job Type:

Contract

Role Type:

License:

RN

State License:

Missouri

100% (Remote) - Trauma Performance Improvement Coordinator 04 Months Contract Location: MissouriKansas City Must be proficient in trauma registry software (DI Trauma Registry, DI Report Writer, etc.) Must have a history of trauma performance improvement Desired a TOPIC Course (Trauma Outcome Performance Improvement Course) Must be self- motivated and driven with attention to details

Education: Bachelor Degree in Nursing required. Knowledge/Professional Licensure/Registration/Certifications: Current Missouri RN licensure, BLS, ACLS and trauma nurse provider certification (TNCC or ATCN) required; PALS or ENPC-strongly preferred; TNCC/ATCN Instructor and Certification in specialty area preferred; Maintain membership in one professional organization (i.e. ENA, AACN, ATS, STN) Demonstrates working knowledge of TQIP, NTDB and COLLECTOR systems. Must be able to analyze information from several systems at one time. Must be self- directed and function autonomously with strong organizational skills. Experience: 2 years related experience in Critical Care or Emergency Department with emphasis in care of the surgical or injured patient.2 years related experience in trauma, ED or rehab care. Management Experience: N/A Administrative Skills: Computer and internet skills and experience required. Familiarity with Windows (e.g. Microsoft Excel, Word, and PowerPoint).

The Trauma Performance Improvement and Patient Safety (PIPS) Coordinator is a registered nurse who is responsible for implementing a system of patient care delivery that focuses on the achievement of outcomes within effective time frames and with appropriate use of resources. Collaborates with the interdisciplinary team to develop and implement the patient care plan and monitors the plan to ensure the quality, timeliness, and effectiveness of services. Will periodically reevaluate and adjust the patient care plan to assure services are appropriate, cost effective, and consistently moving the patient toward independence. Is responsible for ensuring RMC trauma practices & policies are implemented appropriately to provide optimal, research based care to our patients. This is done via direct patient care, audits, policy review, and literature reviews

Thrive Health Care Services

Trauma Abstractor

Posted on:

March 22, 2025

Job Type:

Contract

Role Type:

License:

RN

State License:

Virginia

100% Remote Work JOB TITLE: Data Abstractor I Fully Remote - except NY, CO, and CA Flexible hours as long as they are available for training during normal business hours.

EDUCATION REQUIRED: High school degree (or equivalent) required. PREFERRED: Undergraduate (Associates or Bachelor) degree or successful completion of a certified coding program EXPERIENCE: 1 year in Health Information Management; Coding or Health Registry abstraction experience preferred PREFERRED: RHIA, RHIT, CSS, LVN or RN 2+ years’ experience as a Trauma Registrar/Abstractor required ICD 10 data abstractor system experience required Trauma Registry Course required AIS 15 Course required 2+ years of experience with Level 1 or 2 Trauma Centers (Certified in CSTR or CAISS strong plus) Certified in CSTR or CAISS (strong plus) EMR/Registries in DI or CDM (trauma) Meditech Expanse or Epic or Cerner EMR experience KNOWLEDGE, SKILLS & ABILITIES: Familiar with medical record documentation Basic medical terminology and physiology Able to navigate through the medical record and locate specific documentation Understanding of patient discharge disposition and where to validate in the medical record Ability to extract data from medical record content for abstraction Proficiency in computer skills to include Microsoft Office applications Possess basic keyboard skills Knowledge of medical terminology, quality measures and coding logic.

This position is responsible for abstraction of data for core measure, trauma, VON and/or various cardiovascular services. SUPERVISOR: Manager, Clinical Data Abstraction DUTIES INCLUDE BUT ARE NOT LIMITED TO: Completes abstraction process for assigned facility(ies), including abstraction of cases into the required system (e.g., COMET, TheraDoc, Digital Innovations, NHSN, etc.). Responsible for reviewing medical records to abstract information according to the standards of various regulatory and accreditation agencies (e.g., CMS, TJC, NHSN, etc.). Performs timely abstraction to ensure compliance with standards. Completes edit checks and makes appropriate changes on a timely basis. Follow standards and CSG/Parallon nstructions to abstract all reportable cases. Assist with case follow-up as requested. Attend educational activities as approved by Manager and/or Director. Maintain clinical knowledge of various abstracted measures. Communicate in a timely manner with manager to achieve measure compliance. Submit data timely through the appropriate reporting system. Resolve errors resulting in the rejection of records from the data entry system. Participates in required continuing education programs and annual reorientation. Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement” Other duties as assigned

Atrium Health

Registered Nurse - Atrium Health Virtual Care Remote FT Days

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

North Carolina

The RN Clinical Nurse provides comprehensive nursing care through skillful assessment, diagnosis, outcomes identification, planning, implementation, and evaluation in accordance with facility or department policies, procedures, and/or protocols under the supervision of the nursing leader. The RN Clinical Nurse assists in maintaining a safe work environment and performs all related job responsibilities in a safe manner. The RN Clinical Nurse maintains clinical and professional competency as appropriate to the population of patients served. A registered nurse’s practice is guided by the ANA Code of Ethics for Nurses with Interpretive Statements.

REQUIREMENTS : Work requires walking, standing, sitting, lifting, reaching, stooping, bending, pushing, and pulling. Must be able to lift and support the weight of 35 pounds in handling patients, medical equipment, and supplies. Must speak English in good, understandable terms. Intact sense of sight, hearing, smell, and touch. Finger dexterity. Critical thinking and ability to concentrate. Must be able to respond quickly to changes in patient and/or unit conditions. Physical Abilities Testing required. Additional department specific physical requirements may be identified for unique responsibilities within the department by the nurse leader. EDUCATION, TRAINING, AND EXPERENCE : Graduate from an accredited School of Nursing required; BSN preferred. Advancement eligible based on the Nurse Career Professional Program. Current Basic Life Support for Healthcare Provider status according to American Heart Association. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or; if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works. Additional education, training, certifications, or experience may be required within the department by the nurse leader.

Collects pertinent data and information relative to the healthcare consumer’s health or the situation. Analyzes the assessment data to determine the actual or potential diagnoses, problem, and issues. Identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. Develops a plan that prescribes strategies to attain expected, measurable outcomes. Implements the identified plan, coordinates care delivery, and employs strategies to promote health and a safe environment. Delegates elements of care to appropriate healthcare workers in accordance with any applicable legal or policy parameters or principles. Evaluates progress toward attainment of goals and outcomes. Practices ethically. Practices in a manner that is congruent with cultural diversity and inclusion principles. Communicates effectively in all areas of practice. Collaborates with healthcare consumers and other key stakeholders in the conduct of nursing practice. Leads within the professional practice setting and the profession. Seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking. Integrates evidence and research findings into practice. Contributes to quality nursing practice. Evaluates one’s own and others’ nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules and regulations. Utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible. Practices in an environmentally safe and healthy manner. Participate in committees, shared governance, or facility decision making activities, developing and nurturing research to positively affect clinical outcomes and promotion. Models the Atrium Health mission, vision, and value. Supports and contributes to the Patient Centered Care Philosophy by understanding that every teammate is a Caregiver whose role is to meet the needs of the patient. DocuSign Envelope ID: 14D2E81C-8ED5-4C38-9152-9F6758812159 PHYSICAL

Molina Healthcare

LPN Care Review Clinician, Prior Authorization Remote in WA state

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Washington

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

This position will be supporting our Washington State Plan. We are seeking a candidate with a WA state LPN licensure. Candidates with case management, Utilization Management (UM), Prior Authorization, and direct managed care experience are highly preferred. Further details to be discussed during our interview process. Work hours: Monday- Friday 8:00am- 5:00pm PST including rotational weekend and Holiday coverage. Remote position in Washington State

Any of the following: Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR a bachelor’s or master’s degree in a healthcare field, such as social work or clinical counselor (for Behavioral Health Care Review Clinicians only). Required Experience: 1-3 years of hospital or medical clinic experience. Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license in good standing OR a clinical license in good standing, such as LCSW, LPCC or LMFT (for Behavioral Health Care Review Clinicians only). Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings. Preferred Experience: 3-5 years clinical practice with managed care, hospital nursing or utilization management experience. Preferred License, Certification, Association: Active, unrestricted Utilization Management Certification (CPHM).

Assesses 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 and eligibility for requested treatments and/or procedures. Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members. Processes requests within required timelines. Refers appropriate prior authorization requests to Medical Directors. 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.

Pacific Cancer Care

Triage RN (Remote)

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

California

Pacific Cancer Care has provided superior care for patients for nearly 50 years. We make every patient our priority. We are a family here at PCC, each member of the team cares deeply, often for a very personal reason, and that means a lot to our patients Why Join Us? Our team values the work components of every member to create a culture of people helping people and making a difference in our lives and those we serve.

TRIAGE RN - REMOTE POSITION Manage chemotherapy side effects and oncological emergencies via telephone triage assessment. Telephone and in-person assessment which includes the determination of optimal time and location for patient management (ER, clinic, homecare) and follow-up care as required. Prescribe and communicate treatment plans and patient teaching in accordance with established protocols.

Triages phone calls according to acuity; gives or obtains sound nursing advice/medical response to patient inquiries same day as call (90% of the time) Notifies MD of urgent/critical findings for response within 30minutes. Identifies patients which need to be sent to the emergency room. Responds to patient requests for refill prescriptions, lab or radiology results in a timely fashion. Provide clarification on physician prescriptions to outside pharmacy as necessary. Coordinate referrals to external service providers as needed (home health, DME, etc.); ensure necessary services have been established. Demonstrates an understanding of the most commonly used oral chemotherapy and targeted agents and the potential side effects. Provides patient and family education regarding individual drugs, potential side effects/toxicities and management. Ensures that follow up calls are made to patients on oral agents to ensure compliance and assess for toxicity. Submits prescriptions to specialty pharmacy and obtains prior authorization as required. Completes referral paperwork, ensuring that documentation is thorough and complete including MD signatures. Demonstrates the ability to navigate system (ONCO EMR) to obtain pertinent information. Ability to correctly add tests, activities and medications. Demonstrates knowledge of community and on- line resources, providing information and referral for patients and families as required. Participates in INR monitoring and dosing. Reviews lab results and adjusts Coumadin as appropriate in line with established guidelines and/or MD recommendation. Ensure that Death Certificate worksheets are completed and have appropriate MD signature. Generate sympathy cards, gaining appropriate signatures and sending out to family members. We are looking for an organized, highly disciplined and self-motivated individual able to communicate and coordinate effectively with patients, management, and team members over phone, email, and Zoom/Teams. Manage time effectively. Meet work performance and/or productivity levels whether onsite or teleworking.

IntellaTriage

Remote Hospice Triage RN- PT 1 shift 6p-12a + rotating Sat & Sun 3:30-12a

Posted on:

March 22, 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 4 days out of a 14-day pay period Part- time schedule: Work a minimum 1 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

IntellaTriage

Remote Hospice Triage RN- PT 1-2 shift 3:30p-12a + rotating Sat & Sun 7:30-4p

Posted on:

March 22, 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 4-6 days out of a 14-day pay period Part- time schedule: Work a minimum 1-2 evening shift weekly 3:30p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

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

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

Personalized Health Partners

RN Overnight Telehealth Administrator on Call, Remote

Posted on:

March 22, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

PHP Telehealth Administrators on Call have a passion for providing remote administrative, clinical triage, and care coordination support for the PHP Telehealth provider team, as well as seniors and other residents in a variety of healthcare settings that can include, but are not limited to, skilled nursing facilities, assisted living, and independent living communities, etc. They deliver support in a high touch, person-centered care model and collaborate with the interdisciplinary team to ensure that all residents receive the right care, at the right time.

The CommuniCare Family of Companies currently owns/manages numerous World-Class nursing and rehabilitation centers, specialty care centers, and assisted living communities throughout Ohio, Indiana, Missouri, Pennsylvania, Maryland, Virginia, and West Virginia. We have a single job description at CommuniCare, “to reach out with our hearts and touch the hearts of others". Through this effort we create “Caring Communities” where staff, residents, clients, and family members care for and about one another. When combined with our highly professional and competent staff and efficient and effective systems, this results in a warm, loving environment where our residents become part of the family and enjoy a higher quality of care. Personalized Health Partners (PHP) is the medical practice arm for the CommuniCare Family of Companies. The Administrator on Call would directly support both the PHP Telehealth provider group as well answering calls for triage from our other telehealth use cases outside of the Skilled Nursing and Assisted living environments. The goal of the Administrator on Call is to support the Telehealth provider team as well as our patients to increase wellness, prevent illness, improve clinical outcomes and focus on customer experience and satisfaction.

Required: Must have valid RN license Must be willing to be licensed in the 6 states served (Indiana, Ohio, Pennsylvania, Maryland, Virginia and West Virginia) Strong clinical assessment and medical triage skills, with the ability to prioritize care. Excellent customer service skills, with the ability to collaborate effectively with patients and healthcare teams. Strong critical thinking and problem-solving abilities to manage a wide range of scenarios. Ability to provide care and guidance to both direct-to-consumer clients and healthcare organizations. Compassionate and empathetic approach to patient care. Good technology aptitude. Accurate and efficient in typing. Must be able to work independently and manage time efficiently in a remote environment. Flexibility to work various shifts, including evenings, weekends, and holidays. Preferred Qualifications: Training or clinical experience in geriatrics, primary care/internal medicine and/or ED or urgent care Minimum of 3-5 years of clinical experience in acute care, emergency, or primary care settings. Be open to professional development through training, obtaining certifications if necessary, and attending team meetings Experience working in a collaborative healthcare setting to drive positive outcomes and achieve goals Training or experience in outpatient primary care setting JOB SKILLS: Must have strong oral and written communication skills Must be detail oriented with an ability to work well both independently and in a team setting Exhibit a customer service approach with teams and residents Strong time management skills required. Must be able to prioritize and adhere to competing deadlines while achieving goals Physical Requirements: Works remotely with a flexible work schedule

Coordinate with telehealth providers to ensure appropriate patients receive telemedicine services. Communicate with onsite nursing teams to ensure all clinical needs are coordinated Oversee provider queue in Never Alone Support technical issues that arise for telehealth provider team Monitor EMR to triage routine clinical lab requests, routine imaging results, notifications, etc. that result after hours. Maintain timely documentation of encounters with facility nurses in the EMR Record information directly into CRM system Connect patients that need to be seen acutely by an in-house provider the next day with Central Scheduling Answer and triage calls from Never Alone use cases outside of the SNF use case Provide health education Provide an excellent customer experience to foster high customer satisfaction/retention Practice ethically and in accordance with the Scope and Standards of Practice of their profession and Board Certification. Follow all state and federal regulations, guidelines, and laws Additional Duties Of PHP Telehealth Administrator On Call: Collaborate with telehealth provider group Participation in monthly staff meetings During downtime there may be some additional project related work related to the development of protocols, initial quality review of previous encounters, or projects to be defined as the role evolves.

Staft

Registered Nurse

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

California

Job Title: Remote Nurse Location: Remote (Work from Home) Job Type: Full-Time / Part-Time Salary: Competitive / Based on Experience Urgent Hiring! We’re looking for experienced, compassionate nurses to join our telehealth team immediately. Work from home and provide vital care to patients via virtual consultatio

Active RN license. 2+ years of nursing experience. Strong communication and tech skills. Ability to work independently.

Conduct virtual patient assessments and provide medical advice. Document patient information and follow up as needed. Offer guidance on treatments and health management.

HCR Home Care

Health Home Care Manager (Remote) - Full Time

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

New York

Provide collaborative, client-centered support to Health Home Program clients using the development of person-centered goals, culturally competent care management, and professional healthcare and social service coordination. Health Home Care Managers will evaluate, manage, and integrate solutions and resources for all primary, complex chronic diseases, behavioral health and long-term care needs in the Health Home Program. This position is designated as a higher-skilled Care Manager, capable of exceeding the basic tenants of care management.

Education Requirements: High School Diploma/GED, Associate’s or Bachelor’s Degree in Health and Human Services with 10 or more years of experience working directly with persons with behavioral/mental health diagnosis, substance disorders, or linking individuals with community support resources; OR Bachelor’s or MS Degree, with 5 or more years related experience, in any of the following: child and family studies, community mental health, counseling, education, nursing, OT, PT, psychology, recreation, recreation therapy, rehabilitation, SW, sociology, or speech and hearing; OR NYS Licensure and current registration as an LPN or RN with 5 or more years of experience working directly with persons with behavioral/mental health diagnosis or substance disorders; OR MSW or NYS CASAC Certification with related experience. Qualifications and Requirements: Communicate through speaking to give instructions and explanations to employees/clients, and through hearing to understand employee/client response and questions. Proficient in the use of Microsoft products such as Teams, Outlook, Word and Excel. Sound computer knowledge and skills including an aptitude for using health information technology to guide activities. Possess excellent communication skills. Demonstrated ability to interact well with people of all socio-economic backgrounds in the community. Proven organizational skills and the ability to manage and prioritize multiple assignments. Valid NYS driver’s license along with access to reliable transportation Work Environment: The Health Home Care Manager (Remote) is primarily a home based office setting. The working conditions are classified as sedentary work: Sedentary work - Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Physical Requirements: The following is a description of the physical requirements on a daily basis for the Health Home Care Manager 2. While performing the duties of the job the employee is regularly expected to: Stand Sit Hear Walk Talk Stoop or kneel Repetitive motion

Actively and progressively care manage an enrolled client caseload as determined by Agency guidelines. Develop an individualized plan of care with specific goals/interventions/objectives, to be revised as needed. Provide rehabilitative and supportive counseling geared toward the restoration of clients to their optimum level of social and health functioning. This includes assisting clients and their families with the adjustment to their illness and following medical/behavioral health recommendations. Assist the clients and their families with personal and environmental difficulties, which predispose them towards illness and/or interfere with obtaining maximum benefits from medical care. Timely completion of individualized assessments specific to program needs utilizing NYS HCS-UAS system. Develop long- and short-term plans, when appropriate, including the utilization of community supports with the goal of reducing emergency room and/or in-patient utilization. Communicate directly with members of the care team to provide up-to-date information regarding the client’s care to effectively reduce duplicative services. Consult with the physicians, Managed Care Organizations and other members of the Care Team for the purpose of educating them on the social, emotional and environmental factors related to the client’s barriers to success. Prepare concise, accurate, and timely case notes which are incorporated into the client’s records. Complete client documentation within the time required by Health Home and Agency standards. Proficiently and accurately use multiple software systems to capture care management notes and related activities, and to provide corrections when needed regarding documentation in any one of the EMRs as needed, including the Lead Health Home systems, and HCR’s Database. Attend case conferences and act as a consultant to other agency personnel regarding client’s psycho-social issues. Schedule and maintain client visits, follow-up calls, and provider engagements utilizing effective time management skills. Document active/progressive care management showing multiple points of engagement with a client or collateral contacts over the course of a month. Timely discharge of clients no longer engaged in the Health Home Program. Represent Care Management on agency committees and interdisciplinary team meetings as requested, as well as operate as an ambassador for HCR Care Management out in the community. Network with community-based agency personnel to promote HCR and its services. Meet/exceed performance expectations as outlined in “Care Management Expectations.” Other duties as assigned.

83BAR

Bilingual RN - Healthcare Sales

Posted on:

March 22, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

Texas

Since 2015 we have been working with cutting-edge companies providing innovative care solutions to complex medical conditions. We have employees located across the United States. Through our online marketing ads, we find people in need of medical procedures or treatments, who ask for more information, we then call them to provide the information they need to make and attend an appointment with one of our partner doctors. Our clients aren't your typical healthcare companies.. We work with creative companies with innovative solutions who are trying to help people solve their health issues in new and innovative ways; That's where we come in! We use cutting-edge lead generation and sales automation to help consumers find our clients. Here are a few examples of the companies we work with: A DNA lab testing company that helps people discover if they are at risk of hereditary cancers. A services company that treats people with prediabetes and prevents them from developing Type II diabetes. One-third of adults have prediabetes! A medical device company that helps women who have been struggling with bladder control for years.

We’ve custom-built a web-based system that allows you to access what you need from the convenience of home. You just need your laptop (that meets internet speed requirements) with access to high-speed Internet and a quiet, private space to work. We are currently hiring for part-time positions - and we are looking for applicants available to work shifts between 8:00 am and 9:00 pm CST Monday through Friday and 10:00 am to 5:00 pm Saturday. We are seeking applicants with healthcare experience and the empathy required to successfully connect with the people we are reaching out to help and educate them about the life-changing services our clients have to offer.

Fluent in both Spanish and English. Healthcare background. Strong communication skills. Highly Empathetic. Prior experience in sales/customer service preferred. Self-motivated and adaptable. Access to high-speed internet. Able to commit to a set schedule. Available minimum of 20 hours per week.

As a Clinical Sales Specialist, you will use your medical knowledge and patient care experience to guide those who have reached out to 83bar for information about the care solution that they are looking for. We never cold call, so you will be contacting only those who have expressed an interest in the services that our clients provide and helping them to take the next step in their journey towards a healthier future.

Point32Health

Senior Care Options Transition RN

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Massachusetts

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier. We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

The Care Manager - Nursing (RN CM) will ensure that all members receive timely care management (CM) across the continuum, including transitions of care, care coordination and navigation, complex case management, population health and wellness interventions, and disease/chronic condition management per department guidelines. The nurse care manager possesses strong clinical knowledge, critical thinking skills, and ability to facilitate a care plan which ensures quality medical care for the member. The RN CM works closely with the member, the caregiver/authorized representative, and providers to meet the targeted member-specific goals. Based on national standards for CM practice, the RN CM focuses on empowering the member to support optimal wellness and improved self-management.

Education, Certification and Licensure: Registered Nurse with current unrestricted license in state of residence May be required to obtain other state licensure in states where Point32Health operates Bachelor’s Degree in Nursing preferred National certification in Case Management desirable Experience (minimum years required): 5+ years’ relevant clinical experience Experience in home care or case management preferred Proficiency in second language desirable Experience in specialty areas such as oncology, neurology, chronic condition/disease management a plus Skill Requirements: Skill and proficiency in technical concepts and principles; computer software applications Skilled in assessment, planning, and managing member care Advanced communication and interpersonal skills Independent and autonomous with key job functions Ability to address multiple complex issues Flexibility and adaptability to changing healthcare environment Ability to organize and prioritize work and member needs Demonstration of strong clinical and critical thinking skills Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel): Must be able to work under normal office conditions and work from remote office as required. Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations. Ability to make face to face visits (member home, provider practices, facilities) as needed to meet the member needs and produce positive outcomes Valid Driver’s license and vehicle in good working condition as some travel required May be required to work additional hours beyond standard work schedule. Other duties as assigned and needed by the department

Administer assessments, collaborate with the member/caregiver and providers to develop a plan of care, implement member-specific CM interventions, and evaluate plan of care and revise as needed. Facilitate program enrollment utilizing key motivational interviewing skills Provide targeted health education, proactive strategies for condition management, and communication with key providers and vendors actively involved in the member’s care Perform both telephonic and face to face outreach to assess barriers to wellness, medical, behavioral, and psychosocial needs of the member. Collaborate with member/caregiver and the facility care team to coordinate a safe transition to the next level of care, which includes but is not limited to ensure understanding post-hospital discharge instructions, facilitate needed services and follow-up, and implement strategies to prevent re-admission Performs case documentation in applicable CM system according to department and regulatory standards Collaborates and liaises with the interdisciplinary care team, to improve member outcomes (i.e., Utilization Management, Medical Director, pharmacy, community health workers, dementia care specialists, wellness, and BH CM) Attend and present (as appropriate), high risk members at interdisciplinary rounds forum Maintain professional growth and development through self-directed learning activities Other duties and projects as assigned.

City of Hope

Manager, Patient Generated Health Data Program - Remote

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

Join the transformative team at City of Hope, where we're changing lives and making a real difference in the fight against cancer, diabetes, and other life-threatening illnesses. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and treatment facilities in Atlanta, Chicago and Phoenix. Our dedicated and compassionate employees are driven by a common mission: To deliver the cures of tomorrow to the people who need them today.

The Manager, Patient Generated Health Data (PGHD) Program will lead the development and oversight of a system-wide program for capturing and documenting patient-generated health data. This role involves managing Patient Reported Outcomes (PROs) content and tools across various biopsychosocial domains, ensuring that surveys, remote monitoring, and other PGHD elements align with patient care quality, regulatory requirements, payor mandates, and research objectives. The manager will collaborate with stakeholders across City of Hope entities to standardize and harmonize PGHD practices while coordinating with clinical departments, nursing, research, IT, and operations to maintain data integrity and deliver essential health education throughout the patient’s oncology journey. This is a remote position with up to 20% travel, offering an incredible opportunity to shape a highly impactful program in a dynamic and collaborative environment.

One of the following: Nursing Degree: A Bachelor of Science in Nursing (BSN) degree from an accredited institution and an Active and unrestricted Registered Nurse (RN) licensure in the applicable state; or MPH or MHA: Master of Public Health (MPH) or Master of Health Administration (MHA) from an accredited institution; or PhD or other advanced degree in life science or healthcare Minimum of 5 years of experience in patient care, healthcare administration, clinical, or research operations. 1 year of experience in a leadership capacity. Demonstrated success in coordinating cross-functional teams. Experience with EHRs or clinical information systems required. Experience in project management required.

Design and oversee the implementation of patient-generated health data (PGHD) across the health system, ensuring compliance with clinical, research, and quality standards. Collaborate with executive stakeholders, clinicians, and operational leaders to align PGHD tools with functional and strategic priorities. Partner with operations and IT teams to ensure seamless integration and technical feasibility of PGHD initiatives. Maintain regulatory compliance, including HIPAA and other privacy and quality reporting requirements. Monitor and evaluate project effectiveness, ensuring alignment with business objectives, timelines, and performance metrics. Develop and support education initiatives to enhance PGHD adoption, training, and patient engagement across clinical and non-clinical teams.

Travel Nurse Across America, LLC

Clinical Interview Specialist

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Akansas

TNAA was founded in 1999 by people who believed they could change the travel nursing industry for the better. This vision, along with a culture of honesty, transparency, and unmatched customer service, continues to guide our growth. We are now one of the fastest-growing healthcare staffing firms in the country!

The Clinical Interview Specialist evaluates clinical talent and conducts interviews, which results in placing the right clinical talent at the bedside in expedited timeframes. The Clinical Interview Specialist should possess a wide range of hospital and clinical experience over multiple specialties and be comfortable making recommendations based on this experience in order to support interview services, which SimpliFi provides to its hospital and health system clients. In addition to clinical efficacy, the Clinical Interview Specialist must be confident and competent in communicating effectively with the Client Relationship team. This role works closely with the Client Relationship team, Clinical Directors, Confidence Accelerating Practice (CAP) Managers, and the VP/Chief Clinical Officer.

Associate’s degree in Nursing (ADN) 3 years of nursing experience in multiple specialty areas RN License in at least one state Ability to effectively work in a fast-paced and complex environment and maintain a sense of urgency Ability to build and maintain productive working relationships with cross-functional coworkers Excellent communication skills Proficient with Microsoft Office Outlook, Word, and Excel Ability to travel up to 10% Will accept any suitable combination of education, training, or experience Preferred Qualifications: Bachelor of Science in Nursing (BSN) from a four-year college or university

Review vendor applicants with recent non-acute care experience or other QA concerns such as negative reference, skill mismatch, etc. and provide feedback to SimpliFi Account Manager and/or SimpliFi’s client relationship team Perform clinical team interviews based on client facility preference and offer on behalf of client Monitor workplace trends requiring updates in facility and unit requirements Uphold our Core Values Own Your Relationships - engage others with clarity, transparency, and care Obsess Over the Experience – distinguish yourself by providing the best possible experience every time Simplify the Process – use your unique skills to make the complex easy Defend Our Culture – embrace and encourage the principles that define our company Other duties as assigned

Dane Street, LLC

Group Health Operations Manager (RN/LPN)

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Florida

A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.

100% REMOTE JOB SUMMARY Oversee and ensure the overall profitability of the regional operations center. This includes but is not limited to reaching and exceeding financial & referral goals, properly managing staffing efficiencies throughout the team, managing performance expectations & improvements for existing staff. Present management with regular reporting on any topic requested by the management team. Dane Street’s success relies on individual and team contributions every day. We care for our customers, each other and Dane Street. It is the responsibility for all of us to maintain a positive working environment that promotes client satisfaction and results.

EDUCATION/CREDENTIALS: An Associate’s Degree or Bachelor’s Degree is preferred. RN / LPN License is required. JOB RELEVANT EXPERIENCE: Business experience in a healthcare and/or insurance setting is preferred. Business experience in a Worker’s Compensation and/or Auto insurance setting is preferred. Utilization Review experience is required. JOB RELATED SKILLS/COMPETENCIES: Present exceptional communication skills with a clear understanding of company business lines. The ability to apply critical thinking, manage time efficiently and meet specific deadlines. Computer literacy and typing skills are essential. WORK FROM HOME TECHNICAL REQUIREMENTS: Supply and support their own internet services. Maintaining an uninterrupted internet connection is a requirement of all work from home position.

Driving Revenue Growth: The Operations Manager drives revenue growth by delivering excellent Customer service. This includes meeting scheduling best practices and turnaround time requirements. Ensuring the timely delivery of high quality reports. Managing client inquiries in a timely manner. Optimizing Physician cost Ensuring that client invoices adhere to the agreed upon fee schedule. Overseeing the proper selection of physicians. Specifically ensuring that the team selects the most appropriate physician based on the claimant’s location, the required specialty, and the most appropriately priced physician based on the client’s fee schedule. Building relationships with key physicians to ensure panel retention. Manage Staff Performance and capacity: Monitor key performance metrics of individual Customer Service Representatives (CSR) and Quality Assurance (QA) Specialists. Ensure the team meets or exceeds 85% of output goals for scheduling and Quality Assurance targets. Responsible for hiring new staff members based on increased referral volume and/or the addition of new clients. Conducts performance evaluations that are timely and constructive. Handles discipline and termination of employees as needed and in accordance with company policy. Responsible for the overall production, performance, and quality of the assigned region. Plans and organizes daily activities related to production and operations. Measures productivity by analyzing performance data, financial data, and activity reports. Coordinates with other support departments such as human resources, finance, and IT and BA to ensure successful production operations. Determines labor needs to meet production goals.

Centene

Quality Improvement Specialist

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Illinois

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. THIS POSITION IS REMOTE/WORK FROM HOME. APPLICANTS MUST RESIDE IN THE STATE OF ILLINOIS AND HOLD AN ACTIVE UNRESTRICTED ILLINOIS RN LICENSURE. THE WORK SCHEDULE WILL BE MONDAY - FRIDAY 8AM - 5PM CENTRAL TIME ZONE. Supports the development and implementation of quality improvement interventions and audits and assists in resolving deficiencies impacting plan compliance to regulatory and accreditation standards. Interfaces with a diverse range of clinical and administrative professionals, resolves complex issues, and performs data analytics and reporting activities.THIS POSITION IS REMOTE/WORK FROM HOME. APPLICANTS MUST RESIDE IN THE STATE OF ILLINOIS AND HOLD AN ACTIVE UNRESTRICTED ILLINOIS RN LICENSURE. THE WORK SCHEDULE WILL BE MONDAY - FRIDAY 8AM - 5PM CENTRAL TIME ZONE. Supports the development and implementation of quality improvement interventions and audits and assists in resolving deficiencies impacting plan compliance to regulatory and accreditation standards. Interfaces with a diverse range of clinical and administrative professionals, resolves complex issues, and performs data analytics and reporting activities.You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

Education/Experience: A High School or GED with a current unrestricted RN license A Bachelor's Degree in Healthcare, Nursing, Health Administration, Public Health or related health field: Preferred Work Experience: 2+ years of experience in Quality Improvement Required 3+ years of experience in Managed Care Required Experience in compliance and accreditation Required Knowledge of federal and state regulations/requirements Required. Licenses and Certifications: A license in one of the following is required: Required Licensed Registered Nurse (RN)

Monitors and investigates all quality of care concerns and collaborates with medical director to determine impact and next steps for actions. Monitors provider quality complaints to identify trends and educational opportunities for improvement. Monitors quality improvement initiatives including, but not limited to, development and implementation of preventive health and chronic disease outcome improvement interventions such as: newsletter articles, member education and outreach interventions, provider education, member outreach interventions, medical record reviews, focus groups, and surveys. Analyzes, updates, and modifies procedures and processes to continually improve QI operations. Collects and summarizes performance data and identifies opportunities for improvement. Monitors and analyzes outcomes to ensure goals, objectives, outcomes, accreditation and regulatory requirements are met. Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, AAAHC, URAC, NCQA, EQRO). Conducts internal auditing of compliance with regulatory and accreditation standards. Pursues methods to ensure receipt of data required for trendIng and reporting of various QI work plan metrics, performs adequate data/barrier analysis, develops improvement recommendations, and deploys actions as approved. Participates in various QI committees and work groups convened to improve process and/or health outcomes, and contributes meaningful detail, based on functional knowledge. Completes follow-up as assigned. Manages and monitors assigned quality studies. Investigates and incorporates national best practice interventions to affect greater rate increases. Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements. Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline. Performs other duties as assigned. Additional Responsibilities: Completes Licensed Health Care Risk Management certification program. Performs annual update on Plan Risk Management Program Description. Coordinates the regular and systematic review of all potential adverse incidents in accordance with state statute. Performs other duties as assigned Complies with all policies and standards

Infiniti home health care Agency

Quality Improvement Nurse (Registered Nurse)

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

We are professional, agile and fast-paced. Our work environment includes: Virtual Setting

If you are a compassionate and skilled Registered Nurse looking to make a difference in the lives of patients, we encourage you to apply. Please submit your resume highlighting your relevant experience and qualifications.

Experience: Minimum of [2] years of experience as a Registered Nurse in an acute care setting. long term settings and home health settings Requirements: Valid Registered Nurse license in [State] BLS certification (Basic Life Support) Excellent communication and interpersonal skills Strong critical thinking and problem-solving abilities Ability to work effectively in a fast-paced environment

Chart reviews and quality improvement reccomendations Collaborate with interdisciplinary team members to develop individualized care plans To approve skilled nursing notes

Humana

Mom's Maternity Telephonic Nurse

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

At Humana, caring is everything. You look after our members and patients. We look after you. If caring means something to you too, we’ve got a spot for you. We design competitive and flexible benefits packages to provide our employees a sense of financial security now and in the future Fostering a culture of inclusion is part of the fabric of who we are. We must have a workplace that reflects the people we serve and thrives in part because every person can bring their whole self to work to do their best work. Our vibrant, diverse culture and environment of inclusion is one of our greatest strengths. About Humana Healthy Horizons Humana Healthy Horizons is more than a health plan. We’re human care. Humana Healthy Horizons focuses on helping people achieve their best health. Our dedicated strategies across various markets and states are enabled by partnerships with state and local governments, community-based organizations, and national partners committed to removing barriers to helping people achieve their best health.

The individual in this role will work as an Oklahoma-based, primarily telephonic care manager, assessing and evaluating enrollees’ needs and requirements to achieve or maintain optimal wellness by guiding enrollees/families towards and facilitating interaction with appropriate resources for their care and wellbeing. The individual in this role will work in collaboration with the interdisciplinary care management team. This team includes community health workers, housing support specialists, SDOH coordinators, and care management support assistants. The Mom’s First Maternity Telephonic Nurse work assignments are varied but will focus on those enrollees with primarily maternal health needs. The Mom’s First Maternity Telephonic Nurse will utilize clinical expertise and experience to determine when face-to-face enrollee support is required, engaging the appropriate members of the care management team and/or coordinating in-person meetings between the care manager and the enrollee. This team-based approach is designed to ensure enrollees receive holistic person-centered care. Work assignments for this role are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Must reside in Oklahoma. Active Registered Nurse (RN) license in Oklahoma or compact license (without restrictions) 2+ years of experience of in-home case or care management. 1+ years of acute care experience working in obstetrics, women’s care, labor and delivery, mother-baby, NICU and/or clinical triage. Experience working with Medicaid and/or Medicare Enrollees to coordinate services, care needs or benefits. Knowledge of community health and social service agencies and additional community resources. Exceptional communication and interpersonal skills with the ability to quickly build rapport. Comprehensive knowledge of all Microsoft Office applications, including Word, Excel and PowerPoint. This role is part of Humana's Driver safety program and therefore requires an individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100/300/100 limits. This role is considered member facing and is part of Humana Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.    Preferred Qualifications : Case Management Certification (CCM) Bilingual Spanish Speaking Work at Home Guidance: To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested Satellite, cellular and microwave connection can be used only if approved by leadership Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Performs telephonic and face to face assessments and evaluations of the member’s needs and requirements to achieve and/or maintain an optimal wellness state by guiding members/families toward the appropriate resources for the care and overall wellbeing of the member. Ensures member is progressing towards desired outcomes by continuously monitoring care through assessments and/or evaluations. Creates member care plans. Employs a variety of strategies, approaches, and techniques to manage an Enrollee’s behavioral, physical, environmental, and psycho-social health needs. Employs a variety of strategies, approaches, and techniques to manage an Enrollee’s behavioral, physical, environmental, and psycho-social health needs. Ensures Enrollees are progressing toward desired outcomes by continuously monitoring their assessments and evaluations. Identifies and resolves barriers that hinder effective care and ensures through continuous monitoring of assessments and evaluations that the Enrollee is progressing toward desired outcomes. Makes decisions about their own work methods, occasionally in ambiguous situations, and requires minimal direction, receiving guidance where needed. Follows established guidelines/procedures. Collaborates with providers and community services to promote quality and cost-effective outcomes.  Periodic travel to Humana Oklahoma office for meetings and training.

Community Health Network

Outpatient Clinical Documentation Specialist (RN or MD) IHCI - REMOTE

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Indiana

At Community Health Network, we build teams that deliver exceptional care through empathy, communication and collaboration. We consider ALL an integral part of the exceptional patient experience. We PRIIDE ourselves on not having employees but Caregivers. Join our Community as we make a difference in your community. Caring people apply here.

The Innovative Healthcare Collaborative of Indiana (IHCI) is a joint venture between Community Health Network and Deaconess Health System. Its goal is to support our sponsors and partners in their strategic evolution to positively impact and improve the healthcare delivery system.

Applicants for this position should possess excellent verbal and written communication skills with proficiency in organization and planning; working knowledge of quality improvement theory and practice; knowledge of federal, state and private payer regulations. Registered Nurse with a minimum of three (3) years Clinical Documentation Integrity/Improved in an OUTPATIENT setting Associate or Bachelor of Science degree in Nursing; must be graduate of Accreditation Commission for Education in Nursing or Commission on Collegiate Nursing Education accredited nursing program preferred. AAPC, AHIMA or ACDIS certification required

The Outpatient Clinical Documentation Specialist reports to the Clinical Documentation Integrity Manager and performs patient chart reviews to ensure accuracy Using their clinical and technical knowledge, the Clinical Documentation Specialist is responsible for: timely, accurate, and complete review of patient charts prior to patient encounters Uses a variety of technical platforms to complete workflows Interpreting reports and validating diagnosis codes representing patient symptoms and conditions Communicating professionally with providers to assist in accuracy of documentation; contributing to the provider education body of work and assisting with education initiatives Participating in post encounter reviews, sending queries & providing information Collaborating with and providing clinical support to Risk Adjustment Coders for chart reviews and queries.

Dignity Health

Care Coordination Clinical Educator

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Arizona

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.

This is a remote position. 1 of 2 opportunities available This position will act as a clinical educator and content expert for Care Coordination (CC) staff and leaders across CommonSpirit Health acute hospitals. This position will assist with the design and implementation of onboarding, educational content and training for newly hired and current staff and leaders to ensure they are knowledgeable about CommonSpirit Health workflow processes, regulatory requirements, respective roles and related competencies. Specific educational content developed will include how to use essential clinical applications and how to perform essential job functions and competencies. This position will rely heavily on the ability to independently and proficiently use technology, manage classrooms of people, as well as the ability to communicate and present professionally in order to effectively teach in person and remotely. Upon request this position will also serve as a staff and leadership development consultant.

Required Education, Experience and Skills: Requires Bachelor’s degree in Nursing (Master’s preferred) or Master’s degree in Social Work. A minimum of 2 years of education as well as minimum 2 years of management experience is required (or equivalent combination of education and management experience), preferably in Care Coordination. Requires an active Registered Nurse (R.N.) license or Master’s level SW license in good standing. Requires an expert level proficiency in Care Coordination attained with 5+ years of inpatient experience. Requires extensive knowledge in the areas of case management, utilization management, and/or social services. Must have a working knowledge of hospital and/or post-acute care operations, medical/nursing staff procedures, hospital and community resources. Experience in holding a variety of educational sessions including one-on-one, classroom settings, and web-based training programs. using virtual classroom technologies.

Assist with the design and delivery of onboarding/education for newly hired Care Coordination staff and leaders to ensure they are knowledgeable about CommonSpirit Health Care Coordination processes - including how to use clinical applications (technology); how to perform essential job functions; respective roles and related competencies. Initiate, coordinate, design, and implement education for staff and leaders which supports their ongoing professional development, evidenced-based patient-centered care delivery model, and patient care across the healthcare continuum. Education and staff development programs will be designed with a goal to enhance patient experience, reduce readmissions, prevent unnecessary admissions / ED visits, and support improved utilization of resources along the care continuum. Educational efforts will be aimed at helping to ensure an empowered, knowledgeable workforce while ensuring a plan of care for patients in all stages of health, efficient resource utilization, quality outcomes, and optimized reimbursement. Develop, implement, and maintain current state of the art educational material for staff to use (hard copy, electronic copy, in-person and electronic materials including PowerPoint, e-learning, and video materials) to assist staff in the use of electronic clinical applications and other key work functions for a variety of end users (e.g. entry level, advanced clinical staff, physicians and leaders). Adjust training material and timing to support product releases and regular workflow modifications. Be an expert resource to CommonSpirit Health staff, departments and entities as it relates to Care Coordination activities, processes, workflows, and efforts. Help to manage projects, timelines, implementation, and system design for new clinical applications, new workflows, processes, and policies. This includes assisting with the planning, development, implementation, and evaluation of education and related tools for Care Coordination processes and workflows. Use current research, resources, and tools in the identification of best practices and performance improvement strategies. Collaborate with outside vendors (e.g. naviHealth, Cerner,) to implement and maintain up-to-date Care Coordination education on related applications and products. Support change and participate in the development, implementation, and evaluation of goals/objectives /process improvement activities across the organization. Perform all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provide all customers of CommonSpirit Health with an excellent service experience by consistently demonstrating core values and leadership behaviors. Other duties as assigned, including but not limited to serving as LMS Administrator - creating, uploading, and assigning learning objects in Pathways. Additional Job Functions: Support and assist in planning and coordinating training sessions, annual conferences, projects, and team meetings as requested. Perform short and long-term educational planning and develop related programs as appropriate. Participate in team meetings and seminars as requested to keep current with policy, procedure, and regulatory changes. Lead committees, work groups and/or projects related to the implementation of educational activities. Assist with various ad-hoc projects as requested.

Accord Technologies Inc

RN Medical Case Manager

Posted on:

March 21, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Wyoming

The Medical Case Manager (MCM) is a Registered Nurse and may also be referenced as the Nurse Case Manager (NCM). The MCM implements integrated medical disability case management services with the goal of preventing, minimizing, or overcoming disability. The MCM provides medical expertise and serves as the critical communication link between the parties involved in any medical disability case. The MCM emphasizes returning medically-able individuals to productive service. The MCM ensures timely interventions and facilitates continuous communication while providing patient advocacy through supporting patient choices. As a Registered Nurse, the MCM, provides a professional nursing approach to case management through the Nursing Process involving: Assessment, Planning, Implementation, Monitoring, and Evaluation. The MCM is sensitive to the importance of productive work and sees a return to work as the key outcome

Education: Bachelors in Science Nursing or Associate in Nursing (ASN) or Nursing Diploma. Certification The Medical Case Manager role does require an active RN license in the state they live in and must be a US citizen. National certification in case management or related field preferred License: Unrestricted Current State Registered Nurse License, We need to have a record of RN Licenses for all Medical Case Managers submitted with their new hire paperwork. Experience: 3+ years of clinical experience as a Registered Nurse 2+ years experience in medical case management, discharge planning, utilization review/management to determine the necessity of medical services, occupational health, and/or comparable field Experience in Behavioral Health Chronic Medical Conditions or Oncology preferred,

Responsible for coordinating the treatment pathways of those claims that meet the internal case management criteria, including setting the appropriate treatment plan and other activities that meet an injured worker's/employee's health and return-to-work needs or other productive activity. Understands and implements criteria for identifying individuals for case management services Coordinates case management plans and activities with the human resources department of the injured worker/employee, as appropriate

Humana

Utilization Management LTSS Registered Nurse

Posted on:

March 21, 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 (UM) Nurse 2 RN utilizes clinical nursing skills to support the coordination, documentation and communication of long-term supports and services and/or benefit administration determinations. The UM Nurse work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The UM Nurse 2 work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors

Required Qualifications: Active Registered Nurse license in the state of Virginia, or obtain a multi-state license a bordering contiguous state that participates in the enhanced licensure, (eNLC) without disciplinary action Minimum one, (1) year previous experience in utilization management Minimum two, (2) years prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment Ability to work independently under general instructions and with a team Preferred Qualifications: LTSS service authorization, waiver experience Previous Medicare/Medicaid experience Previous experience in discharge planning and/or home health or rehabilitation Bilingual preferred (Spanish, Arabic, Vietnamese or other)

Uses clinical knowledge, communication skills, and independent critical thinking skills towards. Interpreting criteria, policies, and procedures related to Long Term Services and Support authorizations 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 and organizational strategy and operating objectives, including their linkages to related areas. Follows established guidelines/procedures. Makes decisions regarding own work methods, occasionally in ambiguous situations, requires minimal direction and receives guidance where needed.

Humana

CarePlus - Utilization Management Nurse

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Florida

About CarePlus Health Plans: CarePlus Health Plans is a recognized leader in healthcare delivery that has been offering Medicare Advantage health plans in Florida over 23 years. CarePlus strives to help people with Medicare, or both Medicare and Medicaid, achieve their best possible health and wellness through plans with benefits and services they care about. As a wholly owned subsidiary of Humana, CarePlus currently serves Medicare beneficiaries throughout 21 Florida counties. About Humana: Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers, and our company. Through our Humana insurance services, and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, 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.

Registered Nurse (RN) in the state of Florida with no disciplinary action. Minimum of 2 years clinical experience in hospital acute care experience with a broad background to include ICU, CCU, ER and Med Surg and/or a combination of skilled, rehabilitation, or long-term care. Excellent computer skills and ability to navigate easily using multiple application Proficiency in Microsoft Office Products Word, Excel, Outlook, Power Point and One Note Hours: Monday -Friday 8 am- 5 pm EST Work style: This position is considered primarily remote/work at home Location: Must reside in Florida Travel: 5% to market offices for business needs possible Remote Work at Home Requirements: WAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense. A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required. Satellite and Wireless Internet service is NOT allowed for this role. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information Screening: Associate working in the State of Florida will need Completion of a Level II; AHCA background clearance Fingerprinting. Preferred Qualifications: Utilization management Health Plan experience Previous Medicare/Medicaid Experience a plus Call center or triage experience Bilingual is a plus

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.

Diana Health

Remote Triage Nurse (Full-Time)

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

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 LPN passionate about all aspects of women’s health to provide direct patient care as part of an interdisciplinary care team and to serve as the first line of communication with patients in our clinical phone and messaging triage during office hours. The ideal candidate thrives in a busy practice, loves women’s health and building relationships with patients, is an excellent problem-solver and communicator, and is able to multi-task easily.

Current certification as a Tennessee Licensed Practical Nurse 2+ years of experience in an outpatient preferred Excellent communication, interpersonal, and organizational skills Strong computer skills and familiarity with EMRs Lactation certification (IBCLC, CLC, CLE) preferred, but not required

Patient Care: Act as the first line of call in clinical communications for patients, within guidelines/protocols Administer injections and medications Provide direct clinical care as needed for minor check in visits or lab draws Provide supporting paperwork and education for patients Support clinic visits as appropriate and per training when needed Administrative: Support the everyday flow of clinic acting as back up support for MA Maintaining logs Cleaning of rooms as needed and sterilization of instruments Obtaining and transcribing patient medical records Additional workflow items as the need arises

Info Origin, Inc.

Registered Nurse (RN)

Posted on:

March 21, 2025

Job Type:

Contract

Role Type:

Primary Care

License:

RN

State License:

Kansas

We are seeking a dedicated and compassionate Registered Nurse to join our healthcare team. The ideal candidate will possess strong clinical skills and a commitment to providing high-quality patient care. As a Registered Nurse, you will play a vital role in assessing patient needs, developing care plans, and implementing appropriate nursing interventions. This position requires excellent communication skills and the ability to work collaboratively within a multidisciplinary team.

Current Registered Nurse (RN) license in the state of practice. Experience in critical care (ICU) preferred but not required. Proficiency in medication administration and understanding of pharmacology. Familiarity with computerized tomography (CT) procedures is a plus. Strong background in case management and patient advocacy. Knowledge of MDS processes is advantageous. Experience with electronic health records, particularly Epic, is preferred. Excellent interpersonal skills and ability to work effectively with diverse populations. Commitment to ongoing professional development and nursing best practices.

Conduct comprehensive patient assessments to determine healthcare needs. Administer medications and treatments as prescribed, ensuring adherence to safety protocols. Provide care in specialized areas such as ICU, triage, and ostomy care. Collaborate with healthcare professionals in case management to coordinate patient care. Utilize electronic health record systems like Epic for documentation and tracking patient progress. Perform MDS assessments for long-term care patients. Assist with esthetic laser treatments as needed. Support patients with disabilities by adapting care plans to meet their unique needs. Educate patients and their families on health management and treatment options.

Aflac

Clinician Reviewer

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Georgia

We’ve Got You Under Our Wing We are the duck. We develop and empower our people, cultivate relationships, give back to our community, and celebrate every success along the way. We do it all…The Aflac Way. Aflac, a Fortune 500 company, is an industry leader in voluntary insurance products that pay cash directly to policyholders and one of America's best-known brands. Aflac has been recognized as Fortune’s 50 Best Workplaces for Diversity and as one of World’s Most Ethical Companies by Ethisphere.com. Our business is about being there for people in need. So, ask yourself, are you the duck? If so, there’s a home, and a flourishing career for you at Aflac.

Worker Designation – This role is a remote role. This means you will be expected to work from your home, within the continental US. If the role is remote, there may be occasions that you are requested to come to the office based on business need. Any requests to come to the office would be communicated with you in advance.

What does it take to be successful in this role: Extensive clinical experience/knowledge. Knowledge of medical diagnoses and ICD-10 codes. Strong investigative and analytical skills. Strong customer service and advocacy skills. Strong written and oral communication skills. Strong organizational and time management skills. Ability to analyze health care records in the context of functional capacity. Strong desire and ability to work in a team environment. Flexibility and coachability in the context of organizational growth and process change and development. Demonstrated ability to prioritize workload in a fast-paced environment, with proven organization and time management skills. Education & Experience Required: Associates Degree or Nursing Diploma Three years of experience in the field of health care working directly with patients. Two or more years of experience in absence management industry managing disability claims. Active, unrestricted medical license in the state of residence. Or an equivalent combination of education and experience Education & Experience Preferred: Bachelor's Degree In healthcare or related field. Travel Less than or equal to 10%

Serves as a clinical subject matter expert to disability case managers and provides well-reasoned and timely clinical analyses related to functional impairment. Reviews and evaluates disability claims to determine level of functioning based on knowledge of co-morbid health conditions. • Investigates and resolves inconsistencies in the level of functioning. Through a clinical advocacy approach, the clinician partners with case managers on return-towork plans via contacts with treating providers and employees when applicable. Assists in investigating and resolving inconsistencies in the level of employee functionality related to treating provider opinions, and projections of incapacity and impairment. Coordinates strategies to determine levels of employee functional capacity, utilizing direct contact with treating providers, and/or utilizing internal clinical resources (e.g. medical guidelines, independent medial reviews, internal impairment guides, claim discussion meetings, reviews). Acts as a clinical consultant and resource to the Appeals department when applicable and attends meetings as needed. Provides continuing education for case management staff via mini-clinical lectures, and assists in the development of clinical tools, guides, training, templates, processes, and protocols. Attends and/or presents clinical lectures designed to educate claims staff as requested. Facilitates referrals to ancillary internal and external services, e.g. EAP, disease management programs, advocacy, care managers, etc. as applicable. Identifies barriers in returning to work, to include identifying and prompting optimal health care to facilitate an appropriate and timely return-to-work plan and strategy. Communicates effectively with case managers, employers, employees, and health care providers. Anticipates, recognizes, and responds timely to needs of customers to ensure customer satisfaction. Supports implementation of customer initiatives to drive best outcomes. Reviews assigned customer cases, prioritizes workload, and interprets established processes and guides to resolve customer issues. Provides status updates to case managers to ensure clear communications and transparency. Resolves technical problems by referring to policies, procedures, and specifications, to ensure accuracy and operational consistency. Collects data and prepares clinical reviews, including commentary and an analysis to facilitate decision-making. Inputs relevant data into established systems accurately to allow for data analysis. Performs other related duties as required.

Dignity Health Medical Foundation

Inpatient Concurrent Review RN

Posted on:

March 21, 2025

Job Type:

Role Type:

Utilization Review

License:

RN

State License:

California

Dignity Health Medical Foundation established in 1993 is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health – one of the largest health systems in the nation - with hospitals and care centers in California Arizona and Nevada. Today Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers we provide increasing support and investment in the latest technologies finest physicians and state-of-the-art medical facilities. Our 130+ clinics across the state of California deliver high-quality patient-centric care with an emphasis on humankindness. Through affiliations with Dignity Health hospitals along with our joint ventures and partnerships we offer a robust state-of-the-art health care delivery system in the communities we serve .We strive to create purposeful work settings where staff can provide great care while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled qualities that are vital to maintaining excellence in care and service.

***Please note: This is a non-benefitted, on-call position. ***This position is work from home within driving distance to Sacramento, CA. Position Summary: This position is responsible for monitoring Dignity Health Medical Foundation inpatient admissions and concurrent review for appropriate level of care and medical necessity using InterQual and Medicare criteria. This position will work closely with the hospitalist team Dignity Health Medical Foundation Medical Director’s specialists clinic staff and Inpatient care coordination to communicate all Dignity Health Medical Foundation inpatient needs level of care and medical necessity. This position will also work closely with Dignity Health Medical Foundation clinical staff post-acute staff and hospital care coordination to coordinate the care necessary for successful post hospitalization and transition of care needs across the continuum of healthcare.

Minimum Qualifications: Three (3) years acute care or related experience including experience in case management, utilization review or discharge planning. Clear and current CA RN license. Preferred Qualifications: Concurrent review, prior authorizations for medical determination preferred. Bachelors degree preferred. Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.

Concurrently review patient’s records to collect data to carefully understand the needs of the patient by scrutinizing their background history understanding their current needs and arranging for their wellbeing. Coordinates with other disciplines to facilitate the patient’s individual needs. Makes plans to resolve unexpected care requirements. Anticipates and identifies variances in the care process related to those identified needs. Perform concurrent review of emergent/urgent and continued stay requests for appropriate care admission status level of care following guidelines and policies. Approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other. Complete medical necessity and level of care concurrent reviews for requested services using clinical judgment and established guidelines. Refer to Medical Directors for review depending on case findings. Collaborate with various staff within provider networks hospital teams and Inpatient Care Coordination to establish discharge planning expectations to coordinate transition of care needs. Identify and facilitate resolution of system process problems impeding UM functions. Identify collaborate and resolve. Facilitate the annual update of InterQual (or other screening tool) software create training tools in collaboration with UM leadership. Assist with developing and maintaining efficient and effective documented policies and procedures for non-coverage notifications including Notice of Non-coverage (HINN) and Advance Beneficiary Notice of Noncoverage (ABN) to include compliance monitoring. When barriers are identified assists the patient family caregiver care coordination with Utilization management as related to referrals. Considers the population served by Dignity Health and area clinical integration programs and leads efforts to optimize utilization management and care coordination across the care continuum in the most cost effect manner. Other duties as assigned.

CVS Health

Case Manager RN-Work From Home

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Illinois

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.

The Case Manager RN role is 100% remote work from home and candidates must have an active Illinois RN licensure (but does not need to live in Illinois). Normal Working Hours: Monday through Friday 9:00am – 5:30pm in time zone of residence. Occasional evening, weekend, and holiday shifts per the needs of the team. No travel is expected with this position. The RN Case Manager is responsible for telephonically and/or face to face assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness.

Required Qualifications: Must have an active Illinois RN licensure (does not need to live in Illinois). 2+ years of clinical experience as an RN All clinical experience will be considered, such as Emergency Department, Home Health, Hospice, Operating Room, ICU, NICU, Telemetry, Medical / Surgical, Orthopedics, Long Term Care, and Infusion nursing. Preferred Qualifications: Certified Case Manager (CCM) certification 3+ years’ experience with Microsoft Office Suite Multiple State RN licensure is welcomed but not required. If chosen must be willing and able to obtain multiple state RN licensure after hire (expenses paid for by company) Case Management in an integrated model Discharge Planning experience Managed care experience BSN preferred Education: Associates Degree in Nursing

Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness through integration. Through the use of clinical tools and information/data review, conducts an evaluation of member’s needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. 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 take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Reviews prior claims to address potential impact on current case management and eligibility. Assessments include the member’s level of work capacity and related restrictions/limitations. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining 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. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

Access Healthcare Associates

Clinical Supervisor

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

California

RN/Clinical SupervisorOverviewAccess Healthcare Associates is a mobile medical practice catering to the senior population. We are currently looking for a full-time RN/case manager with experience in assisted living communities. The job of the nurse supervisor is to provide nursing support to our clinical staff including our physicians and practitioners. The ability to efficiently triage changes in patient conditions such as infections, falls, behavioral issues, and lab results, is a necessity. The ideal candidate will have an interest in and prior experience with the elderly population, in particular spent in assisted living communities. The ideal candidate must be friendly, outgoing, motivated, and have sufficient clinical experience including experience with using electronic health records. Candidates must be able to multitask in a busy environment.

The individual should possess the following attributes: Excellent verbal & written communication skills Detail-oriented, strong organization skills Experience preferred: Strong computer skills Excellent interpersonal skills Professional appearance & demeanor Dedicated, reliable, punctual, and flexible Triage/de-escalation skills Background in leadership and management

Oversee the clinical department - 15+ plus virtual staff/medical staff Main communicator between hospitals, facilities, pharmacies, nurses, patients, and family members Carry out patient cases Carry out providers' orders Check/review labs/imaging Carry out prescription orders and refills Coordinate and conduct clinical meetings Delegate tasks as needed Host in-services for facilities, families, and patients as needed Work with upper management to onboard and train clinical staff Assist in producing and adopting clinical protocols and best practices for clinical staff

Community Health Systems

Clinical Review Auditor

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Florida

We know it’s not just about finding a job. It’s about finding a place where you are respected, valued and where your work is purposeful and fulfilling. A place where your talent is recognized, professional development is encouraged and career advancement is possible. Community Health Systems is one of the nation’s leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 70 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.

(Full-Time, Remote) The Clinical Review Analyst is a professionally licensed nurse/LPN who is responsible for effectively managing the denial/appeal process via the performance of comprehensive analytic reviews of clinical and claim documentation. The CRA will perform triage, determine payment viability; and draft and submit credibly defensible appeals (according to payer guidelines) to obtain appropriate reimbursement for care delivered to patients. As a Clinical Review Analyst at Community Health Systems, you’ll play a vital role in supporting our purpose to help people get well and live healthier by providing safe, quality healthcare, building enduring relationships with our patients, and providing value for the people and communities we serve. Our team members enjoy a robust benefits package including health insurance, flexible scheduling, 401k and student loan repayment programs.

Required: Experience: Clinical experience in an acute care setting Education: High School Diploma; Nursing Degree License/Registration/Certification: Must possess current RN/LPN licensure in state of Florida Computer Skills: To perform this job successfully, an individual should have knowledge of Word Processing software, Spreadsheet software and E-mail software Additional Skill Requirements: Must be detail oriented and current in healthcare pathophysiology concepts. Must be able to multitask and seek answers using online tools. Preferred: Experience: Four to six years related experience; Previous healthcare financial services experience or appeals/denials experience Education: Master’s Degree License/Registration/Certification: RN Licensure

Maintains a working mastery of industry-standard utilization review criteria (i.e.: Interqual), coverage guidelines, and payor medical policies Demonstrates knowledge of governmental, managed care, and commercial denial/appeal policies Appropriately reviews and triages denials for A/R, billing, downgrade, appeal, or denial adjustment Able to prioritize and manage caseload without jeopardizing timely filing Demonstrates excellent technical and clinical skills by drafting credible, defensible appeals Conducts thorough evidence-based clinical literature research to support appeals, as needed Understands and files appropriate levels of appeal (i.e.: reconsideration, dispute, appeal, ALJ…) Accurately enters data into the Appeal Tracker, Cerner/ClaimIQ/Artiva, or other programs Notifies department leadership regarding patterns/trends Together works with department leadership and other Denial Management Team Members to develop and facilitate processes which promote job effectiveness and efficiency Ability to perform all other duties as assigned or requested Ensure confidentiality of all patient accounts by following HIPAA guidelines This is a remote position.

Cambia Health Solutions

Appeals Clinician I

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Oregon

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Work from home within Oregon, Washington, Idaho or Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system. Who We Are Looking For: Every day, Cambia’s dedicated team of Appeals Clinicians are living our mission to make health care easier and lives better. As a member of the Health Services Organization team, our Appeals Clinicians utilize clinical expertise to complete the clinical component of all appeal types to resolve member and/or provider appeals – all in service of making our members’ health journeys easier. Are you passionate about being a voice for patients in complex healthcare situations? Do you want to utilize your clinical expertise in a way that impacts thousands of lives? Then this role may be the perfect fit.

Bachelor's Degree in Nursing 3 years of experience in a clinical setting, health insurance, coding/claims review, case management Equivalent combination of education and experience Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) of direct clinical care Bachelor’s degree (or higher) in a health or human services-related field (psychiatric RN or Masters degree in Behavioral Health preferred for behavioral health appeals management); or Registered nurse (RN) license (must have a current unrestricted RN license within either OR, WA, ID or UT) Skills and Attributes: Demonstrated competency in claim review and experience using billing and claims forms. Proven knowledge of medical and surgical procedures and other healthcare practices. Proven competency to apply clinical expertise to ensure compliance with medical policy. Familiarity regarding rules applied to appeals by accrediting bodies, state and federal governments, and employer groups. Knowledge in reading and interpreting medical records, patient data, and member benefits with an ability to communicate complex topics effectively with clinical and non-clinical staff. Knowledge of personal computer software, such as Microsoft Word, Excel, PowerPoint and Access. Ability to prepare and present clear and concise written narratives and decisions. Knowledge of CPT, ICD-9 and HCPCS coding and MCG (Milliman Care Guidelines). Ability to work overtime (more details to come during interview).

Applies nursing expertise and clinical judgement to ensure written appeal decisions are in compliance with medical policy, medical necessity guidelines, reimbursement policies, federal regulation, company policy, industry standard and accepted standards of care. Conducts clinical appeal reviews which adhere to member benefits and provider and hospital contracts. Consults with physician advisers to ensure clinically appropriate determinations when required. Advises and educates non-clinical appeals staff on clinical cases.

Cambia Health Solutions

Payment Integrity RN

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Washington

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Work from home (telecommute) within Oregon, Washington, Idaho or Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system. Who We Are Looking For: Every day, Cambia’s Payment Integrity Audit Team is living our mission to make health care easier and lives better. Payment Integrity Clinician I conducts post service review of claims in prepayment, post payment or audit capacity to ensure appropriate clinical review, reimbursement of claims and accuracy of coding. Applies resources, including but not limited to, internal medical and reimbursement policies and correct coding guidelines based on national standards to support claim review and determination – all in service of making our members’ health journeys easier. If you're a motivated and experienced RN with Payment Audit experience looking to make a difference in the healthcare industry, apply for this exciting opportunity today!

Qualifications and Certifications: Associates or Bachelor's Degree in Healthcare 3 years of experience in a clinical setting, health insurance, coding/claims review, case management or equivalent combination of education and experience Skills and Attributes (Not limited to): Knowledge of medical and surgical procedures and other healthcare practices. Competency to apply clinical expertise to ensure compliance with medical policies and/or reimbursement policies. Ability to read and interpret medical records and patient data and communicate effectively with clinical and non-clinical staff. Excellent computer skills and proficiency working software programs (i.e. Microsoft Word, Excel, and PowerPoint); learn new processes and systems quickly. Strong verbal, written and interpersonal communication and customer service skills. Ability to work in rapidly changing environment. Strong research, analytical, math and problem-solving skills. Ability to work independently; detail-oriented. Must be able to multi-task and set priorities with minimal supervision.

Applies nursing expertise to ensure compliance with medical and reimbursement policies and/or guidelines and accepted standards of care. Ensures that medical records and other documentation requirements follow federal regulations, company policies and industry standards. Serves members and providers by performing reviews of claims along with corresponding medical records (when required) to ensure appropriate payment of claims. Consults with physician advisors to ensure clinically appropriate determinations. Collaborates with other departments to resolve member or provider claims adjudication issues.

J&B Family of Companies

Registered Nurse - Telehealth Pt Assessment - REMOTE in MI

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Michigan

REMOTE or In Office - MUST HAVE VALID MICHIGAN RN LICENSE Our Nursing Team is growing! Great Benefits after 30 days! PTO & Holiday Pay after 90! Summary: Our Staff Nurse's are responsible for conducting patient assessments by phone (ours) to determine individual needs for incontinence supplies. Work Environment: This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Position Type: This is a full time REMOTE or in office position 40 hours per week. Monday through Friday, hours of work vary between 8:00am to 6:00pm. Occasional early mornings, evening and weekend work may be required as job duties demand.

Required Education and Experience: Current Registered Nursing License (RN) with the State of Michigan (MI ONLY - CNL'S ARE NOT ACCEPTED) 2+ years previous work experience demonstrating patience, compassion and strong communication skills Must be great on the computer, able to use multiple databases simultaneously Preferred Education and Experience: 3 years of nursing experience Knowledge of medical terminology Medicare and Medicaid background Durable Medical Equipment (DME)

Consults by phone with client, primary caregiver, primary care physician or specialist, case managers and other community resources to determine if client qualifies for a particular program. Expectation is that Nurse will complete 20-25 assessments daily, on average with 98% accuracy. Conducts clinical assessments by phone and documents the client’s medical history. Monitors success rates. All products ordered must be assessed for use and quantity needs per day. Identifies appropriate product and quantity needs based on assessment. If formulary product will not meet needs, then reviews needs and potential solutions with Nurse Manager. Reassesses if there is a change in a client’s medical condition or an increase in quantity request. Obtains prior authorization from the state contract administrator for off-formulary or over-quantity requests. Reviews letters of medical necessity to determine if client qualifies for product or quantity requested. Reviews accounts for accuracy, reporting any errors to the appropriate department manager/leader. Participates in after-hours emergency call rotation. Understanding of insurance guidelines. Utilize intranet tools to complete assessments. Provides education to other J & B employees or external clients regarding products. Other Duties: All other duties as assigned by management. Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are request of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Omega-Himagine Solutions

Case Management Utilization Review RN

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Oregon

The Utilization Review RN monitors utilization practices from preadmission to discharge to assure cost-effective utilization of resources, quality patient care, and compliance with regulatory requirements.

RN: Registered Nurse Licensed by Oregon State Board of Nursing Preferred: Bachelor's degree in Nursing CCM: Certified Case Manager ACM: Accredited Case Manager Phy-Sit comfortable position, frequent opportunity to move Enviro-Indoor-Comfortable area Hazards-Only unplanned exposure to blood, body fluids HIPAA-Pay-View or read only minimum for work assignment HIPAA-Treat-Originate, view, change nec for work assignment HIPAA-Ops-View or read only minimum for work assignment

This role is responsible for reviewing the medical record to ensure documentation demonstrates medical necessity according to regulatory guidelines. The Utilization Review RN will actively manage and communicate with key members of the care team to secure accurate documentation and admission status

ProgenyHealth LLC

Maternity Case Management Supervisor

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Pennsylvania

The Case Management (CM) Supervisor of Maternity is primarily responsible for managing the CM staff in the day-to-day operations of the department. This includes oversight and adjustment of work queues to maintain workflow balance; monitoring and facilitating adherence to department and company metrics; training of new hires and current staff; and various other duties to support the case management staff and the company program. The Supervisor also assesses the CM Maternity program for opportunities to improve efficiencies and/or improve outcomes. Reporting to the Manager of Maternity CM, the Supervisor will work closely with the management staff and plays a key role in implementing the culture and work environment that promotes and inspires an active, continuous improvement philosophy regarding products and services in line with our company mission.

Registered Nurse (RN) with a current, unrestricted license is required. BSN is strongly preferred. Three or more years of experience in a Case Management role is required. Previous experience in a Maternity case management program preferred. Experience in a team lead or supervisory role managing nursing staff is desired. CCM certification required within the timeframe specified by company policy. Must be available to stay late, as needed, to manage staff and caseloads. Experience with NCQA standards preferred. Must have demonstrated strong problem-solving skills. Must have proven track record of utilizing tact, diplomacy, and strategic thinking in addressing issues and changes in company policy, etc. Must be self-motivated and willing to learn multiple tasks. Must be well organized and able to prioritize tasks. Must have good computer skills and be familiar with using Microsoft Office (Word, Outlook etc.) Must demonstrate accuracy in spelling and documentation. Must have commitment to excellence in customer service.

Supports team members and clients in the day-to-day operations of Maternity CM Department. Meets with staff regularly to touch base, get feedback and to hear and address their concerns or issues. Oversees team caseload in the medical management system and consults with staff to adjust as needed. This includes regular case review (in addition to staff assessments). Provides coverage for CM caseload as needed for emergency coverage.

ProgenyHealth LLC

Utilization Management Supervisor

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Pennsylvania

ProgenyHealth is a leading provider of care management solutions for premature and medically complex newborns positively impacting maternal and infant health outcomes across America. Our program builds a network of support for an uninterrupted continuum of care from prenatal health, through any resultant NICU stay, and all the way to one full year of life. Our team of neonatologists, pediatricians, and NICU nurses provide continuity of care in collaboration with providers from hospital to caregivers at home and throughout the first year of life. We help overcome systemic barriers to support healthier pregnancies and healthier starts to life for all moms and babies, one family at a time.

Reporting to the Director of Utilization Management, the Supervisor will work closely with the management staff and will play a key role in implementing the culture and work environment that promotes and inspires an active, continuous improvement philosophy regarding products and services in line with our company mission statement: To improve the health outcomes of infants in intensive care nurseries through partnership, care facilitation, continuous quality improvement and a firm commitment to excellence.

Registered Nurse (RN) with a current, unrestricted license is required. Two or more years of experience in Managed Care, in a Utilization Review or Case Management role, is required. Experience in a team lead or supervisory role managing nursing staff is desired. Three or more years of clinical experience as a bedside nurse in NICU/PICU/Peds/ICU required. Must be available to stay late as needed to manage staff and caseloads. Experience with URAC standards preferred. Must have demonstrated strong problem-solving skills. Must have proven track record of utilizing tact, diplomacy and strategic thinking in addressing issues and changes in company policy, etc. Must be self-motivated and willing to learn multiple tasks. Must be well organized and able to prioritize tasks. Must have good computer skills and be familiar with using Microsoft Office (Word, Outlook etc) Must demonstrate accuracy in spelling and documentation. Must have commitment to excellence in customer service.

The Utilization Management Supervisor will primarily be responsible for managing the UM nursing staff in the day to day operations of the department. This includes oversight and adjustment of work queues, when needed, to maintain work flow balance; monitoring and implementing adherence to department and company metrics; training of new hires and on-going clinical; and various other responsibilities to support the clinical nursing staff and the company program. The incumbent will also be responsible for assessment of the UM program for opportunities to improve efficiencies and/or improve outcomes.

ProgenyHealth LLC

Utilization Management Nurse

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

None Required

State License:

Pennsylvania

ProgenyHealth is a leading provider of care management solutions for premature and medically complex newborns. Our program promotes appropriate utilization, improves access, educates family members and reduces costs. Our team of neonatologists, pediatricians, and NICU nurses provide continuity of care in collaboration with providers from hospital to home and throughout the first year of life.

The Utilization Management Associate (UMA) will assist the ProgenyHealth UM program by providing administration support to the Utilization Review department. This includes: intake, screening and precertification of appropriate healthcare services. They will also be responsible for assisting the Clinical Care Nurses with clerical tasks associated with discharge planning/utilization review functions. The UMA will report to the Supervisor of Utilization Review. Hours for this job will be Monday through Friday 10:00am to 6:30pm EST, with flexibility as needed.

1 – 3 years of experience in customer service in a healthcare environment. HS diploma or equivalent required. College degree preferred. Insurance/payor experience preferred. Working knowledge of healthcare terminology. Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas as well as interact professionally and effectively with members, clients, and staff from all departments within and outside the company. Problem solving skills with the ability to look for root causes and implementable, workable solutions. Must be proficient at an intermediate to advanced level in Outlook, Excel, PowerPoint, & Word. Must be fluent in English. Proficiency in a second language is highly desirable. Must be self-motivated and willing to learn multiple tasks. Must be well-organized and able to prioritize tasks. Must have commitment to excellence in customer service.

Monitor Member eligibility Perform outreach calls to hospitals for follow-up clinical information and discharge info Process new admissions: this includes update of patient demographics; create new case in BabyTrax®; document new case in client system; assign Clinical Care Nurse Communicate verbally and/or written prior authorizations based on client specifications Receive incoming calls for UM and refer to appropriate staff member Adheres to policies, procedures and regulations to ensure compliance and patient safety. Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements Provides additional support and project work within the various Care Management areas of accountability as needed.

Eye Health America LLC

Clinical Triage Specialist

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

None Required

State License:

South Carolina

Eye Health America is looking for trained ophthalmic technicians who would like to apply their clinical knowledge to help patients in a remote capacity. The ideal candidate has spent at least 2 years working with patients inside an eye care clinic and has strong conversational and problem-solving skills.

At least 2 years of Ophthalmic Technician experience COA certification is a plus! Call center experience is a plus! Adequate training will be provided upon hire

Take inbound patient calls related to: Prescription questions Pre-surgical and post-surgical questions Adverse events related to surgeries and prescriptions Triaging emergent eye issues and scheduling urgent appointments Place outbound calls related to: Patient voicemails with clinical questions Directives from in-clinic providers and staff on clinical communication to patients Patient educational programs Input and maintain accurate and up-to-date patient records, including demographic information Serve as an advocate for patients, addressing their concerns and ensuring their needs are met Maintain patient confidentiality in accordance with healthcare privacy laws (e.g.,HIPAA)

MCMC, LLC

Clinical Quality Assurance Coordinator

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Maryland

MCMC completes over 100,000 reviews each year for more than 400 clients, including almost all of the nation’s largest Health Plans, PBMs, Disability Carriers, TPAs, UR companies, Self-Insured Employers, Taft-Hartley Plans and Government Organizations.

Ready for a Rewarding Career that Fits Your Lifestyle? Imagine a job where you can keep your clinical skills sharp, tackle exciting challenges, AND work from the comfort of your own home. Sounds like the perfect mix, right? MCMC is looking for a self-driven, high-performing Nurse (LPN, LVN or RN) to join our dynamic team as a Clinical Quality Assurance Coordinator. In this role, you’ll ensure our Peer Review case reports are nothing short of exceptional—delivering top-notch quality and integrity, all while staying fully aligned with client agreements, regulatory standards, and state and federal mandates. The position is 100% remote with a schedule of Monday through Friday, 11:30am-8:00pm EST, with occasional holiday coverage and possible weekend coverage as needed. Could you be our next great addition to the MCMC family? Let's find out!

Active nursing license required. Must be a graduate of an accredited nursing program or related medical experience; bachelor's degree preferred. Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values. Must be a qualified typist with a minimum of 40 W.P.M Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet. Must possess excellent skills in English usage, grammar, punctuation and style. Ability to follow instructions and respond to upper managements’ directions accurately. Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met. Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed. Must be able to work independently, prioritize work activities and use time efficiently. Must be able to maintain confidentiality. Must be able to demonstrate and promote a positive team -oriented environment. Must be able to stay focused and concentrate under normal or heavy distractions. Must be able to work well under pressure and or stressful conditions. Must possess the ability to manage change, delays, or unexpected events appropriately. Demonstrates reliability and abides by the company attendance policy.

Performs quality assurance review of peer review reports, correspondences, addendums or supplemental reviews. Ensures clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations. Ensures that all client instructions and specifications have been followed and that all questions have been addressed. Ensures each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications. Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards. Ensure that the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report. Verifies that the peer reviewer has attested to only the fact(s) and that no evidence of reviewer conflict of interest exists. Ensures the provider credentials and signature are adhered to the final report. Identifies any inconsistencies within the report and contacts the Peer Reviewer to obtain clarification, modification or correction as needed. Assists in resolution of customer complaints and quality assurance issues as needed. Ensures all federal ERISA and/or state mandates are adhered to at all times. Provides insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications. Promote effective and efficient utilization of company resources. Participate in various educational and or training activities as required. Perform other duties as assigned.

Valor Healthcare, Inc.

Remote Program Manager Registered Nurse (RN) - Government Healthcare Call Center

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

District of Columbia

Valor Healthcare is looking for a Telehealth Registered Nurse (RN) program manager to join our proposal team for a government contract to support the Global Nurse Advice Line (NAL) which is a service to Military Health System (MHS) eligible beneficiaries. Position Summary The Global NAL will provide access to telehealth registered nurses for triage services, self-care advice, and general health inquiries 24 hours a day, 7 days a week. The NAL also offers customer service and care coordination services to include, provider locator support, specified military treatment facility appointing services, urgent care referral submissions, and customized military treatment facility transfers to support the military treatment facility’s capability for eligible MHS beneficiaries. The ideal candidate will have extensive experience in supervisory healthcare roles, especially in call centers or nurse triage positions with strong leadership and communication skills in implementing programs and projects. Schedule and Remote Eligibility This position is remote eligible as long as you are living in one of the US states. The schedule will be a general 40 hour work week on a day shift, Monday through Friday.

Minimum of 15 years of healthcare call center, telehealth nurse triage programs, or equivalent experience. Minimum of 5 years of supervisory or leadership nursing experience. Bachelors degree in nursing from an accredited university required. Active RN license in any state, commonwealth, or District of Columbia. US Citizenship required.

Program Leadership: Lead and supervise a team of healthcare professionals, demonstrating strong leadership, interpersonal, organizational, and communication skills. Program Implementation: Manage the implementation of nurse triage programs, including resource identification, allocation, maintenance, and adjustments as needed. Formal Planning: Develop comprehensive plans for program execution, ensuring that all aspects are well-defined and tracked. Performance Tracking: Oversee the formal tracking and reporting of program performance metrics to ensure alignment with organizational goals. Quality Assurance: Maintain the highest standards of patient care and quality assurance within the call center operations. Regulatory Compliance: Ensure that all programs and activities adhere to relevant healthcare regulations and guidelines. Collaboration: Collaborate with cross-functional teams to ensure the success of healthcare programs and projects. Ensures departmental compliance with regulatory and The Joint Commission requirements. Assists with the hiring, training, directing, development, and evaluating of nursing staff. Responsible for maintaining, educating, and monitoring of Call Center/Communications operations. Acts as liaison to ensure excellent customer service by frequent and timely communication.

Family HealthCare

RN Phone Triage

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

North Dakota

Are you passionate about making a difference in your community? If yes, come join us at FHC where you will be able to provide exceptional services to our unique patients. We are committed to helping the most vulnerable of our community and believe everybody deserves high-quality care regardless of age, nationality, or ability to pay.

Family HealthCare is looking for a Phone Triage Registered Nurse to join our team. Working at Family HealthCare is a very rewarding experience! **Option to be fully remote once trained! Schedule M-F, Full time - no nights, weekends, or holidays

Graduate from accredited nursing program preferred Current North Dakota and Minnesota Registered Nurse licenses required Current BLS certification required

This role is responsible for answering patient inquiries over the telephone and assessing the severity of the patient's symptoms and medical needs according to triage algorithms; Guides the patient to the appropriate level of care and schedules patient appointments over the phone with appropriate healthcare providers/facilities/physicians.

A Mother’s Touch Homecare Agency

Registered Nurse

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Ohio

We are seeking a dedicated and compassionate Registered Nurse (RN) to join our healthcare team. The ideal candidate will possess a strong commitment to providing high-quality patient care in various settings, including hospitals, assisted living facilities, and medical offices. This role requires excellent clinical skills, the ability to work collaboratively with a multidisciplinary team, and a passion for improving patient outcomes.

Current Registered Nurse (RN) license in the state of practice. Experience in pediatrics, behavioral health, or assisted living is preferred. Familiarity with infection control practices and protocols. Ability to perform dialysis procedures is a plus. Strong communication skills and the ability to work effectively with diverse populations, including those with disabilities. Knowledge of CT imaging processes is beneficial but not mandatory. Commitment to ongoing professional development and staying current with nursing best practices.

Assess and monitor patient health status, including vital signs and symptoms. Administer medications and treatments as prescribed by physicians. Provide education and support to patients and their families regarding health conditions and care plans. Collaborate with healthcare professionals to develop and implement individualized care plans. Perform specialized procedures as needed, such as spinal taps and cardiac catheterization. Ensure adherence to infection control protocols to maintain a safe environment for patients. Assist in the management of patients with behavioral health issues or disabilities. Document all patient interactions accurately in medical records.

Molina Healthcare

Sr Specialist, Quality Improvement (RN) Remote

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Leadership / 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.

Molina's Quality Improvement function oversees, plans, and implements new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs for members in accordance with prescribed quality standards; conducts data collection, reporting and monitoring for key performance measurement activities; and provides direction and implementation of NCQA accreditation surveys and federal/state QI compliance activities. KNOWLEDGE/SKILLS/ABILITIES The Senior Specialist, Quality Improvement (Registered Nurse) contributes to one or more of these quality improvements functions: Quality Interventions, Quality Improvement Compliance, and / or Quality Reporting.

Required Education: Bachelor's degree in nursing or higher Required Experience: Min. 3 years’ experience in healthcare with minimum 2 years’ experience in health plan quality improvement, managed care, or equivalent experience. Required License, Certification, Association: Active and unrestricted RN license for the State(s) of employment Preferred field: Clinical Quality, Public Health or Healthcare. Nursing: Master's or higher Preferred Experience: 5 - 7 years hospital clinical experience and prior managed care. Excellent professional writing skills, and solid critical thinking skills. Preferred License, Certification, Association: Compact licensure Certified Professional in Health Quality (CPHQ) Registered Health Information Technician (RHIT), or Certified Medical Record Technician with training in coding procedures (as required by state/location only), or Certified Professional Coder (CPC)

Acts as a lead specialist to provide project-, program-, and / or initiative-related direction and guidance for other specialists within the department and/or collaboratively with other departments. Implements key quality strategies that require a component of near real-time clinical decision-making. These activities may include initiation and management of interventions (e.g., removing barriers to care); preparation for Quality Improvement Compliance surveys; preparation and review of potential quality of care and critical incident cases; review of medical record documentation for credentialing and model of care oversight; and any other federal and state required quality activities. Monitors and ensures that key quality activities that involve clinical decision-making are completed on time and accurately in order to present results to key departmental management and other Molina departments as needed. Writes narrative reports to interpret regulatory specifications, explain programs and results of programs, and document findings and limitations of department interventions. Creates, manages, and/or compiles the required documentation to maintain critical quality improvement functions that have a component of clinical decision-making. Leads quality improvement activities, meetings, and discussions with and between other departments within the organization. Often the Senior Specialist will be assigned activities where clinical expertise is important to the activity. Surfaces to Manager and Director any gaps in processes that may require remediation. In particular, the Senior Specialist may be asked to focus on parts of the process where a clinician's perspective would be valuable to uncover process gaps or limitations.

CVS Health

Utilization Management Nurse Consultant- Work From Home-PST

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Washington

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 Utilization Management (UM) Nurse Consultant role is fully remote but must reside in PST zone. Normal Working Hours: -Monday through Friday between 8am-5pm PST. -There is an occasional weekend shift requirement per the needs of the team - Holiday rotation per the need of the department. There is no travel expected with this position. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records.

Required Qualifications: Must reside in PST zone. RN with active and unrestricted state licensure in state of residence 3+ years of clinical experience as an RN preferably in the following areas: Med/Surg, Telemetry, ICU, NICU, Long term care, cardiology Preferred Qualifications: 1+ years’ experience in either Precertification or Utilization Review 1+ years’ experience Managed Care Strong telephonic communication skills 1+ years’ experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook) Experience with computers toggling between screens while using a keyboard and speaking to customers. Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills Ability to manage multiple priorities, effective organizational and time management skills required Ability use a computer station and sit for extended periods of time Education: Associates Degree in Nursing required, BSN preferred

Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member. Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

PROACTIVE HOME CARE

Quality Assurance & Chart Audit Nurse (RN Preferred) – Home Health & Hospice

Posted on:

March 20, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Michigan

Proactive Home Health & Hospice Care is dedicated to providing compassionate, high-quality care to patients in their homes. We are seeking an experienced Quality Assurance & Chart Audit Nurse to join our team. The ideal candidate will have a strong background in home health and hospice, be detail-oriented, and be proficient in WellSky/Kinnser EMR.

Requirements: RN preferred (LPNs with strong experience in chart auditing may be considered). Minimum of 2 years of experience in home health and/or hospice quality assurance. Proficiency in WellSky/Kinnser EMR system. Strong knowledge of Medicare guidelines, CoPs (Conditions of Participation), and OASIS documentation. Excellent attention to detail and organizational skills. Ability to work independently and collaborate with interdisciplinary teams.

Conduct chart audits to ensure compliance with Medicare, Medicaid, and accreditation standards. Review clinical documentation for accuracy, completeness, and adherence to regulations. Provide feedback and training to clinicians regarding documentation improvements. Assist with policy and procedure updates related to quality assurance. Monitor compliance with state and federal guidelines for home health and hospice care. Identify areas for improvement and work with the clinical team to enhance patient care quality. Assist with survey preparation and regulatory compliance reviews.

Community Health Network

Remote Registered Nurse (RN) - Ambulatory Imaging

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Compact / Multi-State

Community Health Network was created by our neighbors, for our neighbors. Over 60 years later, “community” is still the heart of our organization. It means providing our neighbors with the best care possible, backed by state-of-the-art technology. It means getting involved in the communities we serve through volunteer opportunities and benefits initiatives. It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients. And above all, it means exceptional care, simply delivered — and we couldn’t do it without you.

Graduate of National League for Nursing (NLN), Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), or National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA) accredited school of nursing, or three years of related professional nursing experience. Licensed as a Registered Nurse (RN) with a valid license to practice in the state of Indiana as listed in the Nurse Licensure Compact (NLC). Interventional Radiology, OR, or Critical Care experience preferred. Must be reliable and detail oriented. Must work from home with reliable internet.

The Ambulatory Registered Nurse functions as a member of the imaging team, and will be responsible for the following task to be completed at their home base: Schedule invasive medical imaging guided procedures following HIPPA guidelines. Review and research medical history, medications, allergies and notes. Manages multiple communication avenues and prioritize accordingly. Provide each patient with instructions related to procedures including but not limited to: pre-procedure instructions, medical instructions, arrival time, and post procedure transportation requirements. Verify the validity of orders and accurately transcribes written orders. Promptly fields and/or directs incoming calls, promptly responds to patient and/or staff inquiries. Collaborate with Physicians regarding preferences for procedures and pre-procedure requirements. Serves as the liaison between patients, providers, and IR department and staff.

Aware Recovery Care, Inc

Per Diem Ambulatory Detox & MAT Nurse

Posted on:

March 19, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

Compact / Multi-State

The Ambulatory Detox & MAT Care Coordinator provides direct and indirect patient care and coordination of care to Aware Recovery Care clients. The Ambulatory Detox & MAT Care Coordinator works in collaboration with the admissions, agency admin, Clinical NP and agency management to coordinate care for clients within the program. Position Highlights: Compact license required. This is a part time role with an hourly rate of $33-$39 per hour contingent on experience, education, and licensure. This role is remote, but candidate must have an active compact license and reside in a compact state. Only applicants from the following states will be considered: GA, IN, KY, ME, MA, NH, OH, RI, VA Weekend and evening availability are a requirement. Bi-lingual in Spanish preferred.

Key Competencies: Strong assessment skills and holistic health knowledge regarding addiction Flexible work hours some evening and weekend hours are required Exemplary motivational interviewing and deep listening skills Strong interpersonal and group communication skills, and ability to collaborate Demonstrates patience and adaptability in the face of environment and situation fluctuations Resolution-focused with the ability to think critically and creatively Working knowledge of supplementary and alternative Addiction Treatment modalities Skill in the use of personal computers and related software applications. Knowledge of clinical operations and procedures. Knowledge of related accreditation and certification requirements Appreciation and respect for principles of diversity, equity, and inclusion. Ability to engage with diverse audiences (age, gender, nationality, race/ethnicity, profession, etc. Required Skills/ Qualifications: RN licensure within the states served- must hold a compact license. One year of professional clinical nursing experience in home health care or at least one year of professional nursing experience within the past three years. Possess a fundamental knowledge and understanding of most current medications prescribed in Detoxification and MAT settings. Possess a fundamental knowledge and understanding of the MMW Process, MATs, EHR, Screening, Medical Comorbidities, Dual Diagnosis, Infection Control, Infection Control and Management, documentation and transition to IHAT

Obtain additional state licensures as requested by ARC as quickly as possible Develop a cohesive and collaborative relationship with all Clinical Nurse Practitioners Maintain up-to-date education on current addiction treatment trends, including knowledge of Internet and local resources for those with substance abuse. Communicate and collaborate with Intake Department to help identify potential AmbD/MAT and IHAT clients Provide Telehealth and telephonic support to clients and allies as they go through the detoxification process. Submit timely clinical documentation in an Electronic Medical Record (EMR) system. Coordination of services with the client, family, care team and providers to ensure client goals are met. Maintain a weekly schedule for daily client visits and keep NP updated with changes in client status. Maintain HIPAA compliance Complete daily telehealth MAT and AmbD client follow-up appointments on a standardized schedule Involvement in self-evaluation and professional development. Perform miscellaneous job-related duties as assigned

Dunson and Associates

Registered Nurse

Posted on:

March 19, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

We are seeking a compassionate and dedicated Registered Nurse to join our healthcare team. The ideal candidate will provide high-quality nursing care to patients across various settings, including hospice palliative medicine, infectious disease care, and occupational health. This role requires a strong commitment to patient advocacy, effective communication skills, and the ability to work collaboratively within a multidisciplinary team.

Current Registered Nurse (RN) license in good standing. Experience or training in hospice palliative medicine is preferred. Knowledge of infectious disease protocols and occupational health practices. Proficiency in diagnostic evaluation techniques and specimen collection processing. Ability to lift patients safely and assist with mobility as needed. Strong interpersonal skills with the ability to communicate effectively with patients, families, and team members. Commitment to maintaining high standards of patient care and safety. Previous experience working with individuals with disabilities is a plus.

Deliver comprehensive nursing care to patients, including assessment, planning, implementation, and evaluation of care plans. Provide specialized care in areas such as hospice palliative medicine and infectious disease management. Conduct diagnostic evaluations and specimen collection processing as required. Assist in the care of toddlers and individuals with disabilities, ensuring their comfort and safety. Administer treatments and medications as prescribed while adhering to established standards of care. Maintain accurate patient records and documentation in compliance with healthcare regulations. Collaborate with physicians, therapists, and other healthcare professionals to develop individualized care plans. Educate patients and their families about health conditions, treatment options, and preventive measures. Participate in ongoing professional development activities to enhance nursing skills and knowledge.

Sequoia Home Health

Quality Assurance Registered Nurse (QA RN)

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

The Sequoia Difference At Sequoia Home Health and Hospice, we’re passionate about our work and take pride in the quality of service we provide. Our community is uniquely diverse, and it’s our aim to fulfill the unique needs of our patients through excellent individualized care. Our focus is to help facilitate a smooth and safe transition home and provide life-changing service with the amount of care and dignity our patients and their families deserve.

Sequoia Hospice is growing and looking for experienced, compassionate Quality Assurance Registered Nurse (QA RN) to join our team! JOB SUMMARY: The OASIS Review Nurse is a professional, registered nurse responsible for analyzing data integrity and consistency of OASIS documentation and assessment processes. This position will ensure appropriate ICD-10 coding and sequencing and will work with clinical staff to clarify documentation and data integrity issues.

Registered nurse with current license to practice professional nursing in the state. Bachelor’s degree required 2-5 years of clinical home health experience required. Working knowledge of OASIS and ICD-10 coding. OASIS certification (COS-C) preferred; OASIS Home health ICD-10 coding certification preferred. Knowledge of federal regulations and state licensure requirements.

Prospectively reviews all OASIS assessments to ensure appropriateness, completeness, and compliance with federal and state regulations and Seaport Scripps Home Health. Utilizes OASIS variation or alert reports when reviewing OASIS data. Ensures appropriate ICD-10 coding and sequencing as it relates to the patient’s medical condition, including any co-morbidities. Consults with appropriate clinical staff to clarify any data integrity issues and works with clinician to make appropriate corrections per Seaport Scripps Home Health. Reviews visit utilization for appropriateness of care guidelines and patient condition; reports potential financial losses and/or underutilization to the Clinical Supervisor/designee. Notifies Seaport Scripps Home Health leadership team of problematic trends as a result of OASIS review. Works with managers to address trends that affect the agency’s outcome and process measures noted during OASIS/ review. Makes OASIS inter-rater reliability visits with clinical staff. Participates in Quality Improvement and Corporate Compliance activities as assigned. Assists with other chart audit activities as assigned. Maintains professional and technical knowledge by attending educational workshops and reviewing professional publications.

Centene

Utilization Review Clinician - ABA

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

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. ***POSITION IS REMOTE BUT CANDIDATE MUST RESIDE IN FLORIDA*** **Ideal candidate will have BCBA Certification*** Position Purpose: Performs reviews of member's care and health status of Applied Behavioral Analysis (ABA) services provided to determine medical appropriateness. Monitors clinical effectiveness and efficiency of member's care in accordance with ABA guidelines.

Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience. License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required. Master’s degree for behavioral health clinicians required. Behavioral health clinical knowledge and ability to review and/or assess ABA Treatment Plans preferred. Knowledge of ABA services and BH utilization review process preferred. Experience working with providers and healthcare teams to review care services related to Applied Behavior Analysis Services preferred. License/Certification: LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Mental Health Professional (LMHP) required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required Board Certified Behavior Analyst (BCBA) preferred

Evaluates member’s care and health status before, during, and after provision of Applied Behavioral Analysis (ABA) services to ensure level of care and services are medically appropriate related to behavioral health (BH) and/or autism spectrum disorder needs and clinical standards Performs prior authorization reviews related to BH to determine medical appropriateness in accordance with ABA regulatory guidelines and criteria Analyzes BH member data to improve quality and appropriate utilization of services Interacts with BH healthcare providers as appropriate to discuss level of care and/or services provided to members receiving Applied Behavior Analysis Services Provides education to members and their families regrading ABA and BH utilization process Provides feedback to leadership on opportunities to improve care services through process improvement and the development of new processes and/or policies Performs other duties as assigned Complies with all policies and standards

AlphaForce Technology Solutions

Clinical Review Nurse - Prior Authorization

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Indiana

Position: Clinical Review Nurse - Prior Authorization Location: Remote – Indiana Potential to Extend: Yes 3 Months Pay-Rate: $45/Hr. on W2 Shift: 8AM-5PM EST Monday – Friday (training and work schedule) Disqualifiers: No computer literacy, add reasoning for big gaps in employment, NEED a professional environment (childcare needed if applicable) 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. Required Skills/Experience: Bachelor’s degree in Nursing and 2 - 4 years of related experience LPN - Licensed Practical Nurse - State Licensure required Authorization requests and determine medical necessity of service Medicare and Medicaid regulations Utilization management processes InterQual knowledge

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 members transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all members 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

Cortex

Telehealth Registered Nurse - Remote RTM & PCM

Posted on:

March 19, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Remote Contractor RN - Chronic Care Management (CCM) Position Overview: We are seeking a dedicated and detail-oriented Registered Nurse (RN) with a compact state license to join our team as a remote RN specializing in Remote Therapeutic Monitoring and Principle Care Management. The ideal candidate will have exceptional patient phone-side manner, strong documentation skills, and the ability to build rapport and trust with patients while working independently in a remote environment.

Valid Compact (multi-state) U.S. RN license (required). Prior experience in Chronic Care Management or Remote Patient Monitoring (RMP) is a plus. Proficient in using computers, EMRs, and related systems. Exceptional interpersonal and communication skills (both written and oral). Reliable, detail-oriented, and able to follow standard operating procedures. Positive, professional, and team-oriented attitude. A dedicated quiet workspace with high-speed, reliable internet. Access to a working and up-to-date computer or laptop, along with a quality headset.

Provide high-quality services to assigned patients. Complete patient caseloads efficiently each week, adhering to company guidelines and SOPs. Maintain exceptional patient interactions via phone, building trust and rapport with empathy and professionalism. Document all patient encounters accurately and comprehensively in accordance with program requirements. Collaborate with the care team and other healthcare professionals as needed to ensure continuity of care. Utilize strong computer skills to navigate software systems, maintain patient records, and communicate effectively.

HCA Healthcare

Virtual RN PRN

Posted on:

March 19, 2025

Job Type:

Role Type:

Triage

License:

RN

State License:

Tennessee

Provide appropriate compassionate advice to callers using evidence based clinical decision tools to help callers make personal health decisions. Make cross referrals as indicated. Facilitate referrals and event registration through internal transfer mechanisms.

KNOWLEDGE, SKILLS AND ABILITIES: Demonstrates knowledge and understanding of organizational and departmental policies, procedures and systems Communicates clearly and concisely both verbally and in writing Establishes and maintains long-term customer relationships, building trust and respect Demonstrates good judgment in handling situations not covered by written or verbal instructions Able to work effectively with internal and external customers Able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly, and transcribe accurately Able to handle multiple priorities and manage stress appropriately EDUCATION: The position requires an entry knowledge level generally obtained through completion of an Associate Degree or an equivalent in demonstrated work experience. EXPERIENCE: 1 year of clinical nursing experience required; 3 years preferred CERTIFICATE/LICENSE: Active RN license in state of residence required and ability to obtain licensure in all states served by HCA.

Utilizes nursing skill and along with approved protocols to provide telephone nurse triage and/or health advice to consumers with clinical questions or symptoms. Facilitates referrals for health services as appropriate via telephone and performs all components of call processing Ensures performance standards are met and accepts constructive feedback Speaks with a pleasant, professional phone voice and provides superior customer service to create an exceptional patient experience. Documents caller information and outcomes in a relational database system in accurately and as prescribed by current standards and policies Maintains confidentiality, HIPAA and PHI compliance Communicates appropriately and clearly with departmental management, co-workers and callers and exhibits willingness to master new work routines and methods Practices and adheres to HCA’s “Code of Conduct” and “Mission and Value Statement” Provides homecare, advice and/or education to callers that respects the cultural, spiritual, intellectual/educational, and psychosocial differences of individuals and preserves caller’s autonomy, dignity and rights. Maintains and contributes to a collaborative professional and ethical work environment. Actively participates in team meetings and engages in the processes of the contact center

NantHealth

Director, Clinical Solutions | Remote | AirStrip

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Texas

Are you ready to link your passion with a purpose? At AirStrip, we build technology that enables clinicians to diagnose earlier than ever before, accelerate life-saving interventions, reduce the cost of care, and save lives. We provide mobile-first clinical surveillance and alarm communication management technology that unlocks siloed data from patient monitors and transforms it into contextually rich information easily accessible on mobile devices and the Web. We’re seeking innovative thinkers who love doing meaningful work. If you’re looking to bring your skills and expertise to a growing technology company, it’s time for you to join us!

AirStrip is adding a Director, Clinical Solutions to our team. In this role, you will develop clinical strategies to support both Delivery PMO, Sales and Product Development vision for the Clinical Solutions team to enhance patient outcomes and expand industry market share. As a leader within the Delivery Project Management Office, you will lead building and growing a team of Clinical Consultants (CCs) to support the execution of all AirStrip product implementation. You'll lead the development of clinical relationships with healthcare institutions for net-new prospects and identified expansion opportunities to grow relationships in existing accounts. You'll establish goals and metrics for the clinical consultants, developing department processes and report to the leadership team key metrics that drive business and staff success. You'll work closely with R&D, Product, Marketing, Sales and Delivery PMO to remain current on all Clinical Solutions product offerings in order to successfully educate both our internal and external customers. Please note, this position requires 75-80% travel. You are regularly traveling Monday-Friday to client locations across the United States, multiple weeks in a row.

Education & Experience Requirements: Bachelor’s of Science in Nursing 10+ years of experience supporting selling activities and service delivery in healthcare software and solutions with a sustained and demonstrable record of success in Digital Health, Healthcare IT, Alarm Management, Clinical Communications and Patient Monitoring 5+ years of experience in acute care clinical workflows, including the knowledge to effectively establish credibility and the ability to provide solutions targeting clinical and operational workflow improvements Required Knowledge, Skills, and Abilities: A passion for patient safety and workflow improvement A high degree of passion, respect and listening skills Previous management experience Must possess excellent presentation skills Willingness to travel up to 80% Ability to work in a team environment that collaborates with multilevel disciplines, including excellent interpersonal and communication skills with the willingness to work with cross functional teams and individuals General office technology skills required (MacBook Laptop, Microsoft Applications, MS Teams, Zoom, WebEx) Ability to comply with AirStrip regulatory guidelines Ability to prioritize and manage time effectively Must possess excellent organizational skills to determine workload priorities Critical thinking/problem solving. Exercise sound business reasoning to assess issues, make decisions, and overcome challenges

Interface at all levels within a customer’s clinical organization and coordinate highly clinical information and unit-based workflow requirements Support delivery of clinical programs pre and post-sale to include ADPIE deliverables including clinical assessments, clinical design strategy, user acceptance testing, go-live support and ongoing customer clinical engagements. Manage budget, resource allocation and operational efficiency for the Clinical department. Hire, coach and direct a team of Clinical Consultants Provide emerging customer clinical requirements feedback to Product Management and serve as an active participant on the new product release committee Effectively communicate project goals and expectations to team members and stakeholders in a timely and clear fashion Develop and maintain clinical learning materials and manage delivery and access of materials. Establish key clinical stakeholder relationships Develop leading clinical practices and tools for project execution, management, training and support Design and present user stories, use cases, site assessments, clinical requirements, and workflow diagrams

NantHealth

Clinical Consultant | Remote | AirStrip

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

Are you ready to link your passion with a purpose? At AirStrip, we build technology that enables clinicians to diagnose earlier than ever before, accelerate life-saving interventions, reduce the cost of care, and save lives. We provide mobile-first clinical surveillance and alarm communication management technology that unlocks siloed data from patient monitors and transforms it into contextually rich information easily accessible on mobile devices and the Web. We’re seeking innovative thinkers who love doing meaningful work. If you’re looking to bring your skills and expertise to a growing technology company, it’s time for you to join us!

AirStrip is adding a Clinical Consultant to our team. In this role, you serve as one of AirStrip’s clinical workflow and informatics SME's during technology implementations with clients. You engage directly with clients’ clinical champions, end users, including both nurses and physicians, clinical IT staff and partner vendors to optimize the value of AirStrip's tech solutions. Drawing upon your previous clinical experience and expertise, you'll assist as an internal resource for pre-sales activities, implementation, training support and strategic product discussions. Please note, this position requires 75-80% travel. You are regularly traveling Monday-Friday to client locations across the United States, multiple weeks in a row.

Education & Experience Requirements: Bachelor's of Science in Nursing (or other health care related BS AND MSN), along with an active RN license Recent clinical experience (within last 5 years) in adult critical care, Telemetry, or Emergency Department 5+ years or more overall clinical experience in one or more of the above-mentioned areas. 2+ years of experience supporting clinical workflow initiatives in a hospital system involving clinical informatics, deployment of new technologies with successful adoption among physician and nurse users, including EMR, Monitoring alarms and mHealth technologies (strongly preferred) Required Knowledge, Skills, and Abilities: Demonstrable advanced clinical skills and knowledge in cardiac and critical care nursing and standards of care for critical care patients. Solid clinical workflow knowledge, including how departments relate to one another and process flows in between them Excellent verbal and written communication skills, including demonstrated ability to develop and deliver presentations, workflow designs, and training materials Strong ability to explain data and insights concepts to non-technical audiences and to communicate clinical informatics concepts and tasks to cross-functional teams Ability to instill confidence and persuade customers and coworkers Deep knowledge and experience with electronic medical records and workflow of medical and nursing staff around use of EMRs and other automated systems. Demonstrated project management, organizational and interpersonal skills Self-assured and results oriented, able to work independently as well as collaboratively. Strong analytical skills – understands how to collect, analyze, and leverage data to achieve clinical/business objectives Experienced knowledge of computer operations and ability to competently use MS Office – i.e. Word, Excel, Outlook, Visio, and other applications.

Employ clinical knowledge and understanding of clinical workflow design / redesign to propose AirStrip solutions that improve and optimize client’s workflow and processes Conduct clinical workflow design sessions at project sites, gathering data and working with the client’s clinical staff in developing new processes and workflow improvements Develop drafts of clinical documentation and assist with clinical marketing and support of new products and services Conduct hospital level training or facilitate client team meetings prior to or during initial deployment of solutions to ensure that physicians and nurses drive key use cases within their workflows to generate value and data required for clinical effectiveness. Participate with AirStrip innovation, engineering, and operations teams to ensure an efficient and comprehensive interaction with clients at the assessment, testing, validation, initial deployment, and steady state phases of the client relationship Interact with client physicians and nursing champions through planning, go-live, and post-deployment to enable adoption of AirStrip solutions and communicate feedback Deliver AirStrip solutions focused presentations to groups and demo how AirStrip solutions will meet prospect and customer needs​ Lead and coach customers to success through ADPIE methodology including workflow “day in the life” positioning​, go live support and ongoing education Manage multiple, simultaneous projects from assessment through clinical implementation Assist Sales team with sales calls and clinical discovery sessions to accelerate new account development and expansions​ Develop leading clinical practices and tools for project execution, management, training and support​ Design and present user stories, use cases, site assessments, clinical requirements, and workflow diagrams​

HCA Healthcare

Triage LPN

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Tennessee

The Licensed Practical Nurse/Licensed Vocational Nurse (LVN/LPN) delivers high quality, patient-centered care by performing a variety of delegated basic patient care services. In collaboration with the RN and other members of the care team, the LPN/LVN provides individualized, comprehensive care consistent with the scope and standards of the specialty. Licensed Practical Nurse (LPN)Identifies care compliance and/or knowledge deficits; delivers appropriate, evidence-based information pertaining to medical conditions, procedures and services; provides guidance to applicable resources

Completion of an accredited Licensed Practical Nurse program and NCLEX exam Minimum of 1 year experience in a hospital or clinic setting (working in the role/title of an LPN) – Telehealth experience preferred Must possess and maintain a LPN licensure in state of residence; Other state licensures may be required based on business needs and direction from site leadership. Additional state licensures identified at time of hire, applications to be submitted within 120 days of employment Additional requests for licensure as identified during employment, applications to be submitted within 45 days of request Employee is responsible for licensure fees; company compensation available for costs incurred to meet business needs that are outside of required criteria for state of residence

Performs all components of call processing for inbound and outbound contacts; Ensures complete, timely and accurate documentation of call handling in applicable system(s) Utilizes approved forms, files, protocols and systems for intake and delivery to support clinical material provided Able to identify emergent clinical concerns and promote safe outcomes under the direction of a Registered Nurse Escalates calls to an RN warranting comprehensive assessments/ clinical triage Demonstrates effective time management skills in all aspects in their role as LPN within NCCM Assists with Intake Orders and process for follow-up; provides clarification with provider as needed Assists with referrals/appointments Speaks with customers, patients and stakeholders in a pleasant and professional tone; demonstrates superior customer service Preserves caller’s autonomy, dignity and rights Receptive to constructive feedback and coaching; Demonstrates the ability to be kind, compassionate, considerate, approachable, friendly and open-minded Maintains confidentiality and HIPAA compliance on all internal and external channels Ensures individual performance, productivity and quality standards are met Functions within the scope of an LPN as defined by local, state and federal regulations/guidelines ; Adheres to NCCM clinical SOPs Promotes and adheres to Code of Conduct Maintains positive work environment; Communicates appropriately and clearly with department leadership and co-workers; Escalates issues/concerns to Leadership as appropriate Understands, supports and adheres to the NCCM vision and strategy Suggests ideas for positive changes to department policies and procedures Easily adapts to changes in work environment or job assignment; Exhibits willingness to master new work routines and methods Performs other duties as assigned DUTIES AND RESPONSIBILITIES, Licensed Practical Nurse (LPN) – Senior: Demonstrates and maintains previous level responsibilities Goal-oriented, focused team player Maintains positive working relationships and fosters cooperative work environment; Demonstrates ability to positively influence others; Finds and establishes win-win situations Capable and available to provide floor and call/work flow implementation and support to LPN(s) as needed Performs one-on-one feedback to meet clinical objectives as directed by leadership Actively participates in meetings and engages in process development Serves as a subject matter expert on policies and procedures, call handling and database software; Qualified to train and mentor LPNs Able to facilitate crucial conversations at all levels and in all directions Maintains professionalism in high-stress environment; ability to meet established deadlines as defined by leadership Demonstrates a level of business acumen and maturity that would be reasonably expected for this mentor level position Attends all site meetings as directed by leadership

CVS Health

Case Manager RN- Work From Home- San Antonio, TX

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

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

This Case Manager RN role is fully remote; however, candidates must reside within 45 minutes (reasonable driving distance) from the local office located at 7034 Alamo Downs Pkwy, San Antonio, TX 78238. No weekends or holidays will be required. The Case Manager RN is responsible for telephonically and/or face to face assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness. The Case Manager RN develops a proactive course of action to address issues presented to enhance the short- and long-term outcomes as well as opportunities to enhance a member’s overall wellness through integration.

Required Qualifications: Must have an active current and unrestricted RN multi state licensure in Texas Willingness to obtain additional state licenses will be required upon hire (expenses will be covered by company). 3+ years clinical practice experience as an RN required 1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications Must reside within 45 minutes (reasonable driving distance) from the local office located at 7034 Alamo Downs Pkwy, San Antonio, TX 78238. Travel to the San Antonio office may be required for quarterly meetings or PRN meetings. Must be able to work Monday through Friday 8:00am-5:00pm CST with flexibility to rotate to 10:00am-7:00pm CST on occasion when required to meet business needs. Preferred Qualifications: Case Management in an integrated model Bilingual in Spanish and English Strong computer skills Education: Associates Degree required BSN preferred

Through the use of clinical tools and information/data review, conducts an evaluation of member’s needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. 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 consider information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Reviews prior claims to address potential impact on current case management and eligibility. Assessments include the member’s level of work capacity and related restrictions/limitations. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining 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. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

Molina Healthcare

IRIS SDPC (RN)

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Wisconsin

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.

Are you seeking a unique nursing position that gives you a great work/life balance and lets you support people to live the lives that they choose? Then you’ll want to keep reading about this rewarding work opportunity! We are currently looking for a Registered Nurse licensed in Wisconsin to become our next IRIS Self-Directed Personal Care (SDPC) RN. This is a remote position, where you will partner with people in your community who are enrolled in the Wisconsin IRIS program – a Medicaid long-term care option for older adults and people with disabilities. People in the IRIS program who need personal care services have the choice to enroll in the IRIS Self-Directed Personal Care (IRIS SPDC) option. You can learn more about IRIS SDPC on the Wisconsin Department of Health Services website here, and learn about the IRIS program here. While this role is home-based, you will have regularly scheduled visits with people in their homes and communities. As an IRIS SDPC RN, you’ll provide oversight and guidance to the people enrolled in the IRIS SDPC option. You’ll also build relationships with the people you partner with and ensure that they’re getting the most out of the IRIS Self-Directed Personal Care option through assessment, oversight, training and education. IRIS SDPC RNs are responsible for administering the Wisconsin Personal Care Screening Tool; creating person-centered plans of care; providing personal care oversight to a group of people in IRIS, providing education and training for IRIS participants and care providers, and conducting the required documentation and follow-up. As an IRIS SDPC RN, you’ll play an important role in helping people of various backgrounds and abilities live their lives the way they choose.

REQUIRED EDUCATION: Associates Degree in Nursing REQUIRED EXPERIENCE: Minimum 2 years of experience in nursing with at least one year of home health serving individuals with developmental disabilities, physical disabilities, or the elderly. Demonstrated computer and software skills required, proficiency with Microsoft Office Suite and database operation/maintenance skills and data entry experience. Excellent written and verbal communication skills required and the ability to adapt communication styles to fit situation. Strong teaching and mentoring skills. Strong analytical and problem-solving skills. Good organizational and time management skills with ability to manage tasks independently. Flexibility in the work environment and willingness and ability to adapt to changing organizational needs. REQUIRED LICENSE, CERTIFICATION, ASSOCIATION: Current unrestricted license in the state of Wisconsin as a Registered Nurse. Valid Driver’s License PREFERRED EDUCATION: Bachelor’s Degree in Nursing PREFERRED EXPERIENCE: Experience providing care through the Wisconsin Medicaid Personal Care Program or one year of home care experience

Provides personal care assessments and oversight to the My Cares Groups by administering the Wisconsin Personal Care Screening Tool and addendums as required Documents assessment as required by individual tool and Department of Health Services policies and by completing oversight visits and calls as required Oversees a My Cares Groups of participants, develops individual plans of care, ensures physician orders for care are obtained and reviews and revises plan of care as needed Submits for Prior Authorization for personal care services Complies with all Department of Health Services policies and SDPC Guidelines, procedures, and practices along with documentation and program regulations Provides personal care training to participants or care providers as requested and provides educational materials as needed Completes collateral contacts with IRIS Consultants and Long-Term Care Functional Screeners and physicians to ensure care needs are met Completes other duties as assigned Overtime work may be required May be required to drive 50% of the time during a given day of member home visits Exposure to members homes which may include navigating stairs, exposure to different environments, and pets

Oula

Manager of Clinical Informatics

Posted on:

March 19, 2025

Job Type:

Part-Time

Role Type:

Informatics

License:

None Required

State License:

New York

Oula delivers maternity care built around our patients – offering comprehensive support before, during, and after pregnancy. With fewer C-sections and higher VBAC success rates, our research-backed approach is delivering better outcomes. Our team of trusted midwives, OBGYNs and dedicated care navigators ensure our patients get the type of care they need in the moments that matter most. Since launching in 2021, we’ve expanded our services to include Preconception and Miscarriage Care, Pregnancy Care, Hospital-Based Delivery, Postpartum Support, and Gynecology. We have 3 clinics in New York, with exciting expansion on the Horizon! Come join our team of clinicians, innovators, operators, and technologists, passionate about setting a new standard in maternity care.

We’re looking for a Manager of Clinical Informatics to own Oula’s EMR workflows. Oula clinicians work in their respective health system’s EMR systems, and Oula’s technology integrates with each of those systems. We’re looking for someone to serve as an internal expert in the capabilities of the systems and act as a conduit between IT teams and our clinicians’ needs. This role reports to the Director of Clinical Services Implementation. This is a part-time position of 20 hours/week the role is remote with a compensation range of $60-$65/hr.

5+ years in clinical informatics or project management within healthcare IT Direct experience optimizing workflows within EPIC General understanding of EPIC's API capabilities and use cases, preferred. A track record of project management experience acting as a conduit between IT and Clinical. Experience collaborating with both IT and clinical stakeholders. Detail oriented and highly organized.

Build upon Oula’s playbook of must-have EMR configurations, particularly in Epic, that guide each health system implementation toward efficient and compliant clinical workflows. Work closely with the IT teams at health systems, Oula’s internal IT & engineering teams, as well as with third-party integration experts, to scope and advocate for Oula’s configuration needs. Align new EMR system settings and parameters with existing clinical standards. Customize templates, order sets, alerts, and other system components to align with Oula’s standard of care, best practices and regulatory standards. Serve as Oula’s internal owner of clinical EMR workflows, collaborating with healthcare providers and IT teams to understand workflow requirements and operational challenges. Develop and maintain documentation related to EMR configuration, workflows, and user manuals. Manage EPIC configuration meeting structure, cadence, invitations between Oula and health system partners, focused on speed-to-launch.

Oula

Perinatal RN

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Oula delivers maternity care built around our patients – offering comprehensive support before, during, and after pregnancy. With fewer C-sections and higher VBAC success rates, our research-backed approach is delivering better outcomes. Our team of trusted midwives, OBGYNs and dedicated care navigators ensure our patients get the type of care they need in the moments that matter most. Since launching in 2021, we’ve expanded our services to include Preconception and Miscarriage Care, Pregnancy Care, Hospital-Based Delivery, Postpartum Support, and Gynecology. We have 3 clinics in New York, with exciting expansion on the Horizon! Come join our team of clinicians, innovators, operators, and technologists, passionate about setting a new standard in maternity care.

We are looking for a Remote Perinatal Nurse to support our patients in between their visits at our clinic. We’re searching for someone empathetic and detail-oriented to answer patient questions, review labs and imaging results, and support care coordination to provide high-quality patient-centric care. You will work directly with our provider and customer experience teams to provide a best-in-class experience for our patients. This role reports to the Senior Director of Care Continuity

Three or more years as an OB/GYN nurse in the field of obstetrics/gynecology or women’s health with experience providing and/or coordinating perinatal care A bachelor’s and/or nursing degree from an accredited program Active Compact RN License Additional Benefit: NY license in addition to compact Strong computer skills and familiarity with EMRs (experience with Athena is a bonus) Experience with maternal-fetal medicine support and strong ultrasound interpretation experience is highly desired Familiarity with outpatient perinatal care workflows and high risk pregnancies Passionate about improving perinatal care through a combination of clinical care, technology, patient empowerment and education An empathetic listener and communicator with the ability to connect with a wide variety of audiences and respond to a wide variety of needs A cultural carrier with full alignment to Oula’s commitment to deliver the highest degree of patient centered care Organized as it relates to daily tasks and as well as an ability to work towards longer term goals and projects Flexible in your approach and ability to adapt to changing circumstances Comfortable working across distance and maintaining east coast hours regardless of location Ability to work on a strong team of professionals in a culturally diverse environment Spanish or non-English language proficiency is considered a bonus

Provide first-line review for all lab and imaging results, including communicating with patients regarding results per Oula clinical policy Answer inbound clinical questions from patients via messages in the Oula Patient Portal and phone calls within RN scope of practice Lead clinical portions of our new patient screening and onboarding process, including review of risk factors/medical history as needed and review of medical records for patients transferring care to Oula Partner with OB, midwife, NP, and care coordination teams to deliver high-quality continuity of care for our patients Coordinate with external clinical partners (e.g. maternal-fetal medicine, labs, imaging partners) where needed to ensure Oula patients are getting the care they need outside of our ecosystem Communicate MFM consultation results to patients in a timely, clear, and supportive manner Assist in coordinating follow-up care based on MFM recommendations Support basic ultrasound interpretation and documentation within RN scope of practice Collaborate with the clinical team to ensure seamless integration of MFM insights into patients' care plans

A&C Private HomeCare

Registered Nurses, PRN or Consultant

Posted on:

March 18, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Georgia

A&C Private Home Care is currently looking for RNs Consultants. Retired RNs willing to remain engaged in the profession are welcome to apply. The positions are flexible schedules to meet the needs of our private home care business throughout Georgia. The RNs will help oversee all clinical needs, follow up with case management agencies' recommendations, along with guidance with medication and prescription management.

Experience in Community Health and/or Home Health Care Possesses all credentials required by State and Federal Law Valid Driver's license with good driving record The RNs will assist with the quality assurance and compliance with Rules and Regulations.

Assess health needs, develop and implement appropriate plans of interventions, assess and modify plans in response to changing health care needs of individuals served and interface with case management agencies. Interact with other support staff to ensure continuity and coordination of care. Effectively use community back up support in providing care. Document information and treatments in accordance with rules and regulations Communicate effectively with the Director of Nursing, other support staff, clients, families and outside agencies, as appropriate. Participate in client-centered meetings and staff meetings, as appropriate. Review the implementation of medically prescribed client care plan. Respond to crises and interventions, as needed. Recommend policies and procedures on health issues. Participate in appropriate professional growth and continuing education opportunities. Schedule and conduct monthly staff meetings with LPN's and supporting staff. Provide continues support while at assigned location though out workdays. Must successfully complete and demonstrate proficiency in all areas of required training. Other responsibilities may be assigned

Samaritan Health Services

HRSN Specialist RN I

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Oregon

Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan.

As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together. This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin Candidates residing out of state will need to be able to work Pacific Time Zone hours.

EXPERIENCE/EDUCATION/QUALIFICATIONS: Current unencumbered Oregon RN License required. BSN preferred. One (1) year clinical nursing experience required. Experience or training in the following required: Health care delivery systems and/or managed care patients. Computer applications including electronic documentation (e.g., MS Office, EPIC, Clinical Care Advanced). Experience in the following preferred: Utilization management. Medicare and Medicaid rules and regulations and health plan benefit structure and policy. KNOWLEDGE/SKILLS/ABILITIES: Knowledge of social determinants of health (SDoH) and the relationship to the member’s overall wellbeing. Knowledge of HRSN benefit, managed care principles, OHA requirements and OHP benefits and ability to incorporate this information into the HRSN coordination process. Knowledge of principles and processes for providing customer and personal services, including customer needs assessment, meeting quality standards for services and evaluation of customer service satisfaction. Ability to work, function and communicate on a multi-disciplinary team. Possess the knowledge and skills to develop constructive and cooperative working relationships with others and maintain them over time. Ability to work with all levels within the organization, facilitate communication, and effectively document related activities. Ability to identify complex problems, review related information, employ creativity and alternative thinking to develop and evaluate options and implement solutions respond quickly and appropriately. Ability to organize, plan and prioritize work to complete within required time frames and to follow-up on pending issues. Knowledge of medical terminology, ICD, CPT, and HCPCS codes. Strong communication skills (telephone skills with members, CBOs, interdepartmental communication).

Reviews, assesses, and evaluates clinical information used to support the HRSN (health-related social needs) benefit decisions based on established clinical criteria and applies intermediate knowledge of coding and medical record research. Facilitates professional communication to ensure the HRSN process is completed in a patient centered manner with adherence to quality and timeline standards. Applies knowledge of applicable Medicaid (OHA) rules and regulations to the authorization process.